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PublishedinGreatBritainunderthetitleExtremes:Life,DeathandtheLimitsoftheHumanBodybyHodder&StoughtonLIBRARYOFCONGRESSCATALOGING-IN-PUBLICATIONDATAFong,Kevin.

Extrememedicine:howexplorationtransformedmedicineinthetwentiethcentury/KevinFong.pagescm

Includesbibliographicalreferencesandindex.ISBN978-0-69815161-1

1.Firstaidinillnessandinjury.2.Extremeenvironments—Healthaspects.3.Adventuretravel—Healthaspects.4.Spaceflight—Healthaspects.I.Title.RC86.7.F662014616.02'52—dc232013028124

Whiletheauthorhasmadeeveryefforttoprovideaccuratetelephonenumbers,Internetaddresses,andothercontactinformationatthetimeofpublication,neitherthepublishernortheauthorassumesanyresponsibilityforerrors,orforchangesthatoccurafter

publication.Further,publisherdoesnothaveanycontroloveranddoesnotassumeanyresponsibilityforauthororthird-partyWebsitesortheircontent.

Version_1

ForDee,Jack&Noah

Someofthematerialinthisbookdrawsuponmyexperienceasadoctor.Wherenecessary,thecasedetailsofpatientsIattended,aswellasthenamesofstaffinvolved,havebeenalteredtoprotectconfidentiality.

CONTENTS

TITLEPAGECOPYRIGHTDEDICATIONNOTE

INTRODUCTIONICEFIREHEARTTRAUMAINTENSIVECAREWATERORBITMARSFINALFRONTIERSACKNOWLEDGMENTSSOURCESANDFURTHERREADINGINDEX

LINTRODUCTION

aterthiscenturyasmallcrewofpeoplewillfindthemselvesspiralingtowardMarsfromdeepspace,ontheirwaytobecomingthefirsthumanbeingstosetfootonthesurfaceoftheRedPlanet.Theywillhavecrossedhundredsofmillionsofinterplanetarymilesinthe

process,travelingfartherfromEarththananyoneinthehistoryoftheirspecies.Theywillhavelefttheirhomeplanetbehind,launchingthroughtheskyonarocket-propelledjourneyofbreathtakingviolence,slippingthenarrowlayerofatmospheresmearedaroundEarththatsupportshumanlife.Theywillhavelivedinsideamachineformanymonths,aspecksetinsharpreliefagainstthevoidofspace,havingenduredajourneyofhazardsunparalleledinthefieldofexploration.

Itsoundslikeapreposterousendeavor.Butwhenitcomestoexploration,wehavecomealongwayinashorttime.Acenturyago,therewasstillwhitespaceonthemapsoftheworld,placesthatremainedunexplored.Cartographersattheturnofthetwentiethcenturystillreferredtothelandmassofsnowandicetothesouthasthe“supposed”continentofAntarctica.Theywereabletoillustrateitscoastlineinonlyvaguedetail.

Throughadvancesinscience,engineering,andtechnology,wehavemovedforwardatabreakneckpace—suchthattodaywetalkofthesurfaceofMarsinmuchthesamewaythatwemighthavediscussedtheunknownsoutherncontinentofAntarcticaonlyacenturyago.Wearrivedatthisincrediblepeakofhumanexplorationbycomingtoknowthelimitsofhumanphysiologyandthencloakingitinincreasinglysophisticatedsystemsofartificiallifesupport.Inlargepart,wecansuccessfullyprotectourfragileformfromtheextremesthatthephysicalworldhastooffer.

Asweconqueredthephysicalworldinthetwentiethcentury,wemasteredtheterrainofthebodyaswell.Programsofpublichealthbroughtvaccinationandbettersanitation.Withantibioticstheseadvancesgreatlyincreasedour

andbettersanitation.Withantibioticstheseadvancesgreatlyincreasedourexpectationsoflifeandlongevity.Butonthisfoundationwemountedevenmoreambitiousassaultsagainstdiseaseandinjury.Wespecialized,masteredthetechniqueofanesthesia,learnedtooperatesafelyuponthehumanheart,developednewsystemsoftraumacare,daredtotransplantorgans,anddiscoveredhowtomanipulatetheimmunesystem.Wewentontocreatethenewspecialtyofintensive-caremedicine,aplatformfromwhichtodaywelaunchourmostambitioussurgeriesandmedicalinterventions.Thesearebutafewoftheinnovationsthatcombinedtocreateouraudaciousmodernsurvival.

Thesetwinpursuitsofthelasthundredyears,explorationandmedicine,havechangedthecourseofhumanlife—anddeath.Theyalsoprofoundlyinformedeachother.It’snotsomuchthatwedrewdirectlessonsfromourendeavorsinhostileenvironments.Rather,becauseofourexplorationofthephysicalworld,wecametoacceptthattheextremesofillnessandinjurycouldnotbeovercomewithoutalmosttotalrelianceuponartificeofscienceandtechnology.Oftenittookyearsofresearchtoperfectthatartifice.Inthetwentiethcenturyourexplorationofthelimitsofthehumanbodyandthoseofthephysicalworldrevolutionizedthewaywesawourselvesandthelengthstowhichwewerepreparedtogotoprotecthumanlife.

Inretellingthestoryofhowwearrivedatthispointinmedicine,weusuallyrelateanabbreviatedhistory,ataleofsteadyprogressacrossthecentury.Butwhenconsideredmoreclosely,theeventsthatledtotheseinnovationstelladifferenttale.Thepathtoprogressinmedicinelookslessliketheploddinginductiveadvanceofscienceandmorelikethehaphazardendeavorofexploration.Tofullyappreciateeither,wemustseebothinparallel.

Seeingmedicinethroughthelensofexploration,andviceversa,issomethingIhaveforcedmyselftodo.Ihavespentmyadultlifeengagedinbothpursuitsandintryingtoreconcileonewiththeother.ImajoredinastrophysicsatUniversityCollegeLondonbeforegoingontostudymedicine.Towardtheendofmymedicalstudies,IwasacceptedontoastudenttrainingrotationinaerospacemedicineatNASA’sJohnsonSpaceCenterinHouston.

Itwastherealizationofalong-heldambitionandawaytoindulgemychildhoodfascinationwithhumanspaceflight.IfoundexcusestogobacktoHoustonasoftenasIcould,gainingfarmorefromtheexperiencethanNASAevergainedfromme.IledadoublelifeshuttlingbetweenHoustonandthehospitalwards.I’dleaveapunishingon-callstretchinaUKhospitaltoflyacrosstheAtlanticandsitinonameetingwherepeopletalked,straight-faced,abouthowNASAmightbestgetpeopletoMars.

abouthowNASAmightbestgetpeopletoMars.Iusedtofeelguiltyaboutindulgingmyspace-agepassionforexploration

whenthereappearedtobesomanyquestionstoaddressinthefieldofterrestrialmedicine.Butlater,asIspecializedinintensive-caremedicine,Ibegantounderstandwhatwewereupagainstintryingtotreattheextremesofillnessanddisease.Despitetheadvancedpatientmonitorsandlife-supportmachines,despitetheendlessreamsofinformationwegatheredandtheperpetualvigilance,whenconfrontedbythechallengeofcriticalillness,weoftenfailedmiserably.Ibegantowonderwhichwasthemoreridiculouspursuit:standingattheendofabed,tiltingatthewindmillsofcriticalillness,orstaringdowntelescopesatdestinationsthatlaywaitingtobeexplored.

Overtime,IcametorealizethatthetwohalvesofmylifehadmoreincommonwitheachotherthanIhadpreviouslyimagined.Whenyoulookbackattheeventsthatshapedmuchofmodernmedicineinthetwentiethcentury,attimesyoucan’thelpbutbeamazedatthecapacityofthatdisciplinetoinnovateandovercome.Themechanizationofwarandsocietyprovidednewandterriblewaystoinflictinjuryandpropagatedisease.Inparallel—throughaircraftandlandambulances—italsoprovidedthemeanstoattendpatientsandcasualtieswithanimmediacyneverbeforeseen,leavingdoctorstoconfrontextremesofphysiologytheyhadhithertoneverwitnessed.Togethertheseadvancesconspiredtocreatechallengessogreatastoappear,tothevastmajority,tobeinsurmountable.Buttherewere,nevertheless,alwaysafewbravesoulswillingtopartwithconvention;willingsimplytotry.Ilearnedfromthesestoriesabouthowwearrivedatthispoint,withsuchinflatedexpectationsoflifeandsurvival,thatwhileourmedicalpioneersweren’tconcernedwithgeographicalconquest,theywereverymuchinthebusinessofexploration.

ExtremeMedicineisabookaboutlife:itsfragility,itsfractalbeauty,anditsresilience.Itisaboutacenturyduringwhichourexpectationsoflifetransformedbeyondallrecognition,whenwetookwhatwasroutinelyfatalandmadeitsurvivable.Withhearttransplants,intensivecare,traumasurgery,andstate-of-the-artlifesupport,thisexplorationofthehumanbodywasnolessextremethanourforaysinthephysicalworld.

Thethemeofrapidadvance,usingtechnologyandsciencetosurroundourphysiologylikeacocoon,runsthroughallofthestoriesinthisbook.Eachchapterofthebookfocusesononeofthemodernlimitsofsurvivability—theextremesofcold,heat,criticalillness,traumaticinjury,disease,war,vacuum,andfinallyoldage.Juxtaposedwiththeexplorationsofphysicalextremesisalitanyofextraordinarymedicaladvances.Avant-gardemedicineisfundamentallychangingourideasabouthowourbodiesworkandofthenature

fundamentallychangingourideasabouthowourbodiesworkandofthenatureoftheboundarybetweenlifeanddeath.

Humanphysiologyisasfascinatingasitiscomplexand,withinthelimitsofaphysicalenvironmentthatcansupportit,extraordinarilyresilient.Butthewaywe’veextendedourreach—totheedgeoftheEarthandbeyondintoouterspace—throughtheartificialsystemswehavebuilttoaugmentourbiologyisequallybreathtaking.

Itisthisenhancedunderstandingofhumanphysiology,andournewabilitytoprotectit,thathasinthepasthundredyearsallowedustoextendourreachasanexploratoryspeciesandsimultaneouslylookwithintotheedgesofourownlives.

Thisbookbeginswith“Ice,”achapterthatrevisitsRobertFalconScott’sill-fatedexpeditiontotheSouthPolein1912andconsidershowwecametounderstandthethreatofhypothermiaandlaterturnittoouradvantage.Ourtwenty-first-centurycapabilitiesinexplorationandourexpectationsofsurvivalwouldhavesurelylookedlikethestuffofpurefantasytoScott.

“Fire”tellsthestoryofhowinthedecadesthatfollowedtheWrightbrothers’inauguralflight,wetooktotheskyinremarkableaircraft,madeitafieldofbattle,andpaidthepriceinhumansuffering.Thistale,ofhowthemodernmedicalspecialtyofreconstructiveplasticsurgerywasforgedinthecockpitfiresofWorldWarIIfighteraircraft,isemblematicofourdifficultrelationshipwithnoveltechnologies.Balancingthenewcapabilitiesthattheybringagainsttheharmsthattheyexposeustohasalwaysbeenthechallenge.Bymitigatingtheconsequencesofthoseadvances,progresselsewhereismade.

“Hearts,”thethirdchapterofthisbook,followssomeofthepioneerswhosoughttoexploreacontinentthatatthestartofthetwentiethcenturystoodasunknownandfraughtwithriskasAntarcticahad.Thiscontinentwasnotageographicaldestinationbutinsteadalocationtobefounddeepinthehumanbody:theterritoryofthehumanheart.Theroadtothefirstscheduledheartoperationswasanythingbutstraightforward,andbeforethefinalconquest,theedgesofthatterritorywererepeatedlyprobed—andretreatedfrom—inmuchthesamewaythatScottandhispredecessorshadexploredtheSouthPolarregion.

Massmotortransporttransformedthepaceatwhichourliveswereled,routinelyexposinggreatswathesofthepopulationtokineticenergiestheyhadhithertoneverexperienced.Thiscreatednewmechanismsofinjuryand—simultaneously—themeanstodeliverhealthcarewithanimmediacyneverbeforewitnessed.Thechapters“Trauma,”“IntensiveCare,”and“Water”togetherdiscussthenatureofthischallengeandhowitwasmetwithinnovation.

togetherdiscussthenatureofthischallengeandhowitwasmetwithinnovation.Creatingstate-of-the-artmedicalsystemspushedtheboundariesofmedicineandpushedustothelimitsofourownphysiology.

Thefinalchaptersofthebook,“Orbit”and“Mars,”returnustothefieldofexplorationproperandattempttogiveanappreciationofthemassiveobstaclesthatliebetweenusandthefutureexplorationofspace.Muchoftheadvancethatwehavemadeinmedicineinthetwentiethcenturyhascomethroughwrappingfragilehumanphysiologyinconcentriclayersofartificiallifesupportandallowingittobeprojectedintoextremesthatwewereneverbeforeabletosurvive.Thisstrategy,ofusingtechnologytogobeyondthehumanbody’sinnateabilitytoadaptandsurvive,iscommontoourexplorationinmedicineandinthephysicalworld,includingouterspace.

“FinalFrontiers”looksattheprogressofacenturyasexperiencedfirsthandbycentenarianJamesHudson—amanwhowasbornwhenmapsoftheglobestillincludedterritoriesunchartedandwholivedlongenoughtoseetheworldtalkofexploringMarsthewaytheymighthavetalkedabouttheexplorationofAntarcticawhenhewasaboy.

ExtremeMedicineisabookaboutmedicinebutalsoaboutexplorationinitsbroadestsense—andabouthow,byprobingtheverylimitsofourbiology,wemayultimatelyreturnwithabetterappreciationofpreciselyhowourbodieswork,ofwhatlifeis,andwhatitmeanstobehuman.

January5,1911:CaptainScott’sshipTerraNovaseenfromtheinteriorofateardrop-shapedicecavern—oneofexpeditionphotographerHerbertPonting’sbreathtakingAntarcticimages.

(©Popperfoto/GettyImages)

RICE

obertFalconScottisdying,slowlysuccumbingtohypothermiainatentpitchedonthewastelandsoftheRossIceShelf,fullofthewearyknowledgethathewasnotthefirstexplorertoreachtheSouthPole—onlythefirsttohavelostanentireexpeditionaryparty

doingso.Itis1912.Antarcticaisasinaccessibleasitisfraughtwithrisk;andthat,ofcourse,isitsattraction,leadingmentopitthemselvesandtheirlivesagainstitschallenges.

HavingbeenbeatentothepolebyRoaldAmundsen’sNorwegianexpedition,Scottisnowembarkingonaraceofadifferentkind:thescrambletowritehisletterstothenextofkinofhisexpeditionteam,tellingoftheirbrillianceandhonorandtakingresponsibilityforhavingledthemtotheirdeaths.Timeisagainsthim.

Scott’slifeisapropertydistributedacrossthemanytrillionsofcellsthatcomprisehisbody.Likeallhumanbeings,heexistsinastateoftension.BythatImeansimplythatnatureseeksequipoise:Itwouldlike,asfaraspossible,forallthingstobeasequalastheycanbe.

Thedefaultstateforanatomormoleculeiselectricalneutrality.Herethenumberofpositivelychargedprotons,intheircompositenuclei,andnegativelychargedelectrons,inorbitaroundthem,isequal.Butwithalittleeffort,atomsandmoleculescanbemadetoloseorgainoneormoreelectrons,andinsodoinglosetheirneutrality.Thisisachievedbyimpartingalittleenergy—throughchemicalreaction,radiation,orelectricaldischarge.Energytransformsmoleculesandatomsintoions.Itchangestheirnature.Theybecomemoredynamic,capableofbeinginfluencedbyandgeneratingelectricalormagneticfields.Inthebody,ionscanflowacrossporousbarriers—ofthetypethatcomprisethewallsofourcells—becauseanegativechargeseekstoneutralizeapositivecharge.

Themachineryofourcellsisdesignedtoseparatechargedionsacrosscell

Themachineryofourcellsisdesignedtoseparatechargedionsacrosscellmembranes.Thatprocessofseparation,ofcreatinginequality,leavesasystemoutofstepwiththesimplearrangementthatphysicswouldprefer.Itcreatesthepotentialforsomethingfarmoredynamic:aperson.

Imagineabudgetairlineoperatingaplanethatisonlyhalffull.Saythatit’salong-haulflightandthattheairlinechoosestoexpendalittleenergyingettingitscabincrewtocramallofthosepassengerslikesardinesintothefronthalfoftheplane,leavingtherearoftheaircraftentirelyempty.(This,Ithinkyou’llagree,isasituationwiththepotentialforthereleaseofalotofpent-upenergy.)Nowimaginethatthechiefexecutiveoftheairlinedecidespeoplecansitwheretheylike,justsolongastheypayhimanother$10fortheprivilege.Thepassengersshoutandswearabit,buteventuallymostofthemdecidethatbeingcrammedintothefrontoftheplaneisworsethanpayingthemoneyandbeingabletospreadthemselvesoutevenlyinallthoselovelyemptyseats.Theresultisaplanewhosepassengersaredistributedmoreevenlyandanunscrupulousairlineexecutivewithsomeextracashinhispocket.

Whattheairlinedoeswiththepassengersandcashiswhatthebodydoeswithionsandenergy.Byexpendingenergyincreatingartificialinequality—inthecaseofthebody,bypumpingionstowheretheydon’twanttobe—andthenharvestingandstoringenergyasthesystemattemptstoreturntoequilibrium,youcansaveenergyforlateruse.Thisenergycanbestoredintheformofchemicalintermediateswithincellsandusedtodrivegrowth,repair,replacement,andreproduction.

Weseethisallaroundusinnature.Inweathersystems,forexample,windsblowfromareasofhighpressuretothoseoflowerpressure.Thewindsareamanifestationofinequalitiesinpressureandthesystem’snaturaltendencytosmooththosedifferencesout.Inthesamewaythatthisdifferenceallowsturbinestoharvestenergyfromwind,thebodycanexploittheflowofionsacrosscellmembranes.

Theflowofions,alongwiththebeautifullyelegantmachinerythatexploitsit,makescomplexlifepossible.Itkeepsthewholethatisgreaterthanthesumofitsparts—thewholethatisultimatelyScott—going.

Ithastakenmemostofmymedicalcareertofinallyappreciatethetinyprocessesthatenablebiologicalsystemstostoreandreleaseenergy.Thesebiochemicaleventsindividuallyappeartobearlittlerelationtothewonderoflife,wheninfactcollectivelytheyarelife;theyareeverythingwedo,everythingweare.

Theprivilegeofthehumanbody’scomplexityisboughtataprice:Itmust

Theprivilegeofthehumanbody’scomplexityisboughtataprice:Itmustexpendenergypumpingionswheretheydon’twanttobeinordertokeepthebodygoing.Whenthatpriceisnolongeraffordable,simplicityreignsonceagain.Andheresimplicityissynonymouswithdeath.

—THEENVIRONMENTOUTSIDEthetentabhorsScott’scomplexity.Thereismoreatworkherethantemperaturesthatcanfreezeexposedfleshinseconds.First,thereisAntarctica’saridity.Thecontinent’sgreatsheetsoficeholdwaterlockedaway,andlessthanasingleinchofrainfallsthereeachyear.SotheRossIceShelfisconsideredadesert,anditwillattempttodehydrateanddesiccateScott’sbody.Withmuchofthecontinentthrusttwomilesabovesealevel,Scottishighenoughtomakeheavyexertionuncomfortable,evenfortheacclimatized.That’snottomentionthescouringAntarcticwinds,whichwillcarryheatawayfromhisbody,drivinghistemperaturedown.Alltold,Antarcticaisacontinentoffierceextremes:thecoldest,thehighest,themostparched.Itsclimatehasmadeituninhabitableforallbutthelasthundredyearsofhumanhistory.

BleakthoughAntarcticamaybe,it’simportanttoconsiderhowScott’sbodyreactstohisplummetingtemperature,becausethatprocessisthekeytoanextraordinaryadvanceinfuturemedicaltechnology.

AsScott’scoretemperaturedrops,thepumpsthatmoveionsacrosshiscellmembranesaregrindingslowlybutsurelytoahalt.Theprocessisinexorable.Intheabsenceofenergy,borrowedfromthefueloffoodandburnedinthefireoftheoxygenthatwebreathe,thepumpswinddownandeventuallystop.Theionsbegintoassumeequalconcentrationsoneithersideofthecellmembranes.Thissimplesymmetryishowdeathbegins.

Scottisn’tyetreadytodie.Hisphysiology,ignorantofhispredicament,isdesignedtobattleforhim,tobuyhimeverymomentthatitcan,togivehimhisbestchanceofsurvival.AsScottwrites,hefeelstheheatdrainingoutofhishand.Thebloodvesselsthatruninhisbody’speriphery,carryinghotbloodtohisskin’ssurfaceandlosingthatheatuselesslytotheoutsideworld,areconstricting.Hisbodyhairstandsonendinanefforttotrapmoreairclosetohisskin.Bothofthesemeasuresareanefforttoreduceconductiveheatlosses.InthecontextoftheAntarcticenvironment,however,thisphysiologicalstrategyisnexttouseless.

Next,Scottwillbegintoshiveruncontrollably,generatingenoughheattoslowthedropinhistemperature.Thisshiveringismorethanthecasualtremorwemightexperienceatabusstopinmidwinter;Scott’smuscleswillshakethemselvesashardastheycan,consumingfatandcarbohydratesravenously.

themselvesashardastheycan,consumingfatandcarbohydratesravenously.Thistypeofshivering,alastdesperateattemptatstavingoffdeath,becomesanactofphysicalenduranceinitself.Itcanaccountforfully40percentofthebody’smaximumexercisecapacityanditwillcontinuewhilethereisfuelenoughtodoso.Butshivering,nomatterhowathletically,ismerelyaholdingmeasure,thebody’smethodofbuyingtimeinthehopethatsomethinginitsexternalenvironmentwillchangeforthebetter,notasolutioninitsownright.

Asitproceeds,thedeephypothermiawillgoontoalterScott’smind,makinghimirritableandpossiblyirrational.Whenhisbody’sreservesoffuelrunout,theshiveringwillstop—arespitethatwillonlyacceleratetherateatwhichhecools.Likeamarathonrunnerhittingthewall,Scottisattheendofallofhisreserves.Thereisnothinglefttodrawupon.Mercifully,somethingthatlookslikesleepwillfollowastheelectricalactivityinhisbrainbeginstofail.Hewillslipintoacomawellbeforethechannelsinthecellmembranesofhisheartmuscle,thegatekeepersofelectricalstabilityinthatorgan,arecompromised.Frenziedanarchicrhythmsmayfollow,theheartwrithinguselesslylikeabagofwormsbeforefinallycomingtoastandstill.

Withhisheartnolongerbeating,hisbodywillbestarvedofitsfreshsupplyofoxygen.Butatsuchlowtemperatures,therateatwhichScott’scellsfailanddiewillbedraggedoutintime.Deathresultsfromthefailureofthechemicalprocessesthatdriveourcellularmachinery.Inthedeepcoldthoseprocesses,too,becomesluggish.Thenormalwindowofafewhundredsecondswhenhisbrainisdyingyethiscirculationmightstillbereestablishedwillinsteadstretchtomanyminutes.Thiswindow,elongatedbycoldtemperatures,willbecomecrucialtomedicalpractitionersintheyearsahead.

ButforScottthereisnorescue.Thesecondsbecomeminutes,theminuteshours.Scott,onceablazingfurnaceoflifeonthesubzerowastelandofAntarctica,isfinallynomoreenergeticthantheiceandsnowthatsurroundhim.

—LIKEALLLIVINGBEINGS,wefightagainstthelawsthatgoverninanimateobjectsinanefforttoavoidequilibriumwiththephysicalworld.Throughtheactofliving,wemaintainalevelofcomplexityotherwiseunknownintheuniverse:theabilitytogrow,toadapt,toreproduce,andashumans,thecapacityforsentienceandself-awareness.Asfascinatingandenigmaticasneutronstarsandsupernovasmightseem,yourbrainismorecomplicatedandmoreimpenetrabletosciencethaneither.Whatmakesusdifferent,whatsetsusapartfromthe

inanimatematteraboutus,isourabilitytodefyentropy,toavoidthethermodynamicreorganization,thatwouldseeusreducedtoasimpler,lifelessstate.Asthedecadespass,we—thehumanrace—becomebetteratitandexpandtheenvelopeinwhichlifeispossible.

Forallitspersonaltragedy,Scott’sdeathalsocontainssomehintsaboutthedirectionsinwhichtheenvelopeexpandedinthecenturythatfollowedhisdoomedexpedition.TryingtoconquerAntarcticaforcedustoconfronttheworld’smostextremephysicalconditionsandunderstandthehavocthattheywreakuponthehumanbody.Deepeningthatunderstandingofthebodyallowedustocontinueourexplorationsthere.Ourfrailphysiology,leftunprotectedinthesehostileenvironments,stoodlittlechance.

Thechallengeofexplorationbecamelessaboutthespiritanddeterminationofourploddingexpeditionaryteamsandmoreaboutthechallengeofhow—throughscienceandtechnology—wemightprotectthemagainstchallengesthathadbeenfatalthroughoutallofhumanhistory.Asthedecadespassedandourknowledgegrew,wewereabletoovercomehypothermia.Theanswerlayinunderstandingournarrowlimitsandwhatourbodymighttolerate.Withbetterclothing,habitats,andsystemsoftransport,wecouldgofurther.

Buttodaythatunderstandingallowsustodofarmorethanpersistintheseenvironments:Hypothermiahasbecomeanassettomedicine,atoolforcheatingdeath.

—NEARLYACENTURYafterScott’sexpedition,atwenty-nine-year-oldwomanskiinginthemountainsofNorwaysufferedanaccidentandwentthroughthesamesequenceofphysiologicalevents.ShewasaslifelessasScott,hundredsofmilesfromhelp,trappedbyice,herheartatastandstillassecondsbecameminutesandminutesbecamehours.Butshesurvived.

InMay1999,threejuniordoctors,AnnaBågenholm,TorvindNæsheim,andMarieFalkenberg,wereoutskiingoff-trailintheKjølenMountainsofnorthernNorway,nearthetownofNarvik.Itwasabeautifulevening,oneofthefirstdaysofeternalsunshineatthestartoftheArcticsummer,andtheskiinghadbeengood.TheyfoundthemselvesdescendingintoashadedgullycalledtheMorkhala,aplacetheyknewwell,whichhadagoodcoveringofsnowevenlateintheseason.AllthreewereexpertskiersandAnnabeganherrunconfidently.

Butduringthedescent,Annaunexpectedlylostcontrol.TorvindandMariewatchedfromafarasshetumbledheadlongontoathicklayeroficecoveringamountainstream.Annaslidacrossitonherbackandthenfellthroughahole

mountainstream.Annaslidacrossitonherbackandthenfellthroughaholeintothewater.Herheadandchestbecametrappedbeneaththefrozensurface.Herclothesbegantosoak,theirextraweightcarryingherdeeper,draggingherdownstreamwiththecurrentandfartherbeneaththeice.

TorvindandMariearrivedatthespotjustintimetograbherskiboots,stoppingherfromvanishingunderthelipoftheice.Annawaslyingfaceupwithhermouthandnoseoutofthewaterinanairpocket.Shecontinuedtostruggle,freezing,intheArcticstream.

Noneofthethreecouldhavebeeninanydoubtabouttheseriousnessofthesituation.Annawastrapped,herclothessoakedwithice-coldwater,thestreamcarryingheatawayfromherbody.Eveninthosefirstminutes,hercoretemperaturewasbeginningtoplunge.Torvindcalledforhelponhismobilephone,explainingthelife-and-deathpredicamenttothedispatcher.Asdoctors,Torvind,Anna,andMariehadmanyfriendsandcolleaguesintherescueservices—thedispatcheramongthem.Firminthefaiththattheywouldmakeeveryefforttoexpediteanemergencyrescuehelicopteroramountainrescueteam,TorvindreturnedtohelpkeepAnnafromslippingundertheice.

ButafterwhatseemedtoTorvindlikeaninterminableageofwaiting,herangthedispatcheragain,thistimedemandingtoknowwhynobodyhadyetarrived.“Yes,Torvind,”camethereply,“wearetryingashardaswecan,butyoumustunderstandittakesmorethanthreeminutestomakethesethingshappen.”ToTorvind,fightingforAnna’slife,threeminuteshadseemedlikeeternityenough.

Tworescueteamsweresent;onefromthetopofthemountain,onskis,andanotherfromthetownofNarvikatitsbase.Theskiteam,ledbyKetilSingstad,wasthefirsttoarrive,buttheywerelightlyequipped,andtheirsnowshovelwasn’tenoughtobreakthroughthethickcoveringofice.AlltheycoulddowaslasharopearoundAnna’sfeettohelpMarieandTorvindstopherfromslippingfartherbeneaththeice.

ASeaKinghelicopterhadalsobeenscrambled,buteventravelingatoverahundredmilesanhour,itwouldtakemorethansixtyminutestoreachthemandwouldtakeatleastaslongagaintoflybacktothenearestmajorhospitalinTromsø.

Fortyminutesafterbecomingtrapped,Anna’sdesperatethrashingstoppedandherbodywentlimp.Thehypothermia,nowprofoundenoughtoanesthetizeherbrain,wouldsoonstopherheart.

Anotherfortyminutespassedbeforerescuersfromthebottomofthemountainarrived,carryingwiththemamoresubstantialshovelwithapointedtipthatwasfinallyabletobreakthroughthecoveringofice.

tipthatwasfinallyabletobreakthroughthecoveringofice.Singstad,leadingthemountainrescueteam,wasalreadydeeplypessimistic,

believingthattheireffortsnowcouldonlysucceedinretrievingthebodyofadeadfriend.EightyminuteshadpassedsinceAnnahadfirstfallenintothewater,andherbodywaspulledclearofthestreamlimpandblue.Shehadstoppedbreathingandwaswithoutapulse.

Wecallwhatfollowsdowntime—theperiodfromthemomentofcardiacarrestuntilthepointatwhichspontaneouscirculationandbreathingcanberestored.Inthatinterval,theprocessofdyingbegins.

Beforethatcomesthecrash.Ifyourphysiologyhascrashed,theprocessesthatkeepyoualivehavestoppedworking.Whenconfrontedwithapatientincardiacarrest,you,asadoctor,arestaringatthewreckageofanindividual,hopingdesperatelythatsomethingcanbesalvagedfromthechaos.Frankly,it’saterrifyingfeeling.

Inanyemergencyroom,anyonesufferingcardiacarrestwhoarriveswithmorethanafewminutesofdowntimealmostinvariablydiesorispermanentlydisabled.Mytimeasanewlyqualifieddoctorispepperedwithmemoriesofpoundingdownhospitalcorridorsinthemiddleofthenightansweringthecrashcall:thatterrifyingscreechfromyourpageraccompaniedbyaburstofstaticandavoicetellingyouwhereyouinstantlyneededtobe.Theexperiencewasalwaysgrim.Ofthemanythousandsofpeoplewhosuffercardiacarresteachyear,onlyahandfulsurvivetoleavethehospital.TheoddsalwaysappearedsostackedagainstusandtheoutcomessopoorthatovertimeIbecamedeeplypessimisticaboutcrashcalls.Irememberaregistrar,seeingmydistressattheendofyetanotherfailedresuscitation,puttingacomfortingarmaroundme.“It’snotreallyresuscitation,youknow,”hesaid.“It’sjustafunnydancewedoaroundthedying.”

SoastheresuscitationeffortbeganonAnna’sbodyintheshadowofthoseNorwegianmountains,thechallengeshefacedlookedinsurmountable.ShehadalreadybeenwithoutapulseforfarlongerthananyofthepatientsI’deverrushedtoattendonhospitalwards.Hercoretemperaturewasnowperhapsmorethan20°C.(36°F.)lowerthanitshouldhavebeen.

Torvindinsistedthattheycontinuetheirresuscitationattempts.JustbeforeeightP.M.,morethananhourandahalfafterfirstfallingintothestream,AnnawaswinchedontotheSeaKing.Aboardthehelicopter,movingatspeedacrosstheNorwegianlandscape,thestruggletosaveAnna’slifebecameadesperatescramble.Theartofresuscitation,ifyoucancallitthat,isdifficultevenunder

idealcircumstances.Helicopters,withtheircrampedconditions,deafeningnoise,andvibration,areamongthemostdifficultplacesinwhichtotrytowork.

Once,whentransferringanunstable,criticallyillpatientbyair,Iaskedthepilotwhattheaircraftprotocolswereifthepatientneededresuscitatingmidflight.“Justmindthedoors,”hesaid.“It’susuallybadifyoufallout.”

Thekeytogoodresuscitationistokeepthebloodsuppliedwithoxygenandmovingaroundthebody.Thisisachievedbybreathingforthepatients,ventilatingthemartificially—literallypumpingoxygenintotheirlungs—andthencompressingthechestrhythmicallytoprovidesomethingapproximatingacirculation.Noneofthisisanythinglikeasefficientoreffectiveasthebody’snativeheartbeatandbreathing,butitbuystime.Inprinciple,itsoundsprettystraightforward;inpractice,thereisperhapsnothingthatadequatelydescribesthesickening,repetitivecrunchofribsbeneaththeheelofyourhandortherisingsenseofdesperationyoufeelastheminutestickby.

—WHENTHEYTOUCHEDDOWNatTromsøUniversityHospital,Anna’shearthadnotbeatenforatleasttwohours.Hercoretemperaturewasmeasuredat13.7°C.(56.7°F.)—23°C.(42°F.)belownormal,andloweratthatpointthananysurvivingpatientinrecordedmedicalhistory.Thiswasgenuineterraincognita.AnyfurtherattempttoresuscitateAnnacouldproceedonlyintheknowledgethatinsimilarsituationspastmedicalteamshadalwaysfailed.

Itisoftenhardtoknowhowtoactinthebestinterestsofyourpatients,evenwhentheycantalktoyouandtellyouwhattheywant.Inthemidstofresuscitation,facedwithanunconscious,dyingpatient,youhavetotrytoimaginewhatthepersoninfrontofyouwouldsayifshecould.Itisahorriblydifficultcalltomake.Yourinstinctasahumanbeingistocarryonforaslongasthere’sachanceofsurvival,howeverslim.Butyourthoughtsasamedicalprofessionalaredifferent;thereareharshrealitiestoface.Underordinarycircumstances,theprognosisishorriblybleak.Evenpatientswhoseheartsaresuccessfullyresuscitatedcanhavepermanentanddisablingdamagetotheirbrainsbecauseofoxygenstarvation.

ButtheteamatTromsødecidedtocontinue.DespitetheamountoftimethathadpassedsinceAnna’shearthadstopped,therewasstilltheglimmerofahopethattheterriblecoldmightalsohaveprotectedandpreservedherbrain.

MadsGilbert,theanesthetistleadingtheresuscitationeffort,movedAnnadirectlytotheoperatingroom.Heknewthatraisinghertemperatureatthispointwasgoingtobeamassivechallenge.Warmblanketsandheatedroomsalone

wasgoingtobeamassivechallenge.Warmblanketsandheatedroomsalonewouldn’tbeanythinglikeenough.Raisingthewholebodythroughallthosemissingdegreeswouldtakeanenormousamountofenergy—equivalenttotheboilingofdozensofkettlesofwater.TodothisquicklyandwithoutharmingAnnaintheprocess,Madsknewshewouldhavetobeestablishedonaheart-lungbypassmachine,thesortofdevicenormallyreservedforopen-heartsurgery.Byremovingherchilledblood,circulatingitinthebypassmachine,heatingandthenreturningittoAnna’slifelessbody,theycouldraisehercoretemperaturerapidly.Atleastthatwasthetheory.

Theywastednotime.Thirtyminutesafterbeingestablishedontheheart-lungbypassmachine,Anna’scoretemperaturehadmorethandoubled,reaching31°C.(87.8°F.).Theheartitself,itsmolecularmachinerynowwarmenoughtoworkagain,stutteredatfirst,unabletoregainitsownessentialrhythm.Buteventuallyelectricityonceagainbegantoflowthroughthemuscleofherheart,andthiswasfollowedbywavesofcontraction.

AlittleaftertenP.M.,itstartedtobeatindependentlyforthefirsttimeinatleastthreehours.Thatfirstexplosivebeatwascapturedonfilminanechocardiogram.

Duringtheresuscitation,theteamhadtoplaceacentralline,athintubeinsertedintoamajorbloodvessel,allowingthemtogivefluidanddrugsmoreeasily.Todothis,theyfirsthadtopassaneedleintoherchest,aimingforatargetveinwhosediameterwasnomorethanafractionofaninch.Itisatrickyfeattopulloffatthebestoftimes.Yourelyuponyourknowledgeofanatomyandasteadyhand.Butlyingnexttothatveinisalargepulsatingarterythat,astheytellyouinmedicalschoolwithawrysmile,isalwaysbestavoided.

Butthefightwasfarfromover.DuringthescrambletosaveAnna’slife,theteamhaddamagedthatarteryand,hiddenjustbehindhercollarboneontherightsideofherchest,itbegantobleed.Hereagainthecoldconspiredtokillher.ThehemorrhagethatfollowedwasmadefarworsebyAnna’shypothermicstatebecausebloodlosesmuchofitsabilitytoclotatlowtemperatures.Havinglaboredsohardtosaveherlife,theteamnowfacedthepossibilitythatshewouldbleedtodeath.

Theytransfusedblood,platelets,andclottingfactorsinanefforttoreplacewhathadbeenlostandencourageherbloodtocoagulateoncemore.Cardiothoracicsurgeonsthendecidedtoopenherchest,finallyallowingthemtoisolatethebleedingarteryandstopthehemorrhage.Afterhoursofworkbydozensofpeople,shewasfinallystableenoughtobetransferredtotheintensive-careunit.

Oncethere,herlungsfailed,andtomaintainthelevelsofoxygeninherbloodstream,theteamwasforcedtotakethedrasticstepofestablishingheronadevicethatcouldoxygenateherbloodoutsideherbody,whichfunctionedlikeabypasscircuitforherlungs.Herkidneysalsofailed,andtheirfunctiontoowasreplacedartificiallybyyetanothermachine.

Miraculously,Annasurvivedeventhis,openinghereyesforthefirsttimeafterjusttwelvedays.Butshefoundherselfparalyzedfromtheneckdown,wakingalivebutquadriplegic.Latershegrewangry,askingthedoctorsatTromsøwhytheyhadbeensodeterminedtokeepheralive.Togetherthecostsofherhelicopterrescue,resuscitation,andadmissiontotheintensive-careunitaddeduptomanytensofthousandsofdollars.Allofthiswasdoneforawomanwhoawokealivebutwithabodythatnolongerappearedtowork.Thiswasthebestthatanyonemighthavedaredhopefor,givenhowcoldshe’dbeenandhowlongshe’dgonewithoutapulse.Hadtheirendeavorstrulybeenworthit?Shouldtheyhaveproceededwiththeresuscitationatall?

ButAnna’sparalyzedbodydidnotremainthatway.Itwasn’tanirreversibleinjurytoherspinalcordthatleftherunabletomove,asissooftenthecaseaftertraumaticinjuries.Itwasinsteadherperipheralnerves,damagedbytheextremesofcold,whichhadfailed.Slowlybutsurelythesenervesandherflaccidmusclesbegantorecoverandregaintheirfunction.

Thenervesrecoveredmostslowlyinherextremities.Initiallyshecouldnotuseherarmsandlegsatall.Thoughaftersixweeksshewasreadyfordischargefromthehospital,shecouldnotgohome.Annaspentanotherfourmonthsinarehabilitationunit,slowlygrowinginstrengthandlearninghowtomoveoncemore.Itwasaslowprocess,buteventuallyshewasabletogohome.Medicinehadbroughtherthisfar,andwhereitstopped,herdeterminationhadtotakeover.

Itwouldultimatelytakesixhardyearsofrehabilitationinall,buteventuallyAnnawaswellenoughtoskiagain,wellenoughtoreturntocompletehertrainingasadoctor.EventuallyshespecializedinradiologyandnowworksinTromsø,atthehospitalthathaddaredtosaveherlife.

—ANNABÅGENHOLMISanextraordinarysurvivor.Doctorsexploitedherprofoundhypothermiatosuccessfullyresuscitateheragainstseeminglyimpossibleodds.Whilehersurvivaloccurredinthecontextofanaccident,othershavebenefitedfromhypothermiabydesign.

EsmailDezhbod’ssymptomshadbeguntoworryhim.Hefeltpressureinhis

EsmailDezhbod’ssymptomshadbeguntoworryhim.Hefeltpressureinhischest;attimesgreatpain.Visitingthedoctordidnothingtoallaythosefears.Afteraskinghimsomequestions,hisdoctorgavehimaphysicalexaminationandorderedabodyscantoinvestigatethestructureswithinhischest.Thepicturesdidn’tlie:Esmailwasintrouble.Hehaddevelopedananeurysmofhisthoracicaorta,aswellingofthemainarterialtributaryleadingfromhisheart.Normallynomorethan1.2inchesindiameter,thisvesselhadmorethandoubledinsize,tothewidthofacanofCoke.Withthisswellingcametheriskofrupture.Thegreaterthediameterofthevessel,thegreatertheriskthatitswallmightsuddenlytear.Theconsequenceswouldbecatastrophic.Esmailhadabombinhischestthatmightgooffatanymoment.Aneurysmselsewhereinthebodycanusuallyberepairedwithrelativeease.Butinthislocation,soclosetotheheartitself,therearenoeasyoptions.Thethoracicaortacarriesbloodfromtheheartintotheupperbody,supplying,amongotherthings,thebrain.Torepairit,theflowwouldhavetobeinterruptedbystoppingtheheart.Atnormalbodytemperaturesthisandtheaccompanyingoxygenstarvationwoulddamagethebrain,leadingtopermanentdisabilityordeathwithinthreeorfourminutes.

YetforEsmailtosurvive,therepairhadtobedone.Hissurgeon,theleadingcardiacspecialistJohnElefteriades,decidedtocarryouttheprocedureunderconditionsofdeephypothermicarrest.Heusedaheart-lungbypassmachinetocoolthebodytoamere18°C.(64.4°F.)beforestoppingtheheartcompletely.Then,whiletheheartandcirculationwereatastandstill,Dr.Elefteriadesperformedthecomplicatedrepair,racingtheclockwhilehispatientlaydyingontheoperatingtable.

—ONTHEDAYOFTHEOPERATION,Iwastheretowatchthisremarkablefeatofsurgery.ThoughDr.Elefteriadesisanoldhandwiththetechniqueofdeephypothermicarrest,everytimefeelslikealeapoffaith.Oncethecirculationhascometoastandstill,hehasnomorethanaboutforty-fiveminutestocompletetherepairbeforeirreversibledamagetothepatient’sbrainoccurs.Withouttheinducedhypothermia,he’dhavejustfour.

StandingintheoperatingroomandmarkingthemomentatwhichEsmail’scirculationcomestoastopisasoberingexperience.Atthispoint,nothingissupportinghim:nodrugs,nomachines,nobypasscircuit.Esmail’sphysiologyiscrashinginslowmotion.Upuntilnow,thesurgeryhasproceededinarelaxedfashion.Knifeinhand,paringawaythetissuesaroundtheheart,Johnhaschattedawayasifhe’sdoingnothingmoretaxingthandrivingtothesupermarket.Thatdemeanorchangesatthemomentofcirculatoryarrest.Now

supermarket.Thatdemeanorchangesatthemomentofcirculatoryarrest.Nowthere’snotimeforsmalltalk.

Thehandsoftheclockonthewallswingaround;thedigitaltimercountsofftheminutesandseconds.Johnlaysdownthestitches,elegantlyandefficiently,makingeverymovementcount.Hehastocutoutthediseasedsectionofaorta,alengthofaroundsixinchesorso,andthenreplaceitwithanartificialgraft.Tothishemuststitchothertributariessupplyingthebrainandupperbody.AndallthewhileEsmailisdying.

TheelectricalactivityinEsmail’sbrainis,atthispoint,undetectable.Heisnotbreathingandhasnopulse.Physicallyandbiochemicallyheisindistinguishablefromsomeonewhoisdead.Itseemsimpossibletobelievethathemightbesuccessfullyresuscitatedfromthisstateandgoontobethemanhewasbefore.

Yetafterthirty-twominutes,therepairiscompleteandDr.ElefteriadesisreadytoreestablishEsmail’scirculation.Theteamwarmshisfreezingbody,andveryquicklyhisheartexplodesbackintolife,pumpingbeautifully,deliveringafreshsupplyofoxygentoEsmail’sbrainforthefirsttimeinoverhalfanhour.

Adaylater,IvisitEsmailontheintensive-careunit.Heisawakeandwell,evenifhe’sinalittlepain,andhiswifestandsbyhisbed,overjoyedtohavehimback.

Tocurethisman,hissurgeonshadtocomeclosetokillinghim—usingprofoundhypothermiatobuyhissurvival.Esmailislivingproofthatphysicalextremescancureaswellaskill.

—THEREISANOTHEREXTREMEthatwehaverecentlybeguntoexplore,definednotbyenvironmentalconditions,likeScott’sAntarctica,butbydiseaseandinjury.Modernintensive-caremedicinehangsordinarypeopleoutattheverylimitsofendurance,toendureperilousderangementsinphysiology,withtheexpectationthattheymightsurviveandgoontoleadnormallives.Lifeattheextremescanbelifesaving.

Evolutiondidnotprepareusforlifeattheextremes.Onlyengineeringandtechnologyallowustocheatourenvironmentandourbiologicalfate—andthenonlytemporarily.Oneofthequestionsthisbookwilladdressiswhethertechnologyemboldensusbeforeweunderstanditsconsequences.ThinkagainofthatmedicalteamheatingAnnaBågenholm’schilledbloodandpumpingitbackintoherbody,withonlytheslimmesthopethatshewouldsurvivetoleadanormallife.Perhapswehavenobusinesspushingtheenvelopeafterall.Perhaps

normallife.Perhapswehavenobusinesspushingtheenvelopeafterall.Perhapswehavefinallygonetoofar.

ButAnnadidmakeacompleterecovery.Sheowesherlifetoscience,technology,andmedicineandtoanunderstandingofthebiologyofdeephypothermiathatisasyoungassheis.Sogoesthestoryofourexplorationoftheextremetolerancesofthehumanbody.Itisastoryoftragiclossandoutrageoussurvival,ofquestionsaboutlifeanddeathandanattempttounderstandwhatliesinbetween.

Withinacentury,wehavecometounderstandtheprocessthatkilledScott.Morethanthat,weovercameitandlearnedtouseittoouradvantageinmedicine.Theinterveningdecades—betweenScott’sheroicdeathandAnnaBågenholm’sremarkablesurvival—sawprogressinthefieldofmedicineunparalleledinanyothercentury.Flyingambulances,systemsfortheadvancedmanagementoftraumaticinjuries,theartificialcocoonofintensivecare,techniquestobypassandreplacethefunctionofthehumanheart—allofthesewerenecessarytoallowAnnatosurviveaninsultthatScottcouldnot.Buteachofthoseinnovationsarosebyaccident,theproductsofother,unrelatedchallenges.Therewasnograndschemethroughwhichwearrivedatthispointinhistorywithsuchhighexpectationsoflifeanditssurvival.Inmedicineandphysicalexploration,wemovedforwardintotheunknownalwayshopefulthatgoodfortuneandsurvivallayinstore.

—INTHEEND,SCOTT’SEXPLORATIONaboardtheTerraNovawasn’tinvaineither.Theexpeditionthatheledwasn’tthefirsttoreachtheSouthPole,butitwasonewithanimportantscientificlegacy.Itlaidthefoundationsforthedisciplineofglaciologyandfoundfossilspecimensthatwouldlaterpointtoanincredibletruth:Thesoutherncontinentsoftheworldhadoncebeenlinkedtogetherasasinglelandmass.ThepenguinskinscollectedbyScott’scompanionsApsleyCherry-Garrard,EdwardWilson,andHenryBowersontheirinfamous“worstjourneyintheworld,”atrekacrosstheRossIceShelftoapenguinrookery,providedabenchmarksamplethatwouldlaterhelpscientistsestablishthepersistenceandbioconcentrationofDDTinsecticideafteritsintroductionintotheglobalfoodchaininthetwentiethcentury.

Scott’sexploitsaboardtheTerraNovaweretohavebeenthecrowninggloryofatriumvirateofexpeditionsthatincludedScott’sfirstvoyagetoAntarcticaaboardtheDiscoveryin1902andShackleton’sNimrodexpeditionin1907—endeavorsthatwereinstrumentalinopeningupthecontinentofAntarcticato

science.Scottmayhavedied,butwhatheandhisexpeditionteamstartedattheturnofthetwentiethcenturyintimebecameawiderprogramofscientificresearch,oneoffundamentalimportance.

Bythemiddleofthecentury,thescientificsurveyteamsofseveralnationshadestablishedaplethoraofpermanentlymannedbasesinAntarctica.In1985,observationsbytheBritishAntarcticSurveydetectedthethinningoftheEarth’sozonelayeraroundtheSouthPolarregion:theso-calledozonehole.Ozoneinouratmosphereabsorbsultravioletradiation,protectingusfromitsharmfuleffects.Thisdiscoveryandthelaterrealizationthatozonedepletionwasbeingcatalyzedbyhalogenatomsinchlorofluorocarbons(CFCs)ledtoaninternationalbanonthesesubstances.

Bytheendofthecentury,thesemultinationalscientificeffortsinAntarcticadeliveredsomeofthemostconvincingevidencethatglobalwarmingisarealphenomenon.Scott’sracetotheSouthPolebeganasanexploratoryeffortintotheunknownforwhichhepaidwithhislifeandthelivesofhiscoreteam.However,thelegaciesofScott’sexplorationarediscoveriesthatmightonedaysaveourentireplanet.

Thatisthetruthofallexploration—inscienceorthephysicalworld.Wedonotclimbmountains,traipsetopolaricecaps,splitatoms,orunravelgenomessimplybecause“theyarethere”butbecauseweknowthatitiswithintheunanticipatedfruitsofexplorationthatourimprovedsurvivallies.

Scott’sexpeditionmarkedthebeginningoftheendoftheso-calledHeroicAgeofexploration.TheVictorianconceptofriskingallforhonorandthegreatergloryofGodandcountrywascastintosharpreliefbythecatastropheoftheGreatWar.Aneweraofexplorationwasborn,onethatreliedlessuponthemettleofmenandmoreuponthesystemsofprotectionthatwewereabletoengineertoprotectthem.ItisworthnotingthatafterScottandAmundsen’spartiesfirstarrivedattheSouthPolein1912,nohumansetfootthereagainuntil1956.Andwhentheydid,theyarrivednotinsledsdrivenbyponiesordogsbutinaircraft.

—TORVIND,ANNA,ANDIarewalkingalongMortimerStreet;theyhavebeenlecturingabouttheirexperiencestoanaudienceofdoctorsattheRoyalSocietyofMedicineinLondon.Theyfeelthatthisretellingofthestoryisimportanttochangepeople’spracticeandexpectationsinthefaceofsuchextremehypothermia.

ThereisaquestionImustaskAnna.Ifshe’dhadthechoiceatthetimeofher

ThereisaquestionImustaskAnna.Ifshe’dhadthechoiceatthetimeofherresuscitationatTromsø—giventheextraordinarilylongperiodforwhichherhearthadbeenarrested,knowingthattheoverwhelminglylikelyoutcomewouldhavebeendeathoralifetimeofdisability—wouldshehavechosentolettheteamproceed?

“Yes,”shetellsmeafterashortpause,“becauseyouneverknow.”WecontinueourstrollthroughLondon.Thereisapointwherewateris

rushingfromwhatlookslikeaburstwatermain,flowingacrossthepavingstones.Annaquickensherpace,breakingintoajog.Foramoment,Iwonderifthisisoneofthoseunexpectedaversionsthatdevelopafteratraumaticevent.Shewas,afterall,trappedundertheice,sinkingintorunningwater.Torvindsaysnothing.Perhapsit’ssomethinghe’sseenbefore.Iamintrigued,brieflyhorrified,thatthismightbeasignofvulnerabilityorweakness.

Iamstillponderingthiswhenataxirunsthroughthesizablepuddlethathascollectedinthegutter,drenchingmyfeetandtrousers.AndIrealizethat,aftershewasentombedandfrozeninanArcticstreamandenduredthelowestrecordedtemperatureofanycardiacarrestsurvivorinmedicalhistory,theonlyreasonAnna’srunningisbecauseshe’ssmarterthanme.

SecondWorldWarburnvictimsattheQueenVictoriaHospitalinEastGrinstead.Thestripsoffleshusedforsurgicalreconstructionoftheirfaceswerekeptalivebyanchoringthemtobloodsuppliesattwo

locations.Forthesementheskinwasbridgedtothefacefromtheforearmorchest.(ReproducedbykindpermissionoftheGuineaPigClub)

HFIRE

owmuchofthathastogointhevehicle?”asksthepilot,pointingatthemassoftubes,cables,monitors,andmachinesthatsurroundmypatient.

“Allofit,”Itellhim.Theintensive-caresideroomlookscramped.Itscontentsmustsomehowbetransferredtotheroofofthehospitalandcrammedintothebackofamedical-evacuationhelicopter.

Thepilotsucksairthroughhisteeth,doingthementalarithmetic.It’sawarmday;theairisthin.Hisenginescangenerateonlysomuchlift.Themoreweightwehavetocarry,theshortertherangeofthehelicopterandthemorehazardousthetakeoff.

“Howmuchhastobeinthecabinwithus?”heasks.“Allofit,”Irepeat.Moreair-suckingsounds.“Howmuchdoyouweigh?”heasks,lookingmeupanddown.“About155pounds,”Itellhim.“Howabouther?”hesays,noddingindelicatelyatthenurse.Themaninthebedbeforeuswascaughtinahousefireandisbadlyburned.

Thetraumateamestimatesthatperhapsthefullthicknessofskinoverasmuchas50percentofhisbodyhasbeendestroyedbyfire,thoughit’shardtobesure.Underneaththecharandtheblisters,itisdifficulttoknowwhatremainsviable.Timeistickingby.Keepinghimstablehastakenallourefforts,andweareattheendofwhatwecanofferhereinthisgeneralintensivecareward.Togivehimthebestchanceofsurvival,heneedstobemovedtoaspecializedburnunit.

Wepourfluidintohisveins,tryingtokeepupwiththemassiveevaporativelossescausedbytheabsenceofskincover.Proteinisleakingfromhisvesselsintohistissues;theosmoticpressureistakingmorefluidwithit.Thealveoliofhislungsarefillingasaprotein-richslush—leakingfromhisbloodvessels—exudesintothem.Thosetiny,all-importantsacs—whichallowairtobebrought

exudesintothem.Thosetiny,all-importantsacs—whichallowairtobebroughtintocontactwithbloodandoxygentobeexchangedforcarbondioxide—arebecomingwaterlogged.Thingswillgetworsebeforetheygetbetter.Wemustmovenow.Tomorrowhemaybetoosick.Buttheclosestspecialistbedismorethantwohundredmilesaway,toofarforasaferoadtransfer.We’llneedanaircraft.That’swhythehelicopterpilotishere,stilldoingsumsinhishead,weighingbenefitagainstrisk,asthepatientslowlydrownsinhisownjuices.

—WEDONOTTHINKOFSKINasanorganintheconventionalsense.Itlacksthesolidityandthediscretelocusofthemorefamiliarviscera.Thatelasticbutporouscoveringstretchedoveryourframe,foldsoffleshandimperfectionsthatyouknowwellenoughtotakeforgranted,fulfillsanessentialtask.Itisnolessimportanttoyourcontinuedsurvivalthanaheartorapairoflungs.

Itistemptingtothinkofskinasifitweresimplyabarrier,alineofseparationbetweenyouandtheworldoutside,aconvenientwayofpreventingyourvisceraandtissuesfromsloshingaboutinanunsightlyway.

Itdoesindeedprotect,butasadescriptionofpurposeandfunction,thatisthegrossestofunderstatements.Itdoesmuchmorethanactasabulwarkagainsttheabrasiveworldoutside:Itisthefirstlineofdefenseagainstthemicrobialhordesmassingonitssurface;itpreventstheexcessiveevaporationofthebody’spreciousfluids;itharborsanexquisitelysensitivearrayofdetectorsthatwarnusofharmandallowustorespondfastenoughtoavoidfurtherinjury;anditthermoregulatestokeepuswarmwhenitiscoldorcoolusdownwhenitishot.

Skinisdeeperthanyouthink;insomeareasofthebodyitisuptoafifthofaninchthick.Thestuffatthetopisdead,akeratinizedlayerthatservesthepurposeofphysicalprotection.Belowthatlayerisliving,moisttissuethatneedsnutrientsandabloodsupplyandisvulnerabletoattackandinjury.

Ifyoutakeamicrofinesliceverticallythroughskinandexamineitunderamicroscope,youcanseethecellularstructureofitslayers.Thespecimensmustbestained,otherwisethecellsarelargelyclearandcolorless.Thisishistology,thestudyofthemicroscopicanatomyofcellsandtissues.

Inmyfirstyearatmedicalschool,Ispentmanyhoursstaringintomicroscopes,tryingtomakesenseofwhatappearedtobelittlemorethanwashesofpinkandpurpleabstractart.Attheendofthecourse,weweresupposedtobeabletoidentifyanynumberoforgansandtissuesfromtheirmicroscopicappearancealone.Itwasliketryingtoidentifydifferentnations

fromclose-up,unlabeledphotographsoftheirfieldsandpavements.Sittinginlongrowsalonglaboratorybenchesstackedwithmicroscopes,westrainedoureyestolinkthelecturer’selegantverbaldescriptionstothepurplemessvisiblethroughtheeyepiece.Someoftheslidematerialwaspinkwithwavystrands,likestreakybacon,andwewereassuredthatthiswasaperfectlyacceptabledescriptivetermforthattissue.Intime,andwithalittlehelp,theunderlyingstructurebegantomakesense—thoughnottoeverybody.Oneofmycolleaguesfamouslyfailedthefirst-year,one-hourhistologyexam,havingwrittenonlythedesperatewords“Italllookslikebacontome!”

Whenyoufinallygetyourbearings,youcanseethattheskinisorganizedintodistinctstrata.Thetopmostlayer,theepidermis,formsthetoughbarrierwithwhichwefeelsofamiliar.Thecellsoftheepidermisaredenselypackedandfurthersubdividedintolayers.Thebaselayerconsistsofstemcellsthatboastlargepurple-stainingnuclei.Thesecellsmature,eventuallylosingtheirnucleiandacquiringfilamentsofkeratin,makingthemmorerigid.Astheydevelop,theyascendthroughtheepidermallayertowardthesurface,finishingatthetoptoformatoughprotectivelayerofdeadcells.

Thatlayertendstoreinforceourimageoftheepidermisasadurablebutpassivebarriertotheoutsideworld.Yetitisanythingbutpassive.Thelayersofepidermalcells,constantlybeingbornandmarchingforward,arelikeanever-endingconveyorbeltoffootsoldiersthrowingthemselvesatthewire.Theymountaspiriteddefense:Theycreateadryandacidicenvironmenthostiletobacterialgrowth;theirtentaclelikeappendagesseekoutanddestroyforeignbacterialcells,andtheysecreteenzymesandfattychemicalstofurtherdeterwould-becolonists.Thefightatthesurfaceisfierce—awaragainstperpetualmechanical,chemical,andbiologicalattack.Consequentlytherateofattritionamongthesecellsishigh.Forasingleepidermalcell,thatjourney—frombirthinthebasallayertocombatmaturityonthesurfaceoftheepidermis—takessomethinglikesixweeks.Therateofreplacementmustmatchtherateofloss,andtheentireepidermallayerturnsovereveryforty-eightdays.

Buttheepidermis,thelayerthatwecasuallyrefertoasourskin,representsonlywhatwecansee.Theepidermallayerisrelativelyuniforminappearance:stacksofpurple-stainingpolyhedralcellstoppedbyapalerweaveofpink.Beneaththisthereisthedermis,whichunderthemicroscopelookslikeaverticalsectionthroughachaoticallyplantedvegetablegarden.Therearemicroscopicstructuresherethatlooklikethecutsurfacesofonions.Thatbaconlikeconnectivetissueisfoundhere,dottedwithstrange-lookingwhorls,bloodvessels,andtubes.Heretheskinbecomesmorerecognizableasanorgan,run

vessels,andtubes.Heretheskinbecomesmorerecognizableasanorgan,runthroughwithanetworkofglandsandvesselsandstuddedwithorganelles.Itisfromthislayerthattheskinderivesbothitselasticityanditssupplyofbloodandnourishment.

Togethertheepidermisanddermisformawaterproofbutbreathablelayer.Theyhaveporesthataresmallenoughtopreventingressofwaterdropletsbutlargeenoughtoletmoleculesofwatervaporout.Gore-Texclothingattemptstodothesamething,butasabreathableandwaterproofbarrier,itachievesonlytheverypalestimitationofskin.

Butitisthesensoryarraythatisperhapstheskin’smostremarkablefeature.Abletoresolvepointcontactslittlemorethanamillimeterapart,it’scapablenotonlyofregisteringheatandcoldbutalsoofdifferentiatingbetweenalover’scaressandpainfromaneedletip.Yourskinishonedtoprovideaseriesofeverchanginginputsinresponsetothecruelworldoutside,andtheseinputsshapeyourbehaviorinsuchafundamentalwaythatyouarebarelyawareoftheprocess.

Thatholidayinthesunthatyouseek,thesensationofwarmthonyourskin,isinpartaproductofthepatternofreceptorsthatactivateinresponsetoincidentradiation.Thinkofsummer;thinkofwinter;thinkofplungingheadlongintoapoolofwater.Chancesarethatthefirstthingthatentersyourmindisthatinexpressiblepatternofskinreceptoractivationthatweinterpretaswarmth,cold,orwetness.

Theclothesthatyouarewearingrightnowareinpartchosenbecauseofthewaytheyfeelonyourbody.Thereceptorsinyourskinhelpyoudecidetomoveawayfromdrafts,causeyoutoretreatfromtheroarofthefire,orurgeyoutogetoutofachillypoolofwater.Fewsights,odors,orsoundscouldcompelyoutobehavequitesourgently.

Considerthisfinelytunedearly-warningsystemlinkedtoaconsciousnessthatunderstandsbothluxuriouspleasureandintensepain.Thenimaginesettingitonfire.

—THOUGHPAINFUL,superficialburnsinvolvingonlytheepidermisarelittlemorethanthat.Reddenedbythedilationofbloodvesselsbeneathandtheinflammationofthetissues,theyarerapidlyhealedandrestoredbytheperpetualmarchingofthoseregeneratingepidermalcells.

Evenburnsthatextendbelow,intotheuppertwothirdsofthedermis,retaintheabilitytohealandcoverwithnewskin.Apatchinjuredinthiswaygeneratesislandsofnewepidermalcellsthatspreadandeventuallycoalesce,replacing

islandsofnewepidermalcellsthatspreadandeventuallycoalesce,replacingwhatwaslost.Theseburnsleavethebulkofthesensoryarchitectureintactandareexquisitelypainful.Damagetothetissuearoundpainreceptorsleavesthemconstantlyfiring.Inflammation—theprocessthatmarshalscellsofthebody’sdefensestofightinfectionanddealwithinjury—retunesthepainreceptors,makingthemhypersensitive.Thesameprocessbringsfluidintothewound,whichproducestheblistered,weepingappearance,separatinghealthytissuefromthatwhichisdeadorirreversiblyinjured.

Ittakesgreatefforttosurviveaseriousburn.Certainlytheyareamongthemostformidableinjuriestomanageinemergencymedicine.Afterdeterminedandskillfulresuscitation,specialistburntreatmentmustfollow.Thiscareiscomplex.Inadditiontorepairingandreplacingdamagedskin,itmustalsoaccomplishthedifficulttaskofcompensatingforthefailureofanessentialorgan.

—THEMANWEARETRYINGtocramintothebackofthathelicopterhasalreadybeentheobjectoffrenziedmedicalattention.

Burnedlarynxescanswellandocclude;smokeinhalationcanpreventthelungsfromexchangingoxygenandcarbondioxide;andpoisonousgases—carbonmonoxideandfumesfromburningfurnitureandbuildingmaterials—canasphyxiate.Allofthesewillkillvictimsoffiresinminutesorevenseconds,longbeforetheconsequencesofanyexternalburninjurycanmanifest.

Yetiftheopeningminutesoftheinjurycanbesurvived,thedamagetotheskinleavesaformidableconstellationofproblems.Thevaporbarrierfunctionislost,andthebody’swaterevaporatesuncontrollablyfromdenudedbodysurfacesataratethatisdifficulttoanticipateintuitively.Thelossesarebothinvisibleandincrediblyrapid.Withoutthecoverofskin,yourbodydehydratesassurelyasawetspongeleftoutinthesun.Andtheburnitselftriggersasevereinflammatoryresponseinthebody,compromisingtheintegrityofthebloodvessels,makingthemmoreporousandpermeable,lettingthemspillfluidintosurroundingtissues.

Suchistheseverityofthisreactionthatatthestartofthetwentiethcentury,victimswithaslittleas10to20percentfull-thicknessburnsoverthesurfaceareaoftheirbodywouldoftendie.

Thankfully,thathaschanged,butwhenitcomestoburns,theextentofthesurfaceareainvolvedremainsoneofthekeyprognosticindicators.Inthecareofburns,weweretaughtaruleofthumb:thepercentageareaofbodyinvolvedina

burns,weweretaughtaruleofthumb:thepercentageareaofbodyinvolvedinafull-thicknessburnplustheageofthepatientgavethepercentagechancethatthepatientwouldnotsurvive.Asixty-year-oldmanwithfull-thicknessburnsover40percentofhisbody,forexample,wouldnotbeexpectedtolive.Todaythatisanoutmodedconcept;olderpeoplewithmoreextensiveburnsaresurvivingagainstexpectations,dueinlargeparttotheeffortsofspecialistburnunitsandthehard-wonlessonsofthetwentiethcentury.Aggressiveresuscitationwithfluids,traumasystems,andearlytransfertospecialistunitsallhelpedtoimprovesurvivalrates.

Butin1940themedicalfraternityknewlittleornothingofallofthis.ForapioneeringgenerationofRAFfighterpilots,immolationwasarisktheytookeverytimetheyclimbedintothecockpit.It’stheirexperiencesthathaveshaped—andcontinuetoshape—thescopeandambitionofburntreatmentstothisday.

—ONAUGUST31,1940,theBattleofBritainwasreachingacriticalphase.TheLuftwaffewasmercilesslybombingtheRoyalAirForce’sairfields.FighterCommandwaslosingaircraftfasterthantheycouldbereplaced,andtheremainingpilotswerefatigued.ThroughoutthesouthofEngland,fightersquadronshadscrambledtimeandtimeagaintomeetwavesofGermanbombersescortedbyMesserschmittfighterplanes.Intheheatofthatcombat,theairwasfullofglowingmunitionsandcrisscrossingaircraft.AtRAFKenley,ontheoutskirtsofSouthLondon,thirty-two-year-oldTomGleavehadtakenovercommandof253SquadronfromHaroldMorleyStarr,whohadbeenkilledthepreviousday.Despitetheever-presentdanger,Gleavestillfounditimpossiblenottobecaptivatedbythespectacleoftheworldasseenfromtheair.ScramblingfromKenleythatday,heclimbedquicklyintoaperfectlyblueskyanddazzlingsunlight.NorthofhimlaytheRiverThames,glitteringasitsnakeditswaythroughtheLondonsprawl;tohissouthhecouldmakeouttheKentcoastlineshimmeringinthesummerhaze.Below,unfurlingathundredsofmilesanhour,rolledthepatchworkquiltoftheEnglishHomeCounties.

HavingshotdownnolessthanfiveMesserschmitt109swhileonpatrolthedaybefore,Gleavewasinconfidentform.WithreportsofalargeformationofenemyaircraftconvergingtoattackBigginHillAirfield,GleaveturnedwithhissectionofthreeHurricanestoassistinitsdefense.

Plowingnorth,Gleavesearchedtheskyforevidenceoftheenemy.Suddenlyhefoundtheskyabovehimdarkwithaircraft:columnuponcolumnofJunkers88bombers.Heandhissectionremainedunseen,lessthanathousandfeetbelowandbeyondthem.

belowandbeyondthem.KeentopresstheattackbeforetheGermanturretgunnershadachanceto

fire,GleavepulledthenoseofhisHurricaneup,tookaim,andrakedthefifthbomberinthelinewithcannonshells.Thesmellofspentcartridgesfilledthecockpit;theHurricane’snosedippedwiththerepeatedrecoiloftheguns.Gleavepulledthecontrolcolumn,kickedhardontherudderpedal,turned,anddivedaway.Levelingout,hebegantoclimbagain,attackinganotherbomberintheformation.Forhisthirdpass,hedecidedhewouldtakeontheleadaircraft,whichhadalreadybegunitsdiveinpreparationforabombingrun.Butbeforehecouldmaneuverintoposition,heheardtheclickofaroundstrikinghisaircraftandfeltasuddenheatrisinginthecockpit.

Gleaveglanceddown.Flameswerepushingintotherightsideofthecockpitfrombelow;thefueltankburiedintherootofhisstarboardwingwasalight.HerockedtheHurricanehardandslippeditsidewaysinthevainhopethatthiswouldsomehowquellthefire.Buttheflamesonlygrewfiercer,wrappingroundhisfeetandclimbingtoreachhisshoulders.Plywoodandfabricburstrapidlyintoflamesaroundhim,acceleratedbyfuelfromthebreachedtanks.Inafewshortseconds,thecenterofGleave’scockpithadbecometheheadofablowtorch.Thealuminumsheetinwhichthedialsofhiscontrolpanelweresetbegantomelt.Buthewasfartoohightoditchtheaircraft;therewasnothinghecoulddobutattempttobailout.

Gleavewasstilltetheredtohisvehiclebytheoxygenmaskandradiocordattachedtohishelmet.Hereacheddowntoripthesefromtheirattachments,butthesearingheatbeathimback.Withhisarmsoutstretchedhecouldseetheskinofhishandsbubblingandcharring.Heunclippedhisharnessandtriedtoraisehimselffromhisseat,butcouldnolongerfindthestrength.Trappedwithhisplaneablazeandfallingfromthesky,Gleave’shandfelltothebuttofhisservicerevolverandmomentarilyheconsideredaquicker,lesspainfulend.

However,therewasonelastchance.Ifhecouldopenthecanopy,pitchtheaircraftforwardandflipitoverontoitsback,thenperhapsthemaneuverwouldflinghimout.Gleavetorehisflyinghelmetoff,severinghislastconnectionstotheHurricane.Heslidthecanopyopen,shovedthecontrolcolumnforward,andtheneverythingaroundhimexploded.

Hefoundhimselfpropelledformanyyards,envelopedinaballofflames,finallybreakingfreeintothinairandthentumblingtowardtheground.Hisburnedhandnowreachedagain,notforreleasesorarevolver,butfortheD-ringofhisripcord.

Findingit,hepulledhardandfelttheunfurlingofhisparachuteanda

Findingit,hepulledhardandfelttheunfurlingofhisparachuteandacomfortingtugasitssilkcanopyinflatedabovehim.TheroarofhisengineandthecockpitinfernohadbeenreplacedbysilenceandasereneviewoftheEnglishcountrysidethatoscillatedgentlyasheswungtoandfrobeneathhisparachute.

Hehitthegroundhardandfellontohisside,somehowmanagingtoavoidfurtherinjury.Releasinghisparachute,Gleaveeventuallyfoundthestrengthtogettohisfeet.Hisbootsandsocksappearedtobeintactandlargelyunburned.Butthatwaswherenormalityended.

Histrousershadgoneexceptforasmallpatchprotectedbytheparachuteharness.Abovehisankle,theskinoverhisrightleghadblisteredandballoonedalongitswholelength.Hisleftlegwasinmuchthesamestate,saveforapatchofskinoverhisthighwhichhadbeenrelativelyspared.Theundersideofhisarmsandelbowswereburned,andtheskinhungincharredfoldsfromhishandsandwrists.Hisheadandneck,too,hadbeenexposedtotheinferno,andhiseyeswerelittlemorethanslits.Hisnosehadbeenallbutdestroyed.

Somehowhestaggeredacrossthefieldtowardagateonitsfarside,shoutingforhelpashewent.“RAFpilot,”heblurtedout.“Iwantadoctor.”

—YOUCANJUSTABOUTBEARTOhangontoamugofhotteaat42°C.(108°F.).That’sjusttendegreeshigherthanyournormalcorebodytemperature.It’sprettyunimpressive,really,butthatiswherethelimitsofhumanendurancelie.Thesensationthatforcesyoutodropthecupissetinmotionbyacleverreceptor:aweaveofproteinsinthedermisattachedtoanion-channelcontrolthatopensorclosesdependingonhowhotthechannelis.Theproteinsconvertthesensationofheatintopain.

Foraspeciessoweddedtoexploration,suchamodestthermaltoleranceseemsstrangelylimiting.Buttheproteinsthatthatreceptorisbuiltfrom,andthosethatstacktogethertobuildeverythingfromyourdigestivetracttoyourDNA,starttofallapartat45°C.(113°F.).That’swherethephysiologyofthermalinjurystarts.Astemperaturesclimb,cellslosetheircapacitytoself-repair;vesselsbegintocoagulate,tissuesbecomeirreversiblyalteredandlaterbegintodie.Allofthishappensasyouapproachatemperatureofaround60°C.(140°F.).

Aircraftfuel,properlysuppliedwithoxygen,canburnatover1000°C.(1800°F.).

—

—TOMGLEAVEWOKEUNDERNEATHabedindarkness.HewasatOrpingtonGeneralHospitalinthemiddleofanairraid;thebedwashismakeshiftshelter.Hehadsurvived,butthesurgicalteamsatOrpingtonhadlittleexperiencewithsuchsevereburns.Theyhadcoveredhiswoundsinsolutionsofgentianvioletandtannicacid,theformerforitsantisepticproperties,thelatterasakindofchemicaldressingthatwouldcoverwoundedareasandthenhardenasasupposedprotectivebarriertoinfection.Asatherapyforsignificantburninjurythesemeasureswereatbestineffective.Worsestill,theyencouragedscarringandinfection.Thedressings,simpledrygauzeandbandages,stuckhopelesslytoGleave’sweepingwounds,pullingoffskinwhenevertheywerechanged.

Inevitablysepsissetin,andGleavespentmanydaysslippinginandoutofconsciousness,hallucinatinganddeliriouswithfever.Butheralliedandsurvivedthis,too.Afterseveralweeks,themedicalteamatOrpingtondecidedtotransferhimtotheQueenVictoriaHospitalinEastGrinstead,whichhaddevelopedareputationforplasticreconstructivesurgeryundertheleadershipofArchibaldMcIndoe.

WhentheorderliesarrivedtoprepareGleaveforthejourney,theydressedhiminfullmilitaryuniform,shearingdressingsfromdelicate,partiallyhealedlayersofskin.ThefactthatthemedicalstaffatOrpingtonallowedthisreflectshowlittlewasunderstoodaboutthenatureandtherapyofburninjuriesatthattime.Butthehellish,seventeen-mileroadtriptoEastGrinsteaddeliveredGleavetothecareofMcIndoeandhisteamandthestartofhisreconstructionandrehabilitation.

—WARD3ATQUEENVICTORIAHOSPITALwasawooden-walledhutlinkedtothemainhospitalbuildingbycoveredwalkways.Withinresidedacadreofmendisfiguredbyfire,andin1940themostseverelyinjuredofthesewereHurricanepilots.

Totherearofthewardwasanextensionthathousedabaththroughwhichawarm,weaksaltsolutionwascirculated.Thebathwasarrangedsothataflowranthroughit,exchangingagallonaminute.Afterward,dryingwasachievedbystandingthemennakedinfrontoflargeheatinglamps,thusavoidingtheabrasionoftoweling.ThepilotscametocallthistheSpa,anditwasintothistubthatGleave,withsometrepidation,foundhimselfbeingloweredontheeveningthathearrived.

Heneedn’thaveworried.Hiswoundswerebathedproperlyforthefirsttime,

Heneedn’thaveworried.Hiswoundswerebathedproperlyforthefirsttime,andolddressingsfloatedawaywithoutpullingskinwiththem.LaterhiscleansedwoundsweredressedwithVaseline-coatedgauze:aninventionofMcIndoe’sthatcoveredthewoundbutkeptthedressingsfromsticking.

Afewdayslater,McIndoecametoTom’sbedsideandexplainedwhatneededtobedone.Itwouldtakemanymonthsanddozensofsurgeries,McIndoeexplained.“Youwon’tlikeit,”hesaid,“butit’llbeworthit.”Somethinginthemannerofthissurgeon,standingtherepeeringathimthroughhorn-rimmedglasses,gaveGleaveconfidence.Andforthefirsttimesincetheinferno,hefeltasthoughhehadbeenthrownalifeline.

ArchieMcIndoewasaNewZealander,originallyinvitedtotheUnitedKingdomtojointhepracticeofhisesteemedoldercousinHaroldGillies.HereMcIndoehadgottenatasteforthepossibilitiesthatlayinreconstructivesurgery.HaroldGillieshadpioneeredtechniquesofplasticsurgeryduringtheFirstWorldWar,whenasailorburnedattheBattleofJutlandwasthefirstpatienttoundergothistypeofsurgery.Inretrospect,thecosmeticresultsofthesesurgerieslookprimitiveatbest.Butatthetime,theideathatbadlydamagedfacesmightbereconstructedinthiswaywasrevolutionary.ItwouldfalltoMcIndoetorefineandadvancethesetechniques,andtheairwaroftheBattleofBritainwouldprovidehisdefiningchallenge.

First,Gleavegotneweyelidspinchedfromtheunburnedskinofhisthighs.Thesetinyislandsofskinwereremovedandsculptedintoplace.TheyweresosmalltheycouldrapidlyestablishthemselvesattheirnewlocationonGleave’sface,seizinguponthebedofvesselsandperfusedtissuesthatlaytherewaitingtobecovered,likeaminusculesodofearthbeingtransferredfromonelawntoanother.Oxygenandnutrientsreadilydiffusedintothesesmalltokensofflesh.Andthewoundsleftbytakingthesegraftswerediscreteenoughthattheycouldbelefttohealspontaneously.

Butlargerpatchescan’tbemovedinthisway;theirneedsaremoredemanding.Inplasticsurgery,thebattle,asHaroldGilliesonceputit,isbetweenbloodsupplyandbeauty.Afull-thicknessflapofskinaboutthesizeofanadult’spalm,cutoutandmovedasasingleslab,willdiebeforeithasachancetopickupanewsupplyofblood.

Togetaroundthisproblem,McIndoewouldraiseaflapofskin,leavingitattachedatoneedgelikeatrapdoor.Thiskepttheflapalive,suppliedbythevesselsrunningthroughitsattachededge,butleftitfixedinposition.McIndoewouldthenfoldthesheetofskinintoatube,stitchingitslongedgestoeachothertoprotectitsrawundersurfacefrominfection.

othertoprotectitsrawundersurfacefrominfection.Tomovethistubeofskin,hewouldmakeanincisioninthepatient’sarm

andformapocketintowhichitsfreeedgecouldbetucked.Hewouldthenstitchtheflapintoplace,fasteningarmtothighintheprocess,andwaitforittohealintoposition.Thishealingcouldtakeweeks,duringwhichthepatientwashandicappedbythestrangenewanatomicalarrangement.

Oncetheflaphadestablisheditselfinthepocket,itslinkwiththethighcouldbesevered.Thisarduousprocessleftaflapofskin,previouslyfromthethigh,nowdrawingitsbloodsupplyfromthepatient’sarmandfreetobemovedtoanylocationwhichthearmcouldreach.Thisprocessofwalkingatubeofskinendoverendfromonepartofthebodytoanotherwasknownaswaltzing.Gillieshadinventedthetechnique,butMcIndoebroughtittomaturity,waltzingflapsfromlargerareasthaneverbefore.ItprovidedtheplasticityinMcIndoe’sreconstructivetechnique,allowinghimtoaddresslargerareasofburninjurybywalkingskinupfromdistantuninjuredsites.

ButaestheticconsiderationswereattheheartofMcIndoe’swork.Itwasnotenoughsimplytoprovideprotectivecoverage;cosmesiswasessential.Skinisindeedoneoftheprincipalorgansthroughwhichweareabletoexperiencetheworld.ButMcIndoeunderstoodthatitisalsothemeansthroughwhichtheworldexperiencesus.Whenthewarstartedandthetollofburnedairmenbegantobecomeapparent,itwasthoughtthatthebestthingyoucoulddowiththevictimswastoinstitutionalizethemawayfromsocietywiththeintentionofprotectingonefromtheother.ButMcIndoewasunwillingtoacceptthisfateforhispatients,andhiseffortsinreconstructingtheinjuredwentfarbeyondsurgicalinnovation.McIndoewouldgivethemnewfaces,buttheyinturnwouldbeexpectedtofacetheworldagain.

Ward3becamefamousforitsfeatsofplasticreconstructionandnotoriousfortheanticsofitsresidentairmen.McIndoeresistedthemilitarizationoftheward.TheQueenVictoriaHospitalwashis—quiteliterally.TheAirMinistryhadseenthatcontrolofthefacilitywassignedovertoMcIndoe,anditwasrunbyhisrules.Militarydisciplinewasrelaxed,andrankceasedtohavesignificanceamongthemeninthebeds—except,ofcourse,whenitcametoMcIndoe,whomtheyreferredtoastheMaestro,theBoss,orsimplySir.Beerkegsstoodfreelyaccessibleontheward,andattimesitcametoresemblesomethinglikeaworkingmen’sclub.

Allofthisdidsomethingtodistractfromthegrimnessofthepilots’reality.Notonlyweretheyassaultedbydisturbingodorsofcharandinfection,buttheywerealsoexposedtoaseriesofstrangenewproceduresthatleftthemwitharmsstitchedtemporarilytothighs,abdomens,andfaces,initiallyleavingthem

stitchedtemporarilytothighs,abdomens,andfaces,initiallyleavingthemlookingmorebizarrethaneventheirinjurieshad.

Confrontedwithlongdrawn-outweeksofsuffering,withfreebeerastheironlyrealcomfort,thepatientsofWard3setupadrinkingclub.Atfirsttheystumbledwiththename,comingupwiththeMaxillonians,inreferencetotheirongoingmaxillofacialsurgeries.Buttheyquicklyrealizedthatthiswasunwieldyanddidn’tquitecapturethespiritoftheircircumstances.Theywereanewbreedofcasualtypatientunderthecareofapioneersurgeonarmedwithgroundbreakingtechniques.Theyknewatheartthattheywerethesubjectsofexperimentation—howeverwellintentioned.Andsothedrinkingpartyreformedunderanewname:theGuineaPigClub,withTomGleavethefirstandonlychiefguineapig.

Theclub’sactivitiesmovedrapidlybeyonddrinkingandsingingaroundpianostorehabilitationandsupport.McIndoeorchestratedtripstoEastGrinstead.Therethesoldiersweredispatched,oftenunderprotest,tomixwiththelocalpopulation.ThepeopleofEastGrinsteadgrewtoembraceMcIndoeandhisarmyofstrangelyreconstructedmen.Theywouldmakeeveryefforttoaccommodatethem,removingmirrorsfromtheirpubs,cafés,andrestaurantsandtakingcaretogivethelivesofMcIndoe’sGuineaPigsaveneerofnormality.IntimeEastGrinsteadbecame“thetownthatneverstared,”anditservedastheperfectpreparationfortheGuineaPigs’reentryintoaworldthatinevitablywould.

GallowshumorbecamederigueurfortheGuineaPigs.Theyrecruitedatreasurerwithbadlyburnedlegs,sothathewouldn’trunoffwiththepettycash,andasecretarywhosefingershadbeeninjured,sohecouldn’tkeepminutes.AtthestartofWorldWarII,theGuineaPigClubwastiny.Butwiththeonsetofthebombingcampaign,thosenumbersrapidlyswelled,andbytheend,itsmembershipnumberedmorethansixhundred.TheyweretestingtimesthatsawMcIndoeandhisteamforcedtorefinetheirtechniquesastheywent,learningfromsuccessesaswellasmistakes.Buttheselessonswouldtransformthefieldofplasticsurgery.

—THEPRACTICEOFMILITARYMEDICINEduringthewarfocusedprincipallyuponthesalvageoflifeandlimb.McIndoedidn’tsavethelivesoftheGuineaPigs,atleastnotimmediately.Thattaskwasachievedbythehospitalsthatreceivedthem.ButMcIndoe’sworkandtheexperienceofthosehetreatedtaught

cliniciansthattherewassomethingatleastaspreciousaslifethatmodernmedicinemightpreserve.

Todayplasticsurgeryhasitsownimageproblem.Alltoooftenweassociateitwithtummytucksandcelebritynosejobsratherthantheplightofburnvictims.

ButplasticsurgeryretainsmanyofthevaluesthatdroveMcIndoeandhisheroicclubofGuineaPigs.Itis,inthemain,stillabouttherestorationoffunctionandappearancetopeoplewhoseliveshavebeencruellyandirreversiblyalteredbyillnessandinjury.Thefactthatwe,inmoderntimes,havebeenabletomovebeyondthepursuitofsimplesurvivalissomethingtocelebrate.

Plasticity,inthecontextofsurgery,referstotheabilitytomoldandaltertheappearanceofthebody.McIndoewasabletofindareasofhealthyskinandmovethemtocoverthoseareasthathadbeendestroyedbyfire.Morethanthis,hewasabletoachievearesultthatwasaestheticallyacceptable.Buttherewerelimits.Thesewaltzedskinflapsweresuppliedbyanindefiniteweaveofcapillariesandvenulesrunningthroughthelayersoftissue.Thisbloodsupplywastenuous,andflapsofthistypehadtobelimitedinlengthandbreadthiftheyweretosurvive.Moreextensiveinjurieswerenotsoeasilyaddressedusingthistechnique.

Largerandthickerareasofskinneedmuchgreatervolumesofbloodflowingthroughthemtokeepthemalive.Intermsofbloodsupply,thesituationisakintothedifferencebetweentheneedsofavillagethatsubsistsonthetrickleofdozensofmountainstreamsandthoseofacitybuiltonthebanksofacoursingriver.

Thisproblemcould,intheory,beovercomeifablockoftissuecouldbeharvestedalongwiththearteryandveinthatsuppliedanddrainedit.Thesevesselscouldthenbeconnectedtothebody’scorecirculationatthenewsitetowhichthegraftwasbeingmoved.Bymovingandthenconnectingaflapdirectlytothecirculationinthiswayitcouldbeperfusedwitharichflowofbloodandmadeviablemoreorlessimmediately.

Ifthiscouldbeachieved,thenMcIndoe’swaltzingflapswouldnolongerbenecessary.Insteadfreeflapsofskinandtissuecouldbetakenandmovedinasingleoperation.Nolongerwouldthepatientbeforcedtoundergocountlessoperationsandwaitcontortedforweekswhilethetissueestablishedausefulbloodsupply.

Butthevesselsthatsupplyanddrainsuchflapsofskin,thoughhugecomparedwithcapillarynetworks,arestillvesselsoftinycaliber,and

comparedwithcapillarynetworks,arestillvesselsoftinycaliber,andconnectingthemdemandedalevelofsurgicalprecisionpreviouslyunknown.Withthenakedeye,noonecouldcutandstitchvesselswhosediametermightbelittlemorethanamillimeter.Forthistheywouldneedanewbutfamiliartool.

Bythe1970s,microsurgerywasanestablishedtechnique.Theskin,whoseanatomyhadbeensowellexploredbyhistologistswithmicroscopes,couldnowbemanipulatedsurgicallyusingthesametool.IntimetheuseofopticalaidstomagnifytheviewofthesurgeonbecameasessentialtotheartofplasticsurgeryasMcIndoe’sscissorsorscalpel.Theabilitytooperateunderagreatlymagnifiedfieldofviewmadefinerprocedures,includingtheconnectionofbloodvesselsandnerves,areality.Forthefirsttimeflapsofskin,muscle,andbonecouldbemovedenblocfromonelocationtoanotherinasinglebound—theso-calledfreeflap.

Thisdevelopmentmassivelyexpandedtheplasticsurgeon’srepertoireandgaverisetoaplethoraofimportantandexcitingnewtechniques.Buttheselectionofflapsthatcouldbeusedwasstillrelativelynarrow.Thoughthegraftsmadeavailablebythismethodcouldbemovedquicklyandcouldcovermuchlargerareas,theaestheticresultwassometimeslessthansatisfactory.Authoritiesofthetimereferredtotheseearly,free-flapgraftsas“hamburgersoftissue”or“globsandblobs.”

Tobeofgenuinevalueinaestheticreconstruction,thelibraryofskinandtissueflapsthatplasticsurgeonscoulddrawuponneededtobegreatlyexpanded.Butknowledgeofthevascularanatomyofskin—itsrelationshiptothecorecirculation—wasn’tyetatapointwherethiswaspossible.

Inthe1980s,AustralianplasticsurgeonIanTaylorrecognizedthisandundertookamassiveremappingofthecirculationoftheskin.Insodoing,hereconceptualizedtheanatomyofhumanskinanditsrelationshiptothecirculation.

Priortothiswork,understandingoftheconnectionbetweenthecoreidentifiablevesselsofthecirculationandthesupplyofmoreperipheralstructureswaspoor.Thebodyhasanetworkofnamedarteriesandveinsthatarereproduciblefromoneindividualtothenextwithlittlevariation.Thesedivideultimatelytoformmorevariable,lessdistinguishablevessels.Bythetimetheyarriveattheplanesoftissueunderpinningtheskin,thenetworkhasdegeneratedintoacomplexweaveofsmallandlargelynamelesstributaries.

Thiswasfineifyouwereasurgeonoperatingon,say,theheartortheliver,wheretheprincipalvesselsaregenerallyconstantinappearance,wellmappedbyanatomistsandimmediatelyrecognizable.Butforsurgeonsinterestedinmovingunitsoffleshandskinaround,itwaslikehavinganatlasofGreatBritainthat

unitsoffleshandskinaround,itwaslikehavinganatlasofGreatBritainthatincludedonlyitshighwaysandthentryingtonavigatearoutetoaremotefarmintheScottishHighlands.

TaylorinjectedradiopaquedyesintotheskinofcountlesscadaversandtookX-rayimages.Hegeneratedstunningimagesofthenetworkofsmallbutremarkablyconsistentvesselsthatconnectedthecorecirculationtotheskinandtissuesabove.

Understandingtheseconnectionsandtheroutesthatvesselstookastheyroseupfromdeeperstructures,weavingbetweenplanesofmuscleandfat,allowedhimtodeconstructthebodyintoathree-dimensionaljigsawpuzzle.Taylorcalledthepiecesofthejigsawangiosomes,andtogetherthepiecesconstitutedalibraryfromwhichunitsoftissue,skin,andbonecouldbedrawnandreliablytransferredtoalmostanywhereonthehumanbody.Butthebattlebetweenbloodsupplyandbeautywasfarfromover.

—THEFACEDERIVESITSBLOODSUPPLYfromabranchofthecarotidartery.Thisdivideslowintheneckintoadeepinternalbranchandonethatrunsmoresuperficially.Itisfromthesuperficialdivisionthatthefacegainsitsbloodsupply.Fromthistherearebranchesaplenty,enoughthatweasdoctorsintrainingemployedavarietyofmostlyobscenemnemonicstohelprememberthem.

Runthetipofyourfingergentlybackalongthelineofyourjawuntilthepointjustbeforeitturnsuptowardyourear.Atthispointyoucanfeelthepulseofthefacialarteryasitrunsjustbelowthesurfaceoftheskin.

Fromhereitbreaksoverthesurfaceoftheface,withsmallervesselsrunningaboveandbelowthelipsandbranchesthatrunalongsidethenoseandthenuptotheeyes.Andthisshowerofarteriesjoinswithotherbranchesoftheexternalcarotidarterythatalsocreepacrosstheface.Thisarrangementsuppliesboththefacialskinandwelloveradozenmusclesthatareinvolvedineatingandfacialexpression.Surgeonshadfearedthatthecomplexityofthearterialbloodsupplymightproveaninsurmountablechallengewhenitcametoattemptsatfullfacetransplants.Butmorerecentlydoctorsdiscoveredthatthebloodvesselconnectionsrequiredtosupplyanddrainthefacemightbefewerandsimplerthanpreviouslythought.Thisrealizationtookthefullfacetransplantfromathingofsciencefictionintotherealmofsciencefact.

—

—THEREISSUCHATHINGaslifeafterdeath.It’scalledtransplantmedicine.Afterdeathapatient’sheart,lungs,liver,andkidneyscanbedonatedtogivethegiftoflife.Manylivescanbesavedorimprovedbythatsingleactofgenerosity.Butdeathmustcomefirst.

IntheUnitedStatesmorethanonehundredthousandpeoplearecurrentlywaitingforanorgantransplant.Thelistisgrowingquickly;onaverageanewnameisaddedeverytwelveminutesanddemandoutstripssupply.EachdayintheUnitedStateseighteenpeoplediewaitingforanorgantransplant.Itispossibleforpatientstoreceiveanorgan,removedfromadonor,afterthehearthasstoppedbeating.Thisiscallednon-heart-beatingorgandonationandithasgreatlyincreasedthenumbersoforgansavailableforlifesavingdonations.

Butwaitinguntilthehearthasstoppedbeatingbeforebeginningthetransplantprocessmeansthattheorgansbecomedeprivedofafreshsupplyofbloodandoxygen.Oncethathasceased,theorgansbegintheprocessofdying,andthereisagreaterriskthattheywillfailtofunctionproperlyaftertransplantation.

Someorgansaremoreresilientthanothers.Kidneysinparticularcanendurelongperiodsoflittleornobloodsupplyandstillberesuscitated.Butorganswithhighermetabolicdemands,suchasthelungsandtheheart,farelesswell.Itisbecauseofthisthatanewdefinitionofdeathwascoinedaroundthetimeofthefirsthearttransplants,togivesurgeonsthebestchanceofobtainingaheartthatmightsurvivethetransplantprocessandfunctionwell.

Aftersevereheadinjuries,thebraincansometimesbesodamagedthatitshigherfunctionsarelost,leavingonlythemostessentialreflexiveprocessesintact.Theintrinsicrhythmsthatdriveyourheartortheautomatedactivitythatdrivesyourdigestion,forexample,cancontinueevenifeverythingthatisessentiallyyouhasceasedtobe.

Thisisbrain-stemdeath:theirreversibleandpermanentlossofconsciousnessandcognition.Itisasfinalasthestatethataccompaniesthestandstillofaheartandthearrestofbreathing.Aheartbeatmayremain,andbreathingmightbesupportedartificially,givingtheoutwardappearanceoflife,buttheelementsthatdefineahumanbeingarenolongerpresent.Theorganscontinuetobesupportedbythebeatingheartthatremains,eventhoughdeathhasalreadyoccurred.Butitisfromthesetragiclosses,usuallyfromaccidentsormassivestrokes,thatthebesthopeofnewlifecancome.Braindeathallowsorganstobegiveninthebestpossiblecondition.

Theconversationsthatwehavewiththerelativesandclosefriendsofpatients,insoftlylitroomsonhospitalcorridors,areamongthehardestinallof

patients,insoftlylitroomsonhospitalcorridors,areamongthehardestinallofmedicalpractice.FortheteamthatapproachedarecentlybereavedfamilysomewhereinNewEnglandinMarch2011toaskfortheirconsenttodonatenotonlyaheartoraliverbutalsoaface,thetaskmusthaveseemedimpossible.

Thedoctorstooktheirtime,talkingovertheintricaciesoftheprocedure.Theytoldthemthatitwasamongthefirstofitskindintheworld—andinthatrespectasexperimentalasmuchofMcIndoe’searlywork.Therecouldbenocoercion,onlyopenness.

Therewere,however,reassurances.Thetransplantteammadeclearthattherecipientofthedonatedfacewouldnotresembletheirlovedone.Oncetransplanted,theface,laiduponanewunderlyingstructureofboneandtissue,wouldbeasuniqueinappearanceasanyother.Neitheridentitynorappearancewouldbetransferred.

Buttherewerealsodifficultrealitiestoconfront.Aftertheretrievalofaface,effortsaremadetoreconstructtheappearanceofthedonor.Castsofthefacearetaken,andsiliconmasksaresometimesfashioned.Butnoneoftheserestoresthedonor’sappearanceenoughtoallowthebodytolieinstateinanopencasket.Allofthishadtobeunderstoodandaccepted.Afterdeliberationanddespitethemagnitudeoftherequest,thefamilymembersgavetheirconsent.

—THATDAY,PLASTICSURGEONBOHDANPOMAHAČwassittinginthebackofaprivatejettaxiingontherunwayatBoston’sLoganAirport,waitingtotakeoff.Hewasleadingatransplantteam,makingreadytoretrieveadonororgan.Theplanewasoneofseveralregularlycharteredbythehospital’stransplantservice.Hearts,lungs,livers,kidneys,andotherorganswereferriedurgentlyacrosstheUnitedStatesinthisway.Butthismissionwasdifferent.ThateveningPomahačwasgoingouttoretrieveanorganasapreludetoaprocedurethattheUnitedStateshadneverbeforeseen:thetransplantofacompleteface.

Pomahačhadwaitedalongtimeforthisopportunityandhadfoughthardjusttogainpermissiontoattempttheoperation.Atthetime,onlyoneotherfullfacetransplanthadeverbeencarriedout—byateaminSpainayearearlier.Pomahačwasneverthelessconvincedthatthisprocedureofferedtheonlyrealhopeforpeoplewhohadsufferedcatastrophicfacialinjuries.Butnoteveryonewasofthesamemind.Hepetitionedtheinstitutionalreviewboard(IRB)atBrighamandWomen’sHospitalrepeatedly.Theboard,taskedwithmakingsurethatboththescienceandethicsoftheproposedprocedureweresound,wassupportivebuttooksometimetobeconvinced.Thedifficultywasthat,unlikeothertransplant

tooksometimetobeconvinced.Thedifficultywasthat,unlikeothertransplantsurgery,thetransferofafacedidnotamelioratelife-threateningillness.Thereviewboardhadtoweightheveryrealrisksoftheprocedureagainstitsperceivedaestheticbenefits.

Itwasn’tjustthesurgerythatmightpresentathreat.Tobeabletoacceptatransplantfromanotherindividual,therecipient’simmunesystemmustbeheavilysuppressedtostopthenewlygraftedorganfromcomingunderattack.Forordinaryorgantransplants,thetissuetypeofthedonororganmustbematchedascloselyaspossibletothatoftherecipient.Partofthebody’sformidabledefenseagainstinfectionisitsabilitytodistinguishforeignproteinsandtissuesfromitsown—afunctionfulfilledbythewhitebloodcellspatrollinginourcirculatorysystem.

Oncerecognizedas“other,”foreignbodiesareattackedbybattalionsofimmunecells.Thesecellsdamage,destroy,andlaterengulf.Withoutthisdefense,thesimplestofinfectionswouldprovelethal.Butifyouwantapatienttoreceiveanorgantransplantedfromanotherindividual,thesedefensesworkagainstyou.Thenewlygraftedorganisdetected,attacked,andeventuallyrejectedbythebody.

DuringWorldWarII,plasticsurgeonswereawarethatskingraftstakenfromdonorsrelatedtotherecipientsurvivedlongerthanthosetakenfromunrelatedindividuals.Preciselywhythisshouldbethecasewasunknown,butitgavecauseforthought.ArchieMcIndoehimselfhadobservedthatgraftscouldbeexchangedbetweenidenticaltwinswithoutfearofrejection.Todaydonorandrecipientarematchedascloselyaspossiblewithrespecttospecificmarkerproteinsexpressedbytheircells.Thecloseryourgeneticcode,themorelikelytheseproteinsaretomatch.Theseproteinsarelikeflagsonthemastofashipatwar,announcingitssovereigntyanddistinguishingitfromthenavalvesselsofahostileforeignpower.Forthecellsofthehumanbody,exhibitingthewrongsurface-markerproteinsisakintoflyinghostileflagsandprovokesattack.

Matchingsurfaceproteinsascloselyaspossibleprovidesadegreeofprotection,butultimatelyitonlydelaystheonsetofrejection.Toensuregraftsurvival,therecipient’simmunesystemmustbesuppressed,riskingoverwhelmingandpotentiallyfatalinfection.Pomahač’smanyappealstotheIRBatBrighamandWomen’sHospitalhadopenedthedoor,buteachcasewouldstillhavetobedecidedonitsindividualmerits.PomahačbeganasearchthatwouldleadhimtoDallasWiens.

PomahačfirstheardofDallasatameetingoftheAmericanSocietyofPlasticSurgeonsin2009.Thesurgeonwasduetopresentcasereportsofsuccessesthathehadhadwithpartialfacetransplants.ButspeakingbeforehimwasDr.Jeff

hehadhadwithpartialfacetransplants.ButspeakingbeforehimwasDr.JeffJanis,asurgeonfromTexas,whotoldthestoryofamanwhohadsufferedthenearlytotaldestructionofhisfacebyhigh-voltageelectriccurrent.DallasWienshadbeenhelpingtopaintachurchinhishometown.Hehadclimbedintoacherrypickerinordertoreachtheroof.Whathappenednextremainsunclear.AsthebasketcontainingDallasrosefromtheground,heappearstohavegottencloseenoughtoahigh-voltagepowerlineforittodischargethroughhisbodyformanyseconds,nearlylongenoughtokillDallasandmorethanlongenoughtoburnandalmostcompletelydestroyhisface.

DallaswasresuscitatedintheemergencyroomoftheParklandMemorialHospitalinDallas,Texas.Thesceneswouldhavebeendistressingevenforseasonedhealth-careprofessionals.Electricalburnsarecausedbytheheatingeffectofthecurrentasitpassesthroughtissues.Theresultantburnsrundeep,andelectricalinvolvementoftheheartcanleadtoimmediatecardiacarrest.Thepowerlinehaddischargedthroughhishead,heatingandthenburningthefullthicknessofskinoverhisentireface.Thechargerunningthroughhisbodycauterizedhisface,reducingittoacoagulatedmass.

DallaswasclosetodeathwhenhearrivedatParkland.Theresuscitatingsurgeonswonderedhowhardafightforlifetheyshouldmount.Seeinghowcompletelyhisappearancehadbeendestroyed,theyinitiallywonderedifanyonewouldwanttosurviveinsuchadisfiguredform.

Afacefulfillsarolethatgoeswellbeyondappearance.Itsorificesformtheconduitsthroughwhichairisconductedintoourlungsandthroughwhichfoodbeginsitsjourneydownintoourdigestivetract.Itisthesoleseatofthreeofourfivesenses:sight,smell,andtaste.Fromwhattheresuscitatingteamcouldsee,muchofthathadbeenutterlyobliterated.EvenifDallascouldberesuscitated,whatqualityoflifecouldthismanpossiblyhopefor?

Nevertheless,theycontinued,andlaterJeffJanis’splastic-surgeryteamwouldcoverDallas’sheadbyraisinglarge,freeflapsoftissuefromhisbackandmovingthemupontohisface.ButJaniswasopenaboutthefactthatthiseffortwasalifesavingmeasurewhosegoalwastocoverandmanagethewoundleftbytheelectricalburn.Evenafterthisworkhadfullyhealed,itwasclearthatDallaswouldneedamoreradicalsolutionifanymeaningfulreconstructionweretoberealized.

InthepresentationthatPomahačsaw,Dallaslookedasthoughhehadbeenmassivelyinjured.Ahugefeaturelessgrafthadbeenpulledintoplacewherehisfacehadoncebeen.Pomahačremembersthinkingtohimselfthatthemanintheslideswassocompletelydisfiguredthathenolongerlookedhuman.

slideswassocompletelydisfiguredthathenolongerlookedhuman.Aftertheygotoffthestage,JanisandPomahačgottochatting.Havingheard

ofPomahač’spioneeringworkinthefieldofpartialfacialtransplants,JanissuggestedthatperhapsPomahač’steamattheBrighamcouldhelpDallas.ButPomahačwaspessimistic;hewasunsurehowmuchofthestructureofthefaceremainedintactunderneaththegraft.Tobereconstructed,Dallaswouldneedafullfacetransplantandforthistheunderlyingbloodvesselswouldhavetobeintact.JudgingbythedetailsofthemedicalreportandthephotographsofDallasthatPomahačhadseen,hedoubtedthatthiscouldbethecase.

Still,hedecidedtoinvestigatefurther.PomahačbroughtDallastoBostonandbegantoassesshim.Manyaspectsofhisinjurywereatleastasbadashehadfeared.Hewasblindandhadlostoneeye.Thestructureofthenosehadbeenentirelydestroyed;hehadnolips,andwherethereshouldhavebeenamouth,therewasonlyaslit.Dallaswasreducedtodrinkingthroughastraw,andwhenheate,hehadtroublekeepingfoodinhismouth.Hecouldjustaboutspeak,butthewordsweresometimesmuffledanddifficulttocomprehend.

ButasPomahačcametoknowDallasbetter,hecouldn’thelpbutbewonoverbytheforceofhispersonality.Herewasapatientwhoremainedpositivedespitetheaccidentandopenaboutthedisfigurementhehadsuffered.Hewasalsorealisticinhisexpectationsandclearabouthismotivations.TheinjuryhadleftDallasblindandso,onemightassume,lessconsciousofhisfacialfeatures.Buttheoppositewastrue.InconversationswithPomahač,Dallasexplainedtheprofounddiscomforthefeltinsensingthereactionsofotherstohisappearance—thesilencethatfellinapreviouslybusyrestaurantwhenhesatdowntoeatandthehushthatfilledroomsinhispresence.Hewasacutelyconsciousofallofthis.Butmostofall,heworriedabouthowhisyoungdaughterwouldcopewithquestionsandcommentsfromfriendsasshegrewolder.

Whilethisdidn’talterPomahač’stechnicaldecisions,itcertainlyshiftedhisemphasis.Hewanteddesperatelytohelpthisman,afeelingthatwentbeyondtheordinarydutyofcare.

Pomahačhadbeenpreparingforthepossibilityofperformingafullfacetransplantformorethantwoyears,assemblingacrackteamfromvariousmedicaldisciplines.Heknewthatthesurgeryitselfwasjustthecenterpiece;ahostofcliniciansandotherhealth-careprofessionalswouldbenecessarytomakePomahač’sambitionareality.Forthisplungeintotheunknown,hewouldhavetomakesurethathisteamwasmeticulouslyprepared.ThisresponsibilityhegavetohisfriendandcolleagueTomEdrich,ananesthetist.

Bythisstage,theteamwasoncalltwenty-fourhoursaday,waitingforthephonetoringsummoningthemtoaction.Meanwhile,therewasplentytothink

phonetoringsummoningthemtoaction.Meanwhile,therewasplentytothinkabout.Whereshouldtheintravenouslinesbesited?Whatdegreeofimmunosuppressionwouldprotectthegraftfromrejectionwithoutrunningunacceptablerisks?ForEdrichtherewasthequestionofhowtopreventthepatient’sairwayfromclosingandsuffocatinghimaftertheanesthetichadtakeneffect.Normallyhewouldinsertatubethroughthemouthandthreaditintothewindpipe.Butwithburnpatients,mouthswereoftentoobadlydistortedtoallowthistohappen.

Meanwhile,thequestionofwhetherornotDallascouldbeacandidateforfacialtransplantationdependeduponthestateofthebloodsupplythatremained.Pomahač’steamsetaboutconductinganextensivemappingofhisvascularanatomy,injectingliquidopaquetoradiationintoDallas’sveinsandperformingcomputerizedtomography(CT)scansandmagneticresonanceimaging(MRI)torevealthedelicatenetworkofvesselswovenbelow.

Aftermanyweeksofassessment,Pomahač’steamdecidedthat,despitetheapparentdamage,thekeybloodvesselsremainedintact.TherewasagoodchancethatDallaswouldbeabletoreceiveafacetransplant.Pomahačbeganworkinghimupasacandidate,profilinghisimmunetypesothatthetransplantteamscouldbegintheirsearchforadonorwhowasasuitablematch.Allthatthenremainedwasforthemtofindadonorwhoseimmunotypewasacloseenoughmatch.

Theywaitedforseveralmonths.ThenonedayEdrich’sphonerang.ItwasPomahač,andthoughhisvoiceremainedlevel,Edrichcoulddetectmorethanahintofexcitement.“We’vegotaface,”hesaid.

—FORTHENEXTTWODAYS,nobodyinvolvedinthefacetransplantsleptverymuch.DallaswastoldtomakehiswayfromhishomeinTexastotheBrighamandWomen’sHospitalinBostonasquicklyashecould.Meanwhile,Pomahačsetoutaboardajetaircrafttoretrievethefacefromitsdonor.Hewasnottheonlytransplantsurgeonontheretrievalmission.Underordinarycircumstances,organsareretrievedinacarefullyorchestratedsequence:firstthekidneys,thentheliver,andlaterthelungs.Oncetheotherorgansaretaken,itisnolongernecessarytosupplythebodywithoxygenatedblood,sothehearttoocanberemoved.ButintheyearsprecedingthisfirstattemptatafacetransplantintheUnitedStates,PomahačhadagreedwiththeNewEnglandtransplantcoordinatorsthattheretrievalofthefaceshouldhappenfirst,despitethefactthat

itwasn’talifesavingorgan.Afterremoval,anorgancanbedeprivedofitsbloodsupplyforonlyashort

timebeforeitfailsanddies.Measuresaretakentoextendthatperiodforaslongaspossible,includingiceboxesandpreservativesolutions.Butevenwiththese,thetimethatorganscansurvivewithoutbeingplumbedintoarecipient’snewbloodsupplyislimitedtoafewhours,sothetimingoftheretrievalofDallasWiens’snewfacewascritical.

Asothertransplantteamsfromaroundtheregiongeareduptoperformtheirretrievals,Pomahačreceivedaphonecall.Apatientinurgentneedofahearttransplanthadbeenidentified,andtherewasnotimetowaste.Thecoordinatorswereclear:lifesavingtransplantstookpriority.PomahačwastoldtoleaveBostonwithinthehourandthat,uponarrival,hewouldberacingtheclock.AshescrambledhismedicalteaminBoston,hisheartsank.Earlierintheyear,hehadperformedapartialfacetransplant;onthatoccasion,theretrievalhadtakensixhours.Todayheguessedhewouldhavenotmuchmorethantwo.

Thispresentedahugechallenge.Theretrievalofadonatedfaceisinmanywaysataskfarmorecomplexthantheremovalofthemorefamiliarsolidtransplantorgans.Itmustretainformandfunction,anddozensofdecisionsmustbemaderegardingwhatmuscle,tissue,andbonetotakeandhow.

Pomahačworkedasfastashecould,withtheothertransplantteamsbeginningtocircle.Aftertwohours,theyhadnochoicebuttoaskPomahačtostepaside.Withtheretrievalofthefaceonlypartiallycomplete,theremovalofthesolidorganshadtobegin.Finally,whentheheart-transplantteamleftwiththeirvitalorganinhand,theytookwiththemthebloodsupplytoPomahač’sdonorface.

Fromthismomentonward,thefacewasbeginningtodie.Theteamrancoldpreservativesolutionsthroughitsvesselstoprotectit,butthiscouldbuyonlysomuchtime.IftheywerenotbackattheBrighamwiththenewfaceconnectedtoDallas’scirculationinlessthanfourhours,allwouldbelost.Nowthelastsurgeonsleftintheoperatingroom,Pomahač’steamworkedfuriously.Whentheyfinished,thefacehadbeenwithoutabloodsupplyforoveranhourandstillhadtobetransferredbyroadandairbacktotheBrigham.Itwasgoingtobeclose.

—BACKINBOSTON,EDRICHWASMAKINGhispreparations.Theteamwasassembled,theoperatingroomready,itsmicroscopesandsurgicalsetsprepared.Dallas,

accompaniedbyhisgrandfather,wasusheredintotheoperatingtheatersuite.Therewasnotimetolose;thefacebeingbroughtbyPomahačwouldbefading.Duskyandstarvedofoxygen,itstissueswereslowlydying.Tosurvive,itneededanewhostandanewsupplyofblood.

Dallaswasanesthetizedalmostassoonashearrived.Edrichsiteddriplinesinhisveinsthroughwhichtogivefluidsanddrugsandanotherlineinanarterytomonitorthebloodpressuredirectly,withbeat-to-beatprecision.

BythetimePomahačreachedtheBrighamhospital,theskinofthedonatedfacewasbynowadullthundercloudgray—thecoloroftissueandbloodthathasbeenstrippedofitsoxygen.Itwouldnotbelongbeforeitceasedtobeviableatall.

Pomahačhadtomovequickly.HedissectedoutDallas’sexternalcarotidartery.Havingdividedit,hepinchedthefreeendsshutwithanarteryclamp.Thenhebeganthedelicateworkofconnectingthatvesseltothefacethathehadjustdelivered.Workingquickly,Pomahačthrewstitchafterstitchintoplace.Havingmadetheconnection,hereleasedhisarterialclamp.Forthefirsttimeinnearlyfourhours,bloodranintotheoxygen-starvedtissues.Thefaceblushedpink.

—AFTERTWENTY-ONEHOURSofparingbacktissue,stemmingdangeroushemorrhages,andconnectingbloodvessels,muscles,andbones,theoperationwasfinallycomplete.Theorchestraofsurgeonswithdrew,andEdrich’sanestheticteamhandedthepatientovertotheintensive-careunit.ButPomahač,despitehavingbeenawakefornearlyforty-eighthours,wasn’tquitereadytogotobed.OnceDallaswassettledintheICU,Pomahačvisitedhisroom.Aftercheckinghispatient’snewface,Pomahačtoldthenursethathewasgoingtotakeashowerandchangehisclothes,butthathewouldbebacktospendthenightatDallas’sbedside.

“Dr.Pomahač,”shesaidwithasmile,“Ithinkwecantakeitfromhere.”

—DALLAS’SNEWFACEWASN’Timmediatelyperfectinappearance.Thetissueswereswollenandbulky,andthelinesofsurgicalincisionwereevident.Thefaceitselfremainedlargelyinanimateandwithoutsensation.Pomahačhadexpectedallofthis.Itwouldtaketimebeforethefullbenefitsofthisprocedurewouldmakethemselvesknown.Buteveninthoseearlydays,itwasclearthatDallashad

beentransformed.Heborealmostnofacialresemblancetothemanwhohadbeeninjuredinthatcherrypickermorethanayearearlier.Butnow,wheretherehadbeenablankcanvasofskin,therewereindividualfeatures:anose,eyes,amouth,lips,andthemoredefinitebonycontoursthatmakeafacerecognizable.

Furthersculptingofhisfeatureswasnecessary.Oncetheswellinghadsubsided,Pomahačtrimmedexcesstissue.Nervesandmusclesneededtimetobecomereeducated.ButwhenDallasreturnedmanymonthslater,itwascleartoallthatthesurgeryhadbeenagreatsuccess.Hisappearancewasimprovedtothepointwherehemightenteraroomwithoutanyonegivinghimasecondlook.

Moreimpressivelystill,thenerveshadbeguntoestablishthemselves.Dallascouldnowbegintoexpresshimselfoncemore—relearninghowtosmileandfrown.Heevenregainedhissenseofsmell.Butmostimportantofall,hegainedsensationintheskinofhisnewface.Forthefirsttimesincehisaccident,hecouldfeelhisdaughter’skissesonhischeeks.

—THETALEOFDALLASWIENS’SFACEtellsusmuchaboutmedicalscience’smostspectaculartriumphs,butitisinburnunitsallovertheworldwheretheeverydaybattlesagainstfirearebeingwonbyslowandpainfulincrements.

WithoutMcIndoeandhisGuineaPigs,themanlyinginfrontofmenow,bodyravagedbyburns,wouldhavenohopeofbeingrestoredtosomethingofhisformerlife.Asitis,atleastwecangivehimafightingchance—providingwecangettothespecialistunitintime.

Wefinallyclosethedoorsonourhelicopter.Therotorbladesspinup,themotorswhiningastheygetuptospeed.Werisebackwardfromthehelipadwiththeideathat,shouldtheoverloadedenginesfail,wehaveanoutsidechanceofcrashingintothehelipadratherthanthestreetsbelow.Theoxygenlevelsinmypatient’sbloodstreamcontinuetofall.

Anaircraftalarmbeginstopinginthecockpit.Itiscontinuousandsoundsmalignant.Ilookaroundatthepatientburiedinwiresandtubes,attheequipmentwehavejammedintotherearofthevehicle.Thecabinispacked.Wehavewedgedthegearinaroundthecrew,me,andLouise,thenurse.Iimaginethestrainontheengineandrotorblades.Thepingofthealarmpersists.Itis,atthisearlypointintheflight,amysterytomehowwe’llmanagetogetourhelicoptersafelytoitsdestination.

“Don’tworry,”saysthepilot,asifreadingmymind.“Everythinggetseasieronceyoustartmovingforward.”

March24,1917:The9thBattalion,theCameronians(ScottishRifles),go“overthetop”duringadaylightraidnearArras,northernFrance.(©Popperfoto/GettyImages)

THEART

hewardroundsstartat6:30A.M.That’sthegoodnews.Thebadnewsisthatthepre-round,whentheinternvisitsallofthepatientstoprepareforthewardround,startsat6:00A.M.Iamtheinternwithoneofthetraumasurgeryteams,attheverybottomofthehospital

hierarchy.It’sthelate1990s.Theworstofthelocaldrug-fueledgangwarsarecoming

toanend,buttherearestillplentyofgunsaroundinWashington,D.C.ThecityjockeysforpositionasthemurdercapitaloftheUnitedStates.Notsolongago,therewasanaverageofonemurderanightinthesquaremilearoundtheWhiteHouse.ThisisnothowIimaginedthenation’scapital.

Iworktwelvetofourteenhoursaday.Everythirdday,ourteamisoncall.ThosedaysIworkfrom6:00A.M.throughthenightandthefollowingday,thirty-sixhoursatatime.Ihaveneverworkedsohard.Istayinanapartmentabouthalfamilefromthehospital.I’dimaginedthatI’dspendmyfreetimegettingtoknowthecity,butI’mcompletelyspentbythetimethedaysareover.OnthenightsthatImakeitbacktotheflat,Iforcemyselftostayawakelongenoughtomakeamicrowavemealandeatitstandingatthecounter.

Astimegoesby,Ibecomealittlenervousaboutmyneighborhood.ThenexttimeIseemyresident,Carlo,ImentiontheshadycharactersI’venoticedhangingaround.

“Haveyouseenanyshootingyet?”heasks.Imisunderstandhisquestion,thinkinghe’sreferringtoourcaseloadinthehospital.

“Sure,”Isay.“Weseevictimsofshootingthroughthetraumaroomseverynight.”

“No,”hesaysinathickColombianaccent,“haveyouseen,fromthewindowofyourhouse,someonetakeagunoutoftheirpocketandshootsomebodyelse?”

“No,”Itellhim.

“No,”Itellhim.“Thenyoudon’tliveinabadarea.”

—THECRASHPAGERGOESOFF.TraumaCall.GSW.ETA3mins,flashesthemessageonthescreen.Iclimboutofthetopbunk,tryingnottotreadonthejuniorresidentinthebedbelow.GSWistheunit’sstandardabbreviationfor“gunshotwound.”Ihurryalongtothetraumaroom.I’mnotsurewhattimeitisorhowlongI’vebeenasleep.Wearriveatthesametimeasthepatient.Theparamedicsspitoutastringofjargon:“Eighteen-year-oldfemale,GSWchest,signsoflifeonscene,arrestedinthechopper,nooutput.”

Sheiswearingabluedresswithpolkadots.Herfeetarebare—presumablytheshoesaresomewhereatthecrimescene—butshelooksasthoughshe’sbeenoutonthetown.AprettyAfricanAmericangirl,hermakeupandhairdonecarefully.

Thecrewthathasjustarrivedonthehelicoptercontinueswithcardiacresuscitationwhilemovinghertothegurneyinthetraumabay.

“OK,”saysManish,theseniorresident,“let’scrackthechest.”Thereisnoequivocation;thereisnotime.Thesurgerymusthappenhere,surgeryofthemostdrasticandinvasivekind.Theymustopenthechest,exposetheheartandlungs,lookforasourceofinjury—areasonwhyherhearthasstopped—andfixit.Itneedstohappennow.

Apairofscissorsmakeslightworkofherpartydress.Anothertraumanurseisgettingthesurgicaltraysready.Oneofthejuniorresidentsiscoveringhertorsoiniodinesolutionasahurriedsurgicalprep.

Manishistaciturnatthebestoftimes.Thepaceandgravityofthecasedon’tmakehimanymoreverbose.

“Knife,”hesayslevelly.Thehandleofascalpelisplacedinhishand.Manishrunsitsbladeacrossthe

skin,makinganinch-longincisioninthesideofherchest,justbelowherleftbreast.Hepushesforcepsintotheexposedmuscle,separatingthefibersandcreatingatract.Herepeatsthisexerciseontherightsideofherchest.Ifairhasbecometrappedinthepleura,theliningthatsurroundsthelungs,thenitsaccumulationmightbeenoughtostoptheheartfrombeating.ThisiswhatManishhopesfor:thatthesesimpleholesinthechestwallmightbeenoughtoreleasetrappedairandresuscitatethearrestedheart.Buttonightthereisnosuchluck.Hemustproceed.

Manishreturnstotherightsideofthechestandrunstheknifealongtheline

Manishreturnstotherightsideofthechestandrunstheknifealongthelineofthefifthrib,extendingtheincisionhe’salreadymadeuntilitreachesthebreastbone.Hedividesthemusclebetweentheribsandthenintroducestheribspreader—agothic-lookingpieceofstainless-steelhardwarewitharatchetsystemthatseparatesapairofbluntclaws,pullingthechestapart,separatingthefifthribfromthesixth,exposingthecontentsofthechestcavitybeneath.

Inlesstimethanithastakenyoutoreadthisdescription,Iamlookingatherstationaryheartandlungs.

Manishworksquickly,inspectingthepericardium.Thisbaglikestructuresurroundstheheartlikeaglovearoundahand.Ifitbecomesengorgedwithblood,itwillcompressthebeatingchambersandstopthemfrompumping.This,too,isrelativelyeasytoremedy,buttodayit’snotthesourceofourproblems.Thereisbloodeverywhereinthechestcavity.Asuctiontubegurglesaway.Manishshellstheheartfromitsprotectivepericardialsac.Heinspectsit,hopingthattheremightbeasimplehole,amenabletoquickrepair.Butthisisnotthecase.

Hemovesfartherupintothechestandatlastfindstheinjury.Abullethastornthegreatvesselssurroundingtheheart;herbloodhasbeenpumpedoutintoherchest.Theemptiedventriclehasstruggledandthenfailedtobeat.Thereisnoeasyfixtothis.Theteamstopsresuscitating.

Manishaskstheflightparamedicshowlongshehasbeendown—withoutapulse.“Morethanhalfanhour”isthereply.Helooksattheclockonthewallandcallsoutthetimeofdeath.

Theteamleaves,Manishfirstandthentheotherresidents.Themostjuniormemberoftheteamisleftwiththetaskofclosingthechest.Iamthatperson.Ahugecurvedneedleontheendofawireishandedtome.Iamleftalonewithagirlwhoperhapsanhouragowasatapartywhenamanwithagunsprayedroundsintotheroom.Onepassedintoherchestandthroughherheartanditssurroundingvessels.Inanefforttosaveherlife,Manishhadsearchedforthatinjury,hopingtoaddressitandthenrestartherheart,racingtorestoreafreshsupplyofbloodtoheroxygen-starvedbodyandbrain.Butthemessofrupturedvesselsandchambershadprovedtoocomplicatedtorepairintheshorttimethathehad.

Intheheatofthemoment,duringtheresuscitation,itiseasytobeobjectiveaboutthings,toseparateyourselffromthehorroroftheevent.Evenasalowlyintern,youhaveajobtodo,evenifthatjobistowatchandlearn,startingtheprocessofpreparationthatgetsyoureadyforthetimewhenitmightbeyouwieldingtheknifeandmakingthedecisions.

Alonewithher,it’sharder.Asastudent,theworldofmedicineappearstobe

Alonewithher,it’sharder.Asastudent,theworldofmedicineappearstobefullofpatientswhoaremucholderthanyou,whoareenduringthingsthatyoudon’tneedtoworryaboutjustyet.ButsheisyoungerthanIam,maybeevenateenager.Shebelongsbackattheparty,notlyinghereonagurneywithherdresscuttopieces.

Thesurgeryshe’sundergone,anemergencythoracotomy,isatechniquehonedforpreciselythissituation.Inskilledhands,intherightcircumstances,itgivesavictimofotherwiselethalpenetratingchesttraumaa10percentchanceofsurvival.Theimmediacywithwhichitisbroughttobearisstartling.Itisinsomerespectsasimple,albeitviolent,intervention.Andtodayitwasn’tenough.

Watchingthatproceduresodeftlyexecutedandwithsuchsurety,itistemptingtothinkofcardiacsurgeryasthoughitwereanancientarthonedovercenturies.Butlearninghowtoopenachestandconfidentlyoperateupontheheartissomethingthattookalmosttheentirehistoryofmedicinetolearn.

—IFYOUPLACETHEPALMofyourrighthandflatinthemiddleofyourchest,itsheellyinginthecenterofyourbreastboneandyourfingersextendedsothatyourmiddledigitpointsatyourleftnipple,youcangainagoodimpressionofwheretheheartliesanatomically.Andwhilethebeatofitsapexisbestfeltwelltotheleft,wherethetipsofyourfingersrestingonyourchestnowlie,thebulkofitsmassissurprisinglycentral.Neitherdoestheheartlieflatinthecavityofthechest;itisinsteadslightlyrotated,itsrightsidemoreexposedtowardthefrontofthechest,itsleftslightlyhiddentotherear.Thewholearrangementsitsprotectedbehindthebreastboneandaformidablecageofribs;anevolutionarynodtotheheart’scentralimportance—andvulnerability.

Fromthebreastbone,theroutetotheheartisaninchinastraightline,butthattrivialdistancetookmedicinemorethantwothousandyearstotravel.Thetwentiethcenturysawcenturiesofdogmasetasideandcardiacsurgeryadvanceingreatleapsandbounds.ThesefeatsofexplorationlaidopenthecontinentofthehearttoscienceandmedicinejustasScottandAmundsenpavedthewaytotheAntarcticinterior.

—OUREXPLORATIONOFtheworld’sextremesisinessenceanexplorationofourselvesandthelimitsofthehumanbody.Itisourphysiologyandourinabilitytoprotectiteffectivelyfromtheoutsideworldthatputtheremotecornersofthe

Earthbeyondourgraspuntilwellintothetwentiethcentury.Thatexplorationalsosawusturntothefrontiersofmedicine,toexplorethe

limitsofphysiologyinhealthanddisease.Thesamerevolutionsinscienceandtechnologythatextendedourexplorationsofthephysicalworldhelpedtopushbackthefrontiersofmedicineandsurgery.

Therewere,atthestartofthetwentiethcentury,manyfacetsofhumananatomyandphysiologythatstoodlargelyunprobed—foremostamongthemthehumanheart.Whilenineteenth-centuryscientistshadbeguntomaptheorgan’sfunctionandcomplexity,itremainedaterritoryuponwhichmedicinestillfearedtotrespass.Aslateasthefifthdecadeofthetwentiethcentury,asWorldWarIIraged,theheartwasstillacontinentasdangerousandunknownintheeyesofsurgeonsasAntarcticawastoexplorersoftheheroicage.

Physicianssawtheheartaslargelyinviolate,asacredandcomplexwholethatmustremainintactandunaltered,anorganwithwhichsurgeonscouldandshouldnotinterfere.ThisdogmawasasoldasAristotle’steachingsandremainedunchallengeduntiltheveryendofthenineteenthcentury.Medicaltextbookswarnedagainsttamperingwiththeheart.Inhis1896text,SurgeryoftheChest,esteemedsurgeonStephenPagetmadehispositionclear:“Surgeryoftheheart,”hefamouslydeclared,“hasprobablyreachedthelimitssetbyNaturetoallsurgery:nonewmethod,andnonewdiscovery,canovercomethenaturaldifficultiesthatattendawoundoftheheart.”

Overcomingthereceivedwisdomofthepast,makingthatleapofsurgicalfaith,wasafeatthatrequiredtheterriblebutuniquecatalystofwar.

—ITISWINTER1917.SomewhereontheWesternFront,aBritishinfantrymanismarchingforwardacrossthefrozenearthofno-man’s-land.Thereisablizzardintheairandabitingwindsweepingacrossthebattlefield.Hisclothesarenomatchforthisweather,butthecrackofgunfirepresentsamoreimmediatethreat.FromtheGermantrenches,thereisthesoundofchatteringmachineguns;thefiringpositionsareperhapsfivehundredyardsaway.Atthatrange,inthisvisibility,thereisafainthopethattheirhailcanbeavoided.

TheGermanmachine-guncrewsfirehundredsofroundsaminute,pausingonlytoclearstoppages,improveaccuracy,andpreventtheirweaponsfromoverheating.Eachbulletcantravelhalfamileinunderasecond.Theyspinaroundtheirlongaxesinflight,heldstablebythesamelawofphysicsthatkeepsachild’sspinningtopupright,makingthemachinegunaccurateoverlargedistances.Itisthevelocityoftheroundandthekineticenergycarriedwithitthat

distances.Itisthevelocityoftheroundandthekineticenergycarriedwithitthatmakesthebulletsolethal.

Thesoldieradvances,arifleinhisrighthand.Hisleftisraisedinfrontofhisfacetoshieldhiseyesfromtheheavydriftsofsnow.Throughthatblizzard,aspinningmachine-gunroundfindshim.

Thebullettravelsthroughhisleftarm,justabovehiselbow,slowedbymuscleandflesh.Itcontinues,exitingthearm,piercingfirsthistunicpocketandthenitscontents—anotebookandabundleofletters—beforeencounteringthewallofhischestandfinallythesubstanceofhisheart.

AtthetimeofWorldWarI,gunshotwoundstotheheartwerealmostinvariablyfatal,andcardiacsurgerywasstilllookedupondimly.Backin1883,ChristianAlbertTheodorBillroth,oneofthefoundingfathersofabdominalsurgery,hadthesewordsforwould-bepioneers:“Asurgeonwhotriestosutureaheartwounddeservestolosetheesteemofhiscolleagues.”

ViewssuchasthesecontinuedtoholdswaywellintotheGreatWar.In1916,MajorGeorgeGreyTurner,adoctorintheserviceoftheBritishRoyalArmyMedicalCorps,addressedanaudienceofsurgeonsboundformilitaryduty.Althoughhehadplentyofadviceonothertopics,hehadlittletosayoninjuriestothechest.“These,”GreyTurnertoldhisaudience,“arecommonlythoughttobebeyondthescopeofsurgery,andtomeritverylittleattention....”

Yetthefollowingyear,in1917,GreyTurnerreceivedacasualtyrecentlyreturnedfromtheWesternFront,eighteendaysafterhehadbeeninjuredbyamachine-gunbullet—ourinfantrymanwiththebulletholesinhisarmandhiscorrespondence.

Thesoldierwasinsurprisinglygoodhealthandwasindeedembarrassedtohavebeenforcedtoarriveatthehospitalonastretcher.GreyTurnerexaminedhimandfoundevidenceofabullet’sentryatthefrontofhischestbut,ominously,noexitwound.

AtthetimeofWorldWarI,medicalX-rayswereanovelinvention,buttheirvalueinlocatingbulletsandshrapnelwasrapidlyrecognized,andtheywerequicklyadoptedbymilitaryhospitals.

TheX-raytubesatthedisposalofhospitalsofthetimewereprimitive:acathodeandanodefashionedfrommetalssuchastungsten,separatedinanevacuatedglassflaskanddrivenbytheelectricityfromanoil-poweredgenerator.

Thatradiation,passingwitheasethroughsofttissue,attenuatedbydenserboneandmetalfragments,fallingfinallyuponafluorescentplate,revealedabulletintheregionoftheheart’sleftventricle.Itwasmovingsynchronously

bulletintheregionoftheheart’sleftventricle.Itwasmovingsynchronouslywiththeheartbeatinadisturbingwhirlingmotion.Thebulletappearedtobelodgedinthewallofthesoldier’sheart,itswaistapparentlypluggingthemuscleoftheleftventricle,itstipinsidetheventricle,wrigglingwiththeflowofblood.

GreyTurnerconsideredhisoptions.Ifthebulletmigratedfarther,itcouldleadtoanembolus,showeringfragmentsofclottedbloodorinfectedmaterialintothesoldier’scirculationandblockingdistantarteries,withunpredictableconsequences.Orperhapsitsdislodgementmightleadtorapidandfatalhemorrhage.Evenifitweretoremainstableinsitu,thepresenceofthebulletwouldsurelybeasourceofdisastrousinfection.InGreyTurner’seyes,therewaslittleoptionbuttointervenesurgically.

Theoperationproceededunderaprimitiveanestheticcocktailofalcohol,chloroform,andether.GreyTurnermadehisfirstincision,shapedlikealetterCthesizeofaman’spalm,intheskinontheleftsideofthesoldier’schest.Throughthisheremovedthesoldier’ssixthribandthendividedthethreeribsaboveit,allowinghimtoopenthechestwalloutwardliketherearcoverofabook.Heretractedthelungs,gentlypullingthemoutoftheway,andfinallygainedaccesstotheinjuredheart.Therehecarefullyopenedthepericardium.

—THEBEATINGHEARTDOESNOTSIMPLYexpandandcontract.Towitnessitinlifeistounderstandsurgeons’traditionalreluctancetointerfere.Thereisanelementoftorsioninthewaythatitmoves—wavesspreadingacrossitsmusclefrombasetoapex.Eveninhealth,itscadenceconstantlychanges,acceleratingandslowingperiodicallybutwithaclear,intrinsic,andvitalrhythm.Itexhibitsaphysicaldynamismlikenootherorganinthehumanbody,andthusitisinescapablytheengineoflife,evenasitliesonthetablebeforeyou.

Thereisanatomicalcomplexitytoo:Tributaryveinsflowintothevenacava,thelastgreatvesselofthereturningcirculation.Thepointofentry,theatriumoftherightsideoftheheart,isbutthefirstoffourchambers.Thesecond,separatedfromitbyafibrousthree-leafedvalve,istherightventricle,thickerwalledthantheatriumabove,abletoprovideavolumeofbloodwithenoughenergytosenditthroughthepulmonaryartery,itspulmonaryvalve,andouttocirculatethroughthebloodvesselsofthelungs.

Thatoutflowdividesandfragmentsintoaplethoraofsmallerandsmallervessels,untilfinallytheyformthemanymillionsoffinecapillaries,vesselssometimessmallerindiameterthantheredbloodcellsthatmusttraversethem.

Herethoseredbloodcells,theall-essentialvehiclesofoxygendelivery,mustdistortastheysqueezethroughthecapillaries,snakingaroundthealveolarair

distortastheysqueezethroughthecapillaries,snakingaroundthealveolarairsacs,grabbingoxygenandgivingupcarbondioxideastheygo.

Thenthere’sthereturnjourney.Capillariesbecomevenules,venulesbecomeveinsuntiltheymergetocomprisethepulmonaryvein,returningthecirculatingbloodoncemoretotheheart.Hereathirdchamber,theleftatrium,receivesbloodfromthepulmonaryvein,freshlyladenwithoxygenfromitsvoyagethroughthelungs.

Theleftatriumprovidesjustenoughimpetustopushthebloodthroughavalveshapedlikeabishop’smiter—themitralvalve—whereuponitentersafourthandfinalchamber:theleftventricle.Thisstructure,withitsmuscularwall,mustdevelopenoughforcetoacceleratethebloodofasingleheartbeatoutthroughtheaortaandpasttheaorticvalvetocirculatethroughoutthebody.

Throughthisnetworkofvessels,intothesechambers,overthesesurfaces,bloodmustflowendlessly,neverfaltering,neverformingeddiesorclotting,frommomenttomomentacrosstheentirespanofahumanlife.Andin1917,somewhereinthiscomplexmassofmobile,twistingtissueliesabulletthatMajorGeorgeGreyTurnermustfind.

—GREYTURNERBEGINSHISSEARCH.Hefindsascarcoveringanentrywoundinthewalloftheleftventricle.Thereisnodoubtthatthebulletlieswithin.Hecarefullycupstheheartinhishands,tryingtofeelforthemissile.Theheart,henotes,developsthehardnessofastonewhilecontracting,makingitimpossibletofeelanythingwithin.Inthecycleofeachheartbeathehaslessthanasecondwhenthemuscleisrelaxedenoughforhimtolocatethebullet.Buteventhisprovesimpossible;thebulletistoodeeplyseated.Instead,hepuncturestheheartcarefullybutrepeatedlyintheareaaroundthescar,remarkinguponhowsoliditssubstancefeelsandnotingthattheseneedlewoundsbleedbutstopquicklyoftheirownaccord.Inhiswrittenrecordoftheoperation,GreyTurnernarrateshisexplorationlikeamountaineerdescribinganewroute.Thesearediscoveries,territoriesuncharted.Butthebulletremainselusive.

Unwillingtogiveup,GreyTurnerparestheribstumpsbacktogivehimselfmoreroom.Herotatesthehearttoexamineitsposterioraspect,whereupon—tohishorror—itstops.GreyTurnermassagesthenowflaccidheart,squeezingitinhishands,hopinginsomewaytoresuscitateitbacktolife.Herotatesitbacktoitsproperposition,continuingtosqueezeitinhishands,andfinallyitbeginstobeatagain.Butthebulletisstillnowheretobefound.

Afteranhourandahalfofsearchinginvain,GreyTurnerdecidestofallbackuponthemostfundamentalofthegeneralprinciplesinsurgery:primumnonnocere,“first,donoharm.”Toanypractitionerofmedicine,knowingwhentostopisatleastasimportantashavingthecouragetoproceed.Admittingdefeat,hewithdrawsandclosesthechest,leavingthebulletlodgedintheofficer’sbeatingheart.

GreyTurner’sinstinctstowithdrawwerecorrect.Theprojectilewasleftinplace,andthepatientdulyrecoveredfromhissurgery.Infact,thesoldierinquestionrecoveredfullyandwasevensoughtoutandfoundbyGreyTurnertwenty-threeyearsafterthatabortiveoperation,in1940,aliveandwell.Hisonlycomplaintwasofoccasionalfatigue,butthat,GreyTurnerexplained,thepatienthadattributedtohisexertionsin“thecurrentwar.”

—GREYTURNERwasnottheonlysurgeonoftheGreatWartoattemptcardiacsurgery.Elsewheretherewerereportsofsurgeriestoremovemissilesfromhearts—somesuccessful—butthesewerefewandfarbetweenandnotenoughtoconvincethewidersurgicalfraternitythattheheartcouldbereliablyinterferedwith.Thereceivedwisdomofthetimestood.Theheartwasperceivedasallbutinoperable.

ButWorldWarIIsawthefurthermechanizationofcombat;thepracticeofwarbecamestillmoreefficient,andthespecterofwoundedheartsreturned.Shellfragmentsandbulletsfoundtheirwayintochestsingreaternumbers,andcasualtieswithwoundedheartsoncemorebegantoarriveatmilitaryhospitals.

DwightHarkenhadvisitedLondonasacivilianandhadworkedalongsidetherenownedBritishsurgeonArthurTudorEdwards.In1942,Harkenreturnedasathirty-three-year-oldU.S.Armycaptainandanaspiringthoracicsurgeon,assignedtoapostinBrigadierGeneralPaulHawley’sofficeinGrosvenorSquare,taskedwithassistingtheU.S.Armyinorganizingandcoordinatingmedicallogistics.

HarkenhailedfromthesmalltownofOsceolainIowa.Graduatingnearthetopofhisclass,hewontheopportunitytoattendHarvardMedicalSchool.HarkenremainedatHarvardasagraduate,spendingpartofhissurgicalresidencyinBostonandlaterNewYorkbeforewinningagrantfromtheNewYorkAcademyofMedicinetodevelophisinterestsabroadinalocationandspecialtyofhischoosing.AmbitiousbutnotwishingtocompetewiththelikesofAllenWhipple,EdwardDelosChurchill,andElliottCarrCutler—titansofgeneralsurgery—Harkendecidedtotakeagambleandspecializeinthenewly

generalsurgery—Harkendecidedtotakeagambleandspecializeinthenewlyemergingfieldofthoracicsurgery.Thiswasaboldmoveinanerathatvaluedthegiftedgeneralistmorehighlythanthenarrowlyskilledspecialist.Nevertheless,HarkenchosetotraveltoEnglandandtakeupavisitingfellow’spostattheRoyalBromptonHospitalwithArthurTudorEdwards.

TudorEdwardswasoneofthefewthoracicsurgeons,ifnottheonlyone,intheworldatthetimeofHarken’ssecondment.Hiscaseloadwasprincipallyconcernedwiththetreatmentoftuberculosis.Assistingintheoperatingroom,HarkenmarveledatTudorEdwards’sskillsasatechnician,watchingkeenlyashecarefullyexploredthecontentsofhispatients’chestsandparedbacktuberculoustumors,liberatingbloodvesselsandelementsofthebranchingbronchialtreefromtheirencasement.

YetHarkencouldn’thelpbutwonderwhy,whenconfrontedwiththediseasedheart,whichwasinhiseyesamechanicalentity,TudorEdwardsandhiscolleaguesremainedreluctanttooperate,despitethepioneeringworkofGreyTurner’sgeneration.SowhentheoutbreakoftheSecondWorldWarinterruptedhisapprenticeshipwithTudorEdwards,HarkenreturnedtoBostontobeginhisownexperimentation.

—BACTERIALENDOCARDITIS,ANINFECTIONoftheinnersurfacesoftheheartanditsvalves,wasanalmostinvariablyfatalafflictioninHarken’stime.Intheabsenceofantibiotictherapy,thebacterialinfectionwoulddisintegratetheheart’sinternalstructures.Worse,thepumpingactionoftheheartwouldseedinfectionandembolithroughoutthebody.Harkensoughttocombatthisformidableenemy.Intheory,surgicalremovalofthefocusofinfectionwouldarresttheprocessandgivetheafflictedpatienttheopportunitytosurvive.Butatatimewhentheworldremainedreluctanttoenterthecavitiesoftheheart,Harken’shypothesisneededthesupportofhardevidencebeforehecouldattemptitinhumanpatients.

Hebeganbyworkingondogs.Heoperatedoncanineheartsandattachedmetalclipstothesurfaceoftheirmitralvalves.Hefoundthatthisintrusionalwaysledtoinfectionandtheonsetofbacterialendocarditis.Thisapproachprovidedamodelofthediseasehesoughttotreat,allowinghimtosimulatenaturallyoccurringbacterialendocarditisindogs,anditalsogaveHarkenconfidencethatthecavitiesoftheliving,beatingmammalianheartcouldbeenteredandrepairedwithoutimmediatefatality.

However,Harken’sworkwasonceagaininterruptedbytheeventsofwar,ashewasreturnedtoEnglandin1943andpostedatGrosvenorSquareunderthe

hewasreturnedtoEnglandin1943andpostedatGrosvenorSquareunderthecommandofGeneralPaulR.Hawley,chiefsurgeonintheEuropeantheaterofwar.Here,anticipatingafloodofcasualtieswithpenetratingchestwounds,heandTudorEdwardscampaignedsuccessfullyfortheestablishmentofspecialistthoracicunits.

Inthefirsthalfof1944,presumablyinpreparationfortheimminentAlliedinvasionofEurope,severalspecialistthoracicunitsweresetupthroughoutEngland.InMay1944,DwightHarkenwasreleasedfromhisofficepostinGrosvenorSquareand,tohisdelight,madedirectorofthe15thThoracicCenteratthe160thU.S.GeneralHospitalinCirencester—athousand-bedfacilitycompletewithanearbyrunwaytoreceivecasualtiesfromthebattlefront.ForHarken,thiswasahappyreleasefromtheburdenofhisadministrativeroleatGrosvenorSquare,lettinghimreturntotheoperatingroomandresumehispassionforsurgery.

—THEU.S.ARMYHOSPITALWASBUILTonthegroundsofStowellParkinNorthleach,England.Itamountedtolittlemorethanaclusterofcorrugated-steelNissenhutshousingpatientwardsandsurgicalteams.

ThemonthofMay1944failedtoprovidemuchinthewayofcasualtiestooccupyHarkenandhisteam.Hespentthetimeproductivelynevertheless,preparingandtraininghisclinicalstaffinthenewartofthoracicsurgery.

Theywouldnothavelongtowaittoputtheoryintofullpractice;June6,1944—D-Day—wassuddenlyuponthem.Thehospitalreceivedatidalwaveofcasualties,deliveredbyairfromtheEuropeantheater,firstfromtheinvasionandthenalatersurgeaftertheBattleoftheBulge.Confrontedbycasualtiesarrivingwithmissileslodgedintheirhearts,HarkenconsultedGeorgeGreyTurnerforguidanceonwhetherornottoattempttheirremoval.GreyTurnergaveHarkenhisblessing,statingthatthereweremanygoodclinicalreasonstoremovesuchforeignbodiesbutthattheneurosesthatmightresultfromapatient’sknowledgethathe“harborsanunwelcomevisitorinoneofthecitadelsofhiswell-being”mightgivecauseenough.ThechallengethatHarkenhadsometiculouslypreparedforhadfinallyarrived.

—ONEOFHARKEN’SGREATSKILLSLAYinunderstandingthatthetechnicalabilityofthesurgeonhadtobematchedwithanequallycapableoperatingteam.These

surgeries,particularlythoseinvolvingforeignbodiesinthecavitiesoftheheart,oftendemandedconsiderableintraoperativeresuscitation.WhileHarkennavigatedhiswaythroughtheanatomy,hisanesthetistwouldberesponsibleforactivelyresuscitatingthepatient:providingmassivetransfusionsandbalancingefficientpainreliefagainstthehazardsofbleedingout,hypothermia,andshock.Fortheanesthetistinthesecases,itwaslikeflyingaplaneonfire,hopingtoholditintheairlongenoughforthesurgeontobeabletodousetheflames.

Ratesofbloodlossofuptoaquartandahalfperminutewererecorded,atorrentthatcouldemptythepatient’sheartandbloodvesselsandprecipitatecardiacarrestinamatterofseconds.Thatphenomenon—shockcausedbyhemorrhage—cametobebetterunderstoodlaterinthecenturyasthecompromiseoftheheartandcirculationbyrapidbloodlossandtheconsequentfailuretomeetthemetabolicdemandsofthebody’svitalorgans.Leftunabated,thisprocessleadsinexorablytodeath,andthoughthephysiologyofshockanditsconsequenceshadn’tbeenfullygraspedbythetimeWorldWarIIarrived,Harken’steamhadintuitivelycometounderstandthegreatvalueofmassivewholebloodtransfusioninkeepingpatientsalive.

Bloodwassuppliedinglassbottles.Butkeepingupwiththetorrentiallossesdemandedfarmorethantheirgravity-drivendribblecouldprovide.Toovercomethechallengeofdeliveringbloodatspeedthroughnarrowtubes,theanesthetistwouldinjectairintotheheadspaceoftheflasks,increasingthepressurewithinandthustherateofflow.Occasionallyintheheatofthemoment,theywouldoverdoit,andthejarswouldshatterundertheadditionalpressure,scatteringshardsofbloodyglassthroughouttheoperatingroom.

Harkenmeanwhilewouldbefocuseduponnavigatingsaferoutestoandthroughtheheart.Helearnedthatthesimpleactofhandlingtheheartwasenoughtoprovokeabnormalandpotentiallyfataldisturbancesofitsrhythm.LikeGreyTurner,hecametorecognizetheperilinremovingtheheartfromitsproperposition.Harkenalsodevisedtechniquesforincisingandenteringtheheartwhileexercisingatleastsomecontrolovertheresultanthemorrhage.Heachievedthisbyplacingsuturesoneithersideofhisincisions,leavingapairoflongtrailingthreadsatbothedges.Hisassistantcouldthenholdthesetaut,keepingcontrolovertheopeningintheheartasthoughitwerethemouthofapurse.Inthisway,Harkenwasabletoaccessbulletsandfragmentsofshrapnelpracticallywherevertheylay.

InthetenfraughtmonthsthatfollowedtheAlliedinvasionofEurope,Harkenremovednofewerthan134missilesfromtheheartsofwoundedsoldiers.Thepacewasrelentlessandtheworkloadexhausting;Harkenandhis

soldiers.Thepacewasrelentlessandtheworkloadexhausting;Harkenandhisteamwouldoftenoperatearoundtheclockfordaysonend,sleeping,onimprovisedcots,onlywhenthelullincasualtieswouldallow.Thedemandforthoracicsurgeryoutstrippedthesupplyofadequatelyqualifiedsurgicalteams.Harkenwouldsometimesoperatebydayandthentravelbynight,withhisscrubteam,tolendhisthoracicexpertisetootherhospitals.Whiletheaccountsofthesesurgerieswerefrightening,filledwithstoriesofmassivebloodlossandtensemoments,amongthepatientsuponwhoseheartsHarkenoperatedtherewas—incredibly—notasingledeath.

TheeffectonHarkenofhisexperiencesinStowellParkwastransformative.HehadarrivedinEnglandoptimisticbutunsurethatcardiacsurgeryinvolvingtheinternalstructuresoftheheartmightbeacceptablyperformedinhumans.HereturnedtotheUnitedStatesattheendofthewarconvincedofthisfact.Andthistimethemedicalprofessionsatupandtookfullnotice.Thedocumentedevidencewasunquestionable:Theheartwasopenforconquest.MajorDwightEmaryHarken’sexplorationshadproveditso.

—THESECONDWORLDWARHADBEENbracketedbytwoawardsforadvancesinantibiotictherapy.In1939theNobelPrizewenttoGermanpathologistandbacteriologistGerhardDomagkforhisworkindevelopingcommerciallyavailablesulfonamideantibiotics,althoughtheNaziregimeforbadehimfromacceptingit.In1945,ErnstBorisChain,HowardFlorey,andAlexanderFlemingreceivedtheprizeforthediscoveryofpenicillin.Thesedevelopmentswouldshapethefutureofcardiacsurgeryasmuchasanysurgicaltechnique.Bacterialendocarditis,hithertoanunstoppablediseasewithanearly100percentmortalityrate,wassuddenlyamenabletotreatmentbytheinjectionofantibioticdrugs.ItwasnolongertheundefeatedfoethatHarkenhadsohopedtoslaywithsurgery.ButHarken’swartimeexperiencehadtaughthimthattheheartcouldbeopenedandthemechanismswithinalteredandrepaired.Heturnedhisattentioninsteadtoproblemsofthemitralvalve—atthetime,wildterritorywhererespectablesurgeonswereloathtoventure.

Themitralvalve,seenfrombelowasitopensintotheleftventricle,hastheappearanceofagentlysmilingfishmouthmountedonaringoftissuearoundthesizeofahalf-dollar.Thedelicatelyengineeredmechanismisdesignedtoallowbloodtoflowinonlyonedirection,fromatriumtoventricle.Withoutitssystemofvalves,theheartismerelyapumpthatisaslikelytopushbloodbackwardasitistopushitforward.

Theleafletsofthemitralvalvearepronetodamagefromthechildhoodafflictionofrheumaticfever.Somethingassimpleasathroatinfectioncanleadtowidespreadinflammationandtriggertheimmunesystemtoattackthebody’sowntissues.Theresultingdamageisakintofriendlyfire:Yourbody’sowndefenses,unabletodistinguishforeigninvaderfromself,wreakhavoc,attackingtheskin,joints,eyes,andtheheart.

Whenthishappens,themitralvalvecanbecomenarrowed,andtheopeningthroughwhichbloodcanflowisreduced.Asaconsequence,pressurebuildsupintheleftatriumandistransmittedbacktothefragilecirculationofthelungs.There,exposedtothisunusuallyhighpressure,thetissue-thincapillariescanrupture,spillingbloodandfluidintotheairspacesofthealveoli,causingcoughing,breathlessness,andtheexpectorationofbloodstainedsputum.

Whilerheumaticfeverisadiseaseofchildhood,itscardiacconsequencesareusuallyseenlaterinlifeasthenarrowingofthemitralvalveprogresses.Butthephysiologicaldemandsofpregnancy,whichincludeanincreaseinthevolumeofbloodpumpedoutbythehearteveryminute,canunmaskthediseasedvalve.InHarken’stime,itwasnotuncommontoseeyoungwomenduringtheirfirstpregnancywiththesymptomsofbreathlessnessassociatedwithmitralstenosisandheartfailure.ThisconditionbecameHarken’snewtargetforsurgicalintervention.However,hewasnottheonlyambitiousyoungmandeterminedtoconquerthisterritory,anditprovednottobeanendeavorforthefainthearted.

—HARKEN’SFIRSTFORAYSintomitral-valvesurgerywerefraughtwithcomplicationsandloss.Sixofhisfirstninepatientsdiedeitherontheoperatingtableorshortlythereafter.Afterthesixthfatality,Harken’sconfidencewasbadlyshaken,anditwasonlytheinterventionofhisfriendandcollaboratorDr.LawrenceBrewsterEllisthatpreventedhimfromthrowinginthetowelcompletely.Tocomplicatematters,HarkenhadcompetitiononbothsidesoftheAtlanticfromthelikesofCharlesBaileyinPhiladelphia,RussellBrock(laterLordBrockofWimbledon)atGuy’sHospitalinLondon,andHoraceSmithyinSouthCarolina.

WithinayearoftheendofWorldWarII,techniquesincardiacsurgeryhadbeguntoadvanceallovertheworld.Thiswasmorethansimplecoincidence.Advancesinthefieldofanesthesia,radiology,bloodtransfusion,andantibiotictherapycombinedwiththecatalystofwartoushertheageofcardiacsurgeryintoexistence.

Thecontributionoftheseadvancesisoftenunderstated,asthoughtheywere

Thecontributionoftheseadvancesisoftenunderstated,asthoughtheywerenotentirelyessentialtotheestablishmentofelectivecardiacsurgery.Historyhadnotsimplywaitedforasurgeonboldenoughtobreakwithconventionoronewithsufficientlygiftedhands.Theannalsofsurgeryare,afterall,repletewithsuchindividuals.Ithadbeenwaitinginsteadforameansbywhichmedicinemightprotectthebrittlephysiologyofthosewithdiseasedorinjuredheartsfromtheaddedinsultofsurgery.

Anesthesia,antibiotics,andtransfusionmedicineweretogetheraprimitivesystemoflifesupport,acocooninwhichtowrapthepatientbeforetheonslaughtofthesurgeon’sknife.Priortotheintroductionofmorecarefullycalibratedanestheticvaporizersandsaferanesthetics,itwasnotunusualforpatientstodieasadirectresultoftheunpredictableeffectoftheanestheticgases.Thesemysteriousdrugshadwidespreadandoftendeleteriousimpactsuponthebody.Theywouldcauseprofoundfallsinbloodpressurebutleavetheheartoverexcitableandpronetoarrhythmias;theycouldprecipitaterespiratoryarrest,causehepatitisbyinflamingtheliver,andprovokeseizures.

Therapidandmassivetransfusionofwholeblood,whichitselfhadtobemanagedbyaskilledteam,replacedvolumeslostinhemorrhage,stavingoffshockandpreventinghypotensionandeventualcardiacarrest.Intheperiodimmediatelyaftertheoperation,antibioticdrugswouldkeepinfectionofthoseprofoundsurgicalwoundsatbay.

Withamorestableplatformfromwhichtolaunchsurgicalinterventions,thepossibilityofroutinecardiacsurgerybecameapparenttomany.IntheUnitedStates,HarkenwasthrustintodirectcompetitionwithCharlesBailey,asurgeonofthesameage,basedattheEpiscopalHospitalinPhiladelphia.InthesameyearthatHarkenattemptedhisfirstmitralvalveprocedures,sotoodidBailey.Andheenduredthesamehorrificrateofattrition.

Bailey’sfirstpatient,athirty-seven-year-oldman,hadbeenincapacitatedformorethantenyearswithmitralvalvedisease.Hisleftatriumwas,asaresult,thinwalledandfragile,rupturingduringtheoperationbeforeBaileygotnearthevalveitself.Thepatientbledtodeathinseconds.

Duringhissecondattemptatthesameprocedure,thistimeasameasureoflastresortinatwenty-nine-year-oldwomanprofoundlydisabledbyhernarrowedmitralvalve,hewasabletoaccessandoperateuponthevalve.Heprobedthevalveatfirstwithasurgicalinstrument,buthavingfailedtodilateitsufficientlyinthisway,hedecidedtousehisfingertoincreasethesizeoftheopening.Thepatientdiedtwodayslaterfromheartfailure.

Inthewakeofthesefatalities,Dr.GeorgeGeckeler,chiefofcardiologyattheHahnemannUniversityHospital,wrotetoBailey:“ItismyChristianduty

theHahnemannUniversityHospital,wrotetoBailey:“ItismyChristiandutynottopermityoutoperformanymoresuchhomicidaloperations.”AndBailey’srecordoffailurehadnotgoneunnoticedbycolleaguesandstudents.Infact,theybegantocallhimtheButcher.

Baileywaitedfifteenmonthstomakeathirdattempt,thistimeatMemorialHospitalinWilmington,Delaware,onathirty-nine-year-oldman.Againtheoperationfailed,andmassivehemorrhageinthepostoperativeperiodwasthecauseofdeath.

Baileychosetoperformtheselateroperationsinaseriesofseparatecommunityhospitals,partlybecauseheworriedthatsuccessivefailureswouldnotbetoleratedbyanysinglecenter.Hisfourthfatality,inathirty-two-year-oldmanatPhiladelphiaGeneralHospital,occurredonthemorningofJune10,1948.Thepatient’sheartbecameirritableandarrestedasBaileyhandledit.Despitefranticattemptstomassageitbacktolife,thepatientdiedonthetable.Sensingthatamoratoriumwouldshortlybecalledonhisprocedureifhecouldnotdemonstratesomethinginthewayofsuccess,Baileyhadalreadybookedafifthoperationforthatsameafternoon.LeavingPhiladelphiaGeneral,hedroveacrosstowntotheEpiscopalHospitalforwhathemusthavesuspectedwashislastchancetoshowthatthisprocedurehadvalue.

AttheEpiscopalHospital,ClaireWardwaswaiting.SheknewtheoutcomesofCharlesBailey’spreviousoperations,asdidherfamilyphysician,whohadadvisedhernottovolunteerherselfforthesurgery.Clairewasatwenty-four-year-oldhousewife.Inchildhoodshehadsufferedwithrheumaticfever,andovertheyears,theprogressivenarrowingofhermitralvalvehadledtomountingpressureinherleftatriumandthesymptomsofheartfailure.Theresultingdiseasehadlefthersoshortofbreaththatshecouldnolongerlookafterheryoungchild.IfwhatCharlesBaileyhadpromisedwastrueandthebreathlessnessanddisabilitythatplaguedhercouldbeabolishedbythisoperation,thenforhertheenormousriskswereworthit.

BythetimeBaileyarrivedattheoperatingtheateroftheEpiscopalHospital,Clairewasalreadyontheoperatingtableandbeingpreparedforanesthesia;whetherhediscussedtheearliereventsofthedaywithherisunknown.Theanestheticinduction,whichhadprovedperilousinpreviouscases,wentsmoothly,andoncethepatientwasstable,theoperationproceededrapidly.Thepericardiumwasopened,theheartwasexposed,andsutureswereplacedinthewalloftheleftatrium.Baileyincisedandopenedtheheart,usingfirsthisfingerandthenasurgicalknifetofreethefusedleafletsofthemitralvalve.Satisfiedthatthesemanipulationshadachievedtherequiredresult,hewithdrewand

thatthesemanipulationshadachievedtherequiredresult,hewithdrewandclosedtheheart.Theoperationhadtakeneightyminutes.Thistime,itworked.ClaireWardleftthehospitalaweeklater,muchimproved.Amonthlater,shenolongerhadtotakedigitalis,thecardiacmedicationuponwhichshehadpreviouslydepended.Wardwentontohavetwomorechildrenandlivedforanotherthirty-eightyears.

—BAILEYCARRIEDOUTthisfirstsuccessfulclosed-heartoperationonamitralvalvejustfourdaysaheadofhiscompetitorDwightHarken.Awareofthisandnotonetobeoutdone,Harkenracedaheadwithwritinguphisowncasereport,makinguseofhiscontactsontheeditorialboardoftheNewEnglandJournalofMedicinetoachievethemuchprizedpriorityofpublication.

TherivalrybetweenHarkenandBaileybecamethestuffofloreinthesurgicalcommunityandprovidedsomethinginthewayoflightentertainmentforothercolleagues.Theirinteractionswerenothingifnotferocious.OneresidentwrotethatthetwocriticizedeachotherfiercelyandopenlyatsurgicalconferencesandthatHarkenbecame“peri-apoplectic.”Theywereperhaps,atcore,tooalikeincharactertobeabletotolerateeachother.Theyweremenofambitionandconfidencewhofullyrecognizedtheopportunitythatlayathand.Neitherfollowedthedictatesofconventionalwisdom.Theywereborninthesameyear,attemptedtheirfirstmitral-valvesurgeriesinthesameyear,anddiedinthesameyear.

Thehistoryofthiseraofsurgery,inwhichtheartmaderapidprogressbutduringwhichthereweremanydeathsamongpatients,makesfordifficultreading.Itisunthinkablethatanynewsurgicaltechniquebeingpioneeredtodaywouldproceedifaccompaniedbythesamehorrificrateofmortality.ItistemptingtoregardBaileyandHarkenasbeingsoconsumedbyambitionandcompetitionthattheylostsightofthehumancostoftheirendeavors.Butwhilethepairdidindeedraceandcompete,itisimportanttounderstandthecomplexityofthecasestheyfaced.Physiciansofthetimehadlittleconfidencethatthebenefitsofcardiacsurgeryoutweigheditsrisks.Ingeneral,patientswithdiseasedheartswerereferredtoBaileyandHarkenonlyasalast-ditchoption,whentheywerealreadysocriticallyunwellthattherewaslittletolose.Inthatcontext,thefactthattheirfailingphysiologiesoftencrashedcompletelywhenfacedwiththejointchallengesofexperimentalsurgeryandprimitiveanesthesiaisperhapslesssurprising.

Bailey,itseems,wasdrivenbysomethingmorethansimpleambition.Asatwelve-year-oldchild,hewitnessedhisfatherdyinginhismother’sarmsof

twelve-year-oldchild,hewitnessedhisfatherdyinginhismother’sarmsofheartfailure,breathlessandcoughingupbloodstainedsputum.Inhiseyes,anoperationthatcouldsparesomeonethatfatewasworthallthatheandhispatientswouldsufferinitsdevelopment.HisChristianduty,ashesawit,wasnottostopbuttosucceed.

It’sworthrememberingthattheseeventswerealsoaproductoftheirtime.Theabsenceofformallyorganizedcommitteestooverseemedicalethicscontributedtoamorepermissive,lesswell-scrutinizedstyleofpractice.Butperhapsalsothewar,sofreshinthecollectivememory,alteredtheperceptionofacceptablerisk.Arguablysocietywasmorewillingtoacceptsacrificeinthefaceofawar,whetheragainstmilitaryfoeordisease.Whateveryourperspective,ifitwasn’tforthedoggeddeterminationofBailey,Harken,andtheirpeers,thefateofthebraveClaireWard—andthatofthemanythousandsofpatientswhofollowedinherfootsteps—wouldhavebeenverydifferent.

—WHEREDOESTHELINELIEBETWEENinnovativenewtherapyandexperimentation?Itisblurredatbest,andpushingagainstthefrontiersofphysiologyandmedicinepresentsthephysicianwithdifficultethicalissues.Herethefateofexplorersofthephysicalworlddepartssharplyfromthatofourphysicianpioneers.Explorersrisktheirownlives;doctorsriskonlythelivesofthoseundertheircare,makingtheirendeavoreasierandatthesametimeinfinitelyharder.

Butitwasinthiswaythatthelastgreatchasminallofsurgerywascrossed:theyawninggapofaninchfromthewallofthechesttotheheart.Thecontinentoftheheartwasfinallyopenforexploration.

May18,1969:AU.S.medevachelicoptersetsdowninatinyclearingonHill937(“HamburgerHill”)asawoundedAmericansoldierisrushedaboard.

(©Bettmann/Corbis)

ATRAUMA

ttheBattleofWaterloo,WellingtonnoticedaFrenchdoctorinthemidstofcombat,attendingcasualtiesandmovingthemquicklybyhorseandcartfromthebattlefieldtotherear.UpondiscoveringthatitwasDominique-JeanLarrey—chiefsurgeontoNapoléon

Bonaparte—theBritishgeneralorderedhismennottofireinthedoctor’sdirectionand,accordingtolegend,liftedhishatinsalute.

Inmedicine,theimportanceofspeedhaslongbeenrecognized.Larrey,presentonthebattlefieldsofthelateeighteenthcentury,hadwitnessedheavy-artilleryunitswheelingandthenretreatingrapidlyfromtheadvancingenemywhilecasualtieswereleftbehindunattended.Onlyafterhostilitiesceasedwerethewoundedcollectedandtransportedtofieldhospitals,introducingsignificantdelaysbeforedefinitivesurgerycouldbegin.Andinanageofmorepowerfulfirearmsandartillery,surgeryoftenmeanttheamputationofmorethanoneshatteredlimb.

Forthosesoldierswhosetreatmentwasdelayedlongerthantwenty-fourhours,Larreynotedthatdeathwasfarmorelikely.Hissolutionwastoembedagilehorse-drawncarriageswithfrontlinetroopssothattheinjuredcouldbequicklycarriedfromthefieldofbattleduringcombat.Coupledwitharudimentarysystemoftriageinwhichthecasualtieswereprioritizedaccordingtotheseverityoftheirinjuries,thisinnovationtransformedbattlefieldcare.Menwhosetraumaticinjurieswouldhavepreviouslyprovenfatalwereabletosurvivelargelybecauseofthespeedwithwhichtheywereattended.Thesystemwasfirstimplementedintheclosingdecadeoftheeighteenthcentury,anditsvirtueswereinstantlyrecognized.Larrey’s“flyingambulances”weresoonadoptedthroughoutthearmiesofFrance.

Ofcourseambulanceswouldn’tactuallytaketotheairuntilwellintothetwentiethcentury.ThefirsthelicopterevacuationsofcasualtiestookplaceinWorldWarII,andbythetimetheKoreanWararrived,thesightofcasualties

WorldWarII,andbythetimetheKoreanWararrived,thesightofcasualtiesbeingferriedthroughtheskytomobilearmysurgicalhospitals—betterknownasMASHunits—hadbecomeiconic.HelicopterevacuationofbattlefieldcasualtiescontinuedtoplayakeyroleduringtheVietnamWar,dramaticallyimprovingthesurvivalratesofseverelyinjuredsoldiers.Asaconsequence,duringthe1960s,civilianhospitalsintheUnitedStatesstartedtoadoptthesemilitarysolutionsandbegantouseairtransporttorespondtotraumascenes—roadaccidents,shootings,stabbings,andthelike.

Anewgoalhadarrived.Forthebestchanceofsurvivalinthefaceoftraumaticinjury,itwasunderstoodthattreatmentshouldbeginassoonaspossible.Theconceptofthe“goldenhour”wasintroduced:theideathatafterinjurynomorethansixtyminutesshouldelapsebeforeapatientreceiveddefinitivecare.Themessagewasclear:Delaysinthetreatmentofvictimsoftraumawerenolongeracceptable.Bytheclosingdecadesofthetwentiethcentury,theprocessthatLarreyhadstartedduringtheNapoleonicWarshadledtoarevolutioninciviliantraumacare.

—INJULY1998,AFTERMYBRIEFstintasastudentinterninWashington,mycolleaguesandIstoodonthestepsofthemedicalschoolwearingcapes,mortarboards,andsmilesthatwereimpossibletowipefromourfaces.Itwasover;wehadgraduated.Wethrewourhatshighintotheairandtheofficialphotographerclickedaway.

Asnewlyqualifieddoctors,wemovedintotheMiddlesexHospitaleightweekslater,twenty-fourfresh-facedjuniors,wide-eyedandterrified.Wehadstudiedformorethanfiveyears,endlesslylearningandrecitingthevocabularyandgrammarthatunderpinnedtheartofmedicine.Wehadlearnedthelanguagewellenough;therewasnootherwaytopassthefinalexams.Butstartingworkwasachallengeonadifferentscale.Itwaslikegoingtoliveforeverinacountrywhosemothertongueyouhadonlyjuststartedtospeak.

Inthefirstfewdays,wereceivedinstructiononeverythingfromhowtowashyourhandstothecorrectwaytocompleteadeathcertificate.Theycrammedthepocketsofourlongwhitecoatswithhandbooksandthenshovedusoutontothewards.Forallofourtraining,wewere,atthebeginningatleast,worsethanuseless.Wewereguidednotonlybyourseniormedicalcolleaguesbutbynurses,wardclerks,andhospitalporters—allofwhom,atthatstage,knewfarmoreaboutourjobthanwedid.

Mosteveningsthoseofuswhoweren’toncallretiredacrosstheroadtothe

Mosteveningsthoseofuswhoweren’toncallretiredacrosstheroadtotheCambridgeArms.Therewerebetterpubs,buttotheexhaustedhouseofficer,thisonehadthevirtueofbeingclosest.Wewoulddrinktoomuch,sharethestoriesoftheday,andlaughatoneanother’smostrecentmisfortunesandbreathtakingdisplaysofignorance.

Wequicklydiscoveredthatmostofthejobwasn’taboutlifeanddeath.Toomuchofitrevolvedaroundfillinginformsandorganizingthelistofpatients.Astheteam’smostjuniordoctor,yourjobwastokeepafaithfulinventoryofthepatientsinyourcareandtheirmedicalcomplaints,guidingyourseniorteamaroundfrombedspacetobedspacesothattheycouldbringtheirexperienceandknowledgetobear.

Still,therewererare,terrifyingoccasionswhenyouweretemporarilyalone—usuallyinthemiddleofthenight,standingatthebedsideofablueandbreathlesspatient.Knowingimmediatelythattheyweresickandthatyoudidn’thavetheskillstostopthemfromcrashing,youpickedupthephoneandcalledforhelp.Afterthephonewentdownyouhadafewhundredsecondsofresponsibility:abriefopportunitytomakeadifference—oratleasttoholdthelineandpreventthingsfromgettingworse—beforethecavalryarrived.Thiswashowalloftheemergenciesweresupposedtowork.Youwerelittlemorethanasentinel:responsibleforsummoningamuchmorecapableteamtoconfrontsomethingbeyondyourabilities.Complex,rapidlyevolvingdiseasethatthreatensthelifeofapatientdemandsaswiftanddefinitiveresponse.Theworldofmedicinehascometounderstandthattraumaispreciselythat:acomplex,fast-movingdisease.

—ASASTUDENT,ILEARNEDTHATtraumaderivesfromtheGreekwordfor“wound.”Intheworldofmedicine,itreferstoinjuriessustainedasaresultofviolenceoraccident.Thatpair,violenceandaccident,areasancientasthespeciesitself.Tothenoninitiate,themechanismbywhichtheycompromisethefunctionofthehumanbodylooksasthoughitshouldbeeasytograsp.

Traumais,afterall,nottheresultofabacteriuminvisibletothenakedeyeoravirusthatsubvertsbiologyatthemolecularlevel.Itisnotlikeheartdisease,inwhichunseenplaquesofcholesterollurkinthefat-ladenvesselsofthecoronarycirculation,norisitlikecancer,inwhichsomearcanemalfunctioninthescriptofourDNAleadstotheunstoppabledivisionofacellanditseventualinvasionofourvitalorgans.

Whenyou’refirstintroducedtothespecialtyoftrauma,itisarelieftoencounteradiseaseentityinwhichthelinkbetweencauseandeffectappears

encounteradiseaseentityinwhichthelinkbetweencauseandeffectappearsabsurdlyclear.Inyourimagination,itislittlemorethanthetransferofenergytoamechanismandthedisruptionofitsvitalstructuresortherupturingofitsfuellines.Only,likeeverythingelseinmedicine,underthemagnifyingglass,itturnsouttobebrutallycomplex.

Still,yourfirstforayintothespecialtyoftraumaisdeceptivelystraightforward.“Keeptheoxygengoinginandout;keepthebloodgoingroundandround”remainsthemantra.ThefamiliarBoyScout,ABCprioritylististhefirststep:FixtheAirwayfirst,thenBreathing,andlast,Circulation.

Therearesubtlemodifications.Whileclearingandopeningtheairway,youhavetopayattentiontothespinalcolumn.Thebonesofthespine—thevertebraestackedcarefullyontopofoneanother—formahardbutflexiblehollowtubethatprotectsthebundlesofnervefibersrunninginthesofttissueofthespinalcord.Ifthisbonyarmorhasbeendamaged,thenthecordwillbevulnerabletoinjury,andwagglingtheneckaroundislikelytodamagethosenervefibersandsevertheirconnections,leavingthepatientparalyzedinallfourlimbs.Forthetraumaticallyinjured,protectionandimmobilizationofthespinalcolumnhighintheneckaredeemedasessentialastheletterAinthelistofABCpriorities.

Then,afterhavingdealtwithinjuriesthreateningtheBreathingortheCirculation,you’retaughtthatintraumathealphabetgoesalittlefurtherthanC.ThereisaDandEtolookaftertoo.DstandsforDisabilityandisawayofmakingyouremembertolookforsignsofinjurytothespinalcordbymakingsurethatthepowerinthemusclesandthesensationinthebody’sextremitiesremainintact.TheEisforExposure,andisanaide-mémoiretomakesurethatyouhavelookedfromheadtotoeforhiddeninjuries.Casualtieslyingonstretchershavebeenknowntobleedtodeathfromsmall,penetratingwoundsorscalplacerationshiddenfromfrontalview.Thisiswhytraumateamsunceremoniouslyshearclothingfromvictimsandthenrollthemnakedontotheirside.

Confrontedwiththeworsttraumaticinjuries,it’seasytogetdistractedandmisseasilytreatablebutpotentiallyfatalinjuries.TheABCDEapproachisatightlyhonedprotocol,designedtoofferasystematicapproachtotraumathatstopscasualtiesfromdyingofpreciselysuchoversight.Properlyadheredtoandexecuted,thissystem,dubbedtheAdvancedTraumaLifeSupportprotocol,willgetyouthroughtheworstfiveminutesofeventhemosthorrifictraumacase.

Atleastthat’stheidea.

—

—INTHOSEFIRSTFEWMONTHS,webecamemarginallymorecompetentandmuchlessscaredofjustabouteverything.Wegotusedtobeingexhausted,becausetheworstweeksstillrantooverahundredhours.Welivedandworkedinthesamebuilding.Ourdormroomslinedacorridoronthefourthfloor.Thoughwetriedtomakethemfeellikehome,withscatteredpostersandplants,theywerelittlemorethanaplacetosleep.

Weekends,we’dmakeabreakforfreedom.OnaFridayafternoon,ifyouweren’tdueoncall,yougotyourselfoutofthehospitalasfastasyoucould.Thosewhoremained,holdingthepagersandcoveringtheemergencies,lookedonwithenvyascolleaguesfledthebuilding.

OnFriday,April30,1999,itwasmyturntobeoncallwiththesurgicalteam.Itwasthestartofabank-holidayweekend,whichservedonlytoacceleratetheusualexodus.IstoodattherearentranceoftheAccidentandEmergencydepartmentdressedinhospitalgreens,watchingtheambulancescomeandgo.

TheA&Ewaswindowlessandalwayslookedthesame.Opentwenty-fourhoursaday,everydayoftheyear,itwasconstantlyilluminatedbyflickeringfluorescenttubesandtheglowoftheX-rayboxes.Inside,thewhirlinghandsoftheclockonthewallsomehowdidn’tgiveyouapropersenseofthepassageoftime.Wegatheredinthequietermomentsattherearentrancetothehospital,withitslessthanspectacularviewofthecar-parkasphaltandthesubtlearomaofambulancediesel,tocatchsightofthefadinglightorbreakingdawn.

Itwasafineandunusuallywarmevening.Byhalfpastsix,allbutthemostessentialstaffweregone.Thedepartmentwasquiet,andthecasualtywaitingroomnearlyempty.Peopledrawnoutbythegoodweatherwerepackedintopubsandbarsthroughoutthecityandwellontheirwaytobeingdrunk.Theinjuries—theusualcatalogofassaults,roadaccidents,andanklesturnedoncobblestones—generallyfollowedlater,afterpeoplewerekickedoutontothestreets.Iturnedbackintothedepartment.

Onthewallnexttothenurses’stationwastheredphone,anoldBakelitethingwithadial.Ittookonlyincomingcallsandrangwiththeold-fashionedtrillingofarealbell.Itwastheresothattheambulanceservicecouldcallaheadandtellusiftheywerebringingsomethingbadin,givingustimetoassembleandprepareinthebigresuscitationbaysattheback.

Justbeforeaquartertoseven,theredphonerang.Alex,thenurseincharge,listenedintently,scribbledsomedetails,andputthehandsetdown.Usuallyapithycasesummaryabouttheimminentarrivalofasinglepatientwouldfollow:aheartattack,amassivedrugoverdose,orperhapsastabbing.Thedepartment

aheartattack,amassivedrugoverdose,orperhapsastabbing.Thedepartmentwassetuptotackletheseblue-lightemergencieswithoutbreakingitsstride.Asmallteamwouldpeeloffintothecrashroomsandgetonwiththeresuscitationwhiletheingrowntoenails,superglueaccidents,coughs,andcoldscontinuedtostreaminthroughthefrontdoor.

Butthiscallwasdifferent.Alexraisedhervoicetomakeherselfheard.Therehadbeenabomb,shetoldus,inanearbypubinSoho.Thereweremanycasualties.Amajorincidenthadbeendeclaredsothatwecouldpreparetoreceivecasualties.Thatwasalltheinformationweweregiven.

Weallstoppedforamoment,tryingtodigestthenews.Thenthesoundcame,withheart-stoppingstrangeness,ofeverypagerinthehospitalburstingintosongsimultaneously.Amachine-gunsuccessionofmonotonechimeswasfollowedbythecracklingofthepagers’tinyloudspeakers.“Majorincidentdeclared,”cametheslowanddeliberatevoiceoftheswitchboardannouncer,andthenagain:“Majorincidentdeclared.”

Thetraumateamassembledinthecrashrooms:asurgicalregistrar,aseniorhouseofficer,andme;ourconsultantswerealreadyontheirwaybacktothehospital.Theredphonerangagain.Thereweremanypeopleinjuredandsometrapped.Theambulanceservicewasaskingforamobileteamofdoctorsandnursestogoouttothescene.

Thesurgicalregistrardidn’twanttolosesurgeonswhowouldlikelybeneededtoruntheresuscitationbaysorassistinoperatingrooms.I,ontheotherhand,couldbespared.

Themobileteamwascomprisedofthreedoctorsandthreenurses.Theaccidentandemergencynursingstaff,familiarwiththemajor-incidentdrill,manhandledusthroughthepreparations.IwaspushedintoanequipmentroomthatIhadneverbeforenoticed.Ifoundmyselfpullingonafluorescentsuitanddonningahardhat.Atraumapack,fullofequipmentanddrugs,wasshovedintomyhands.AndthenIwasbeingusheredoutintotheambulanceparkingbays.Beforeanythingmorecouldbesaid,apairofambulancesscreamedintotheparkinglotandflungtheirreardoorsopen.Thesixofusclimbedinside.

IsatclutchingmytraumapacknexttoanA&EregistrarandoppositeChristine,oneofthenurses.Therestoftheteamwasintheotherambulance.Christineleanedinandraisedhervoiceabovethenoiseofthesirens:“Thisisamajorincident,”shesaid.“Youarewearingyourpersonalprotectionequipment.Inyourjacketpocketsandpackarethefollowingitems...”Shestartedreelingoffthelist.

Ijuststaredather.Shewaslookingmerightintheeyeandtalkingtome—

Ijuststaredather.Shewaslookingmerightintheeyeandtalkingtome—nearlyshouting,infact,togetabovethedinoftheenginesandsirens—butitfeltasthoughshewereaddressingsomeoneelse.Shepaused,waitingformetocarryoutmychecks.Ipulledthepocketsopen.Itwasallthere,justasshe’dsaiditwouldbe.Howcouldsheknowwhatwasinmypockets?AndthenIrealizedthatshe,unlikeme,wastrainedforthisevent.She,atleast,knewwhatshewasdoing.

Theambulancewentupanddownthroughitsgears,hurtlingtowardthescenewithusintheback.Thejourneycouldn’thavetakenmorethanfiveminutes.Whenitdrewtoahalt,Ididn’treallyknowwherewehadarrived.Thenthereardoorsopened.

Ittookmorethanafewmomentstoorientateourselves.WewereatthejunctionofOldComptonStreetandDeanStreet,partofLondon’stheaterdistrict.Thestreetsthereusuallythrongedwithtouristsandclubbers.Butasthedoorsopened,itwasunrecognizable.Glasscarpetedthestreet,ambulancescrowdedalloftheaccessroads;theplacewasawashwithcasualties.

Whenwearrived,thescenewasbarelyundercontrol.Thebombhadgoneofflessthanthirtyminutesearlier.Thepubwasstillsmoking;thefirebrigadehadjustfinishedhosingbitsofitdown.AregistrarfromtheHelicopterEmergencyMedicalService(HEMS)hadarrivedaheadofusandhadtakenchargeofthemedicaldecisionmaking.He,alongwiththeambulanceofficers,hadseparatedthewalkingwoundedfromthosemostseverelyinjured.

Whenwearrived,wewerepointedatalitterofbodiesinthemiddleofOldComptonStreetbeingattendedbyparamedicsandfiremen.TheywerethemostseverelyinjuredpeopleIhadeverseen.Theyremainsotothisday.Therewereperhapsadozenpeopleonthegroundinfrontofus.Theywereexposed;mostoftheirclothinghadbeenincineratedintheflashfirethatfollowedthedetonation.Theirbodieshadsufferedburns;someoftheirlimbshadfracturedorbeenamputatedbytheblast.

Intheworstsituations,thetrickisnottothinktoohard.It’sbesttostayfocusedontheonetaskatatimeandtomakethattaskassimpleaspossible.Forfast-movingsituations,thereareprotocolsthatcanbeunpackedanddeliveredalmostreflexively.Whiletheseachievemanythings,oneoftheirmostimportantfunctionsistostopyou—strugglinginthemidstofeventsthatwordscouldneveradequatelydescribe—fromgrindingtoahalt.

Thealphabetofsurvivalcomestotherescue,theAdvancedTraumaLifeSupport.ThosesimpleABCsgetyoumovingandstopyoufromthinking.Youdon’tmuchcareaboutwherethesystemcamefromorhowitwasdesigned.Youarejustgratefulthatitexists,andyouwonderhowanyonecouldbeexpectedto

arejustgratefulthatitexists,andyouwonderhowanyonecouldbeexpectedtocopewithoutit.

—BACKIN1976,DR.JAMESK.STYNERwasflyinghisfamilyfromLosAngelestohishometownofLincoln,Nebraska,afterattendingawedding.Thefamilyhadtraveledsomeconsiderabledistance:eastacrossSouthernCaliforniaandArizona,landingbrieflyinNewMexicotorefuel.

Theytookoffandcontinuedtheirjourneyhome,eventuallyturningnorthoverTexasandupthroughOklahomaandKansas.Astheycrossedoverintotheairspaceoftheirhomestate,Nebraska,theyranintothin,low-lyingclouds.Thedaywascomingtoanend,and,notbeingratedtoflyoninstrumentsalone,Stynerchosetostaybelowthecloudbase.BythetimetheyreachedLincoln,thesunhadalreadyset,buttheywerealmosthome.Then—flyinglowwiththeskiesnearlydark—Dr.Stynerbecamesuddenlydisoriented.Hesteeredhisplanelowacrossapondandrealizedtoolatethathewasbelowthetreetops.

Therewasadeafeningroarastheaircrafthitthetreesandplowedintoandthenacrosstheground,rippingthroughtheunderbrush,disintegratingasitwent.Inthosebriefseconds,JamesStynerwaitedforhislifetoend.Thewingsweretornoffalmostimmediatelyandtheremainingfuselageslidforovertwohundredfeet,spinningsothatitfinallyfacedbackward.Theplanesomehowcametorestupright,itsfueltanksrupturedandspilled,ahugeholegougedinitsright-handside.

Jamesopenedhiseyes,amazedthathehadsurvivedtheimpact.Thelowerribsontheleftsideofhischestwerefractured,andhisforeheadandface,whichhadsmashedintothedashboard,weredeeplycut.Charlene,hiswife,wasnowheretobeseen.

Theworldfellsilentaroundhim.Dazed,hepulledhimselfoutoftheaircraft.Onceoutside,hisheadclearedalittle,andhisprioritybecamethechildrenstilltrappedinthewreckage.

Chris,tenyearsoldandtheeldestofthefour,wasleastinjured—hisarmwasbroken,andhishandwasbleeding,buthewasstillawake,alert,andoriented.Kim,sittingonhislapwiththesamebeltaroundherwaist,wasunconscious,herheadhavingcollidedwithafireextinguisher.Shewasthreeyearsold.Theotherchildren,RickandRandy,wereinevenworseshape.Eight-year-oldRick’sheadwasdeeplylacerated,andhetoowasunconscious.Randy’slegwaspartlyimpaledonthejaggedfuselageandtrappedbeneaththeplane.

Dr.StynergotKimandRickoutfirst.HeknewthatRandywaspinnedand

Dr.StynergotKimandRickoutfirst.HeknewthatRandywaspinnedandinjuredbutfearedthattheaircraftmightyetburstintoflames.Ifthathappenednoneofthemwouldsurviveandso,ashardasitwas,hehadtostageandprioritizetherescueofhisownchildren.HecarriedRickandKimasafedistancefromthewreckageandsetthemdownontheground.ThenhereturnedtotheplaneanddugintothegroundaroundRandy’strappedleg,excavatingandfreeingitfromitsimpalement.Heexpectedittobleedprofusely,butmercifullyitdidn’t.Chris,withhisbrokenarm,managedtofindhisownwayout.

Theygatheredsomeclothesfromthescatteredluggageandpiledthemlikeblanketsovertheyoungerchildren.ItwaswinterinNebraska,andthatnighttemperaturesfellbelowfreezing.Theywaitedintheneardarkness—illuminatedonlybythelightofthemoon—forhelpthatnevercame.Finally,realizingthattheywereontheirown,Jameswentoutinsearchofhiswife,Charlene.Heventuredouttwicewithoutsuccess,returningtothechildreneachtime.Onthethirdoccasion,hefoundher.Shehadbeenthrownmorethanthreehundredfeetfromtheplaneandhadsufferedacatastrophicheadinjury.Charlenewasdead.Withtemperaturesstilldroppingoutside,Jamesnowhadtofocushisattentiononhischildren.

Worriedabouttheinjuriestheyhadsuffered,Dr.Stynerdecidedtogoinsearchofhelp.Fromthecrashsite,theycouldseearoadinthedistance.Hewasawareofpainintheribsoverlyinghisspleenandwonderedifittoomightbeinjuredandbleedingorindangerofrupture.Ifthatweretrue,thenthelongmarchinsearchofhelpwouldonlymakethingsworse.Butwithnoideawhen,orindeedif,rescuerswouldarrive,hedecidedthatheshouldtaketheriskandgoanyway.

Jamestalkedfranklywithhisten-year-oldson,Chris.Hetoldtheboythathewasconcernedaboutthestateofhisownspleenbutmoreworriedaboutthechildren’sinjuries.Heexplainedhisplanstogogethelpandsaidthatifhedidn’treturn,Chrisshouldn’tgolookingforhimbutinsteadstaywithhisbrothersandsister.Hisvoicewascalmandremarkablyfreeofemotion.Jamessaidgood-byeandthenshortlyaftertwoA.M.,hesetoutfortheroad.

Afterwhatseemedaneternity,hefinallyreachedtheroadandflaggeddownacar.Hisfacewascakedwithblood,andinitiallytheoccupantswerehesitanttoleavetheirvehicle.Buthemanagedtoexplainhissituation,andtogethertheyreturnedtothecrashsite.Theygatheredupthechildren,andJamessaidafinalgood-byetohiswife.Then,somehow,thefiveofthemcrammedintothebackofthecaranddroveafewmilessouthtoHebronhospital.

Hebronwasasmallcommunityhospital,andwhentheyarrivedintheearlyhoursofthemorning,thedoortoitsEmergencyRoomwaslocked.Alonenight

hoursofthemorning,thedoortoitsEmergencyRoomwaslocked.Alonenightnursestoodatthedoorandaskedthemtowaitforthedoctorstoarrive.Somehowtheyforcedtheirwayin,butthingsdidn’timprovemuchwhenthehospital’smedicalteamfinallyarrived.Theirapproachlackedstructureandseemedtoignorekeyinjuries.ItbecameobvioustoJamesthattheywereunpreparedforthenatureandextentofthefamily’straumaticinjuries.Slidingoffhistrolley,hestoppedthelocaldoctorsfromtreatinghischildrenandtookovertheircare.Hehadcometoofarforthingstofailhere.

NexthecontactedcolleaguesinLincolnandorganizedtransportbyairbacktohisownhospital.TheylandedatLincolnAirportandtraveledbyroadtoLincolnGeneralHospital’sEmergencyRoom,arrivingateightA.M.—morethanfourteenhoursaftertheircrash.ThereJamesStynercouldfinallyresigntheroleofdoctortoateamofhisfriendsandcolleaguesandoncemorebecomeapatientandparent.

Dr.Stynerwasincensedbyhowlongithadtakentogethischildrenthetraumacaretheyneeded.Hedidn’tblamethephysiciansandnursesatHebron,buthefeltthathe’dbeenabletodeliverbettercareasatraumavictimatthesceneoftheaccidentthanhe’dreceivedatthelocalhospital.Ifthatwasthecase,thesystemwasbroken,andthingswouldhavetochange.

Intheyearsthatfollowedtheaccident,JamesK.Stynerinvestedallofhiseffortsindesigningastraightforwardprotocolforthemanagementofcasesoftrauma;onethatcould,ifnecessary,bedeliveredbyeventhesmallestofhospitals.Hebaseditonexistingmodelsforthedeliveryofcardiacresuscitation,adoptingthatpowerfulABCapproachandextendingit.Justfouryearsafterhisplanecrash,Dr.JamesK.Styner’sAdvancedTraumaLifeSupport(ATLS)coursewasadoptedbytheAmericanCollegeofSurgeons.Hetrainedpeopletodeliverlifesavingtraumacarewhatevertheirsituation,andthenhetrainedthemtotrainothers.CoursessprangupallovertheUnitedStatesandthenallovertheworld.Intheyearsthatfollowed,ATLSwentviral.Todate,morethanamillionpeoplehavelearnedtofollowit.Ina2006lecture,StynertoldtheremarkablestoryofitsoriginsandfinishedbyjokingthatithadspreadaroundtheworldandwouldsoonbetaughtontheMoonandMars.Hewasn’tfarwrong.

—ONTHECHAOTICSOHOSTREET,IcheckedthefirstofthecasualtiesIreached.Hewaslyingontheground,hisclothesintatters,hisskinscorched.Therewere

nailsembeddedintheskinofhischestandabdomen,buthishandswerewarmandhecouldstilltalktomeclearly.Ipushedanintravenousdripintoaveinonhisarm.Itriedtostickadressingoverthetopofitbutitwouldn’thold;thelayersofburnedskinjustsloughedoffunderneath.I’dneverseenanythinglikeit.Grabbingacrepebandagefrommypack,Iwounditaroundthelineandtieditinplace.Andthen,havingdonethelittleIcould,IrealizedIhadtoleavehimwiththeparamedicsandmoveontosomeoneelse.IturnedtodiscoveramuchmoreseriouslyinjuredmanwithChristinealreadyathisside.

Therewasbleeding;atleastthat’swhatIremembermostofall.Oneofhislegswasmissingandhisfaceandchestwereburned.Bitsofshrapnelprotrudedfromhisremaininglimbs.Hewasawakebutonlyjust.Istartedatthetop,atA,checkinghismouthforinjuryorobstruction.ThenontoB:Igotmystethoscopeoutandwentthroughthemotionsofplacingitsbellonhischest.Butabovethechaosofthesceneneitherthegentlerushofairnorthedrumofhisbeatingheartwasaudible.Iputmycheekclosetohismouthandturnedmyheadtolookathischest,watchingforitsrhythmicriseandfallandtherushofwarmairagainstmyface.Atthispointoneofthefiremenpointedouttheamputatedleg,worriedperhapsthatIwasignoringtheobviousinjury.

Hewasright,ofcourse.WhenitcomestotraumathealphabetarguablyshouldstartatCforCirculation.Majorhemorrhagehastobedealtwithfirst.Theadultheartcirculatesaroundfivelitersofbloodaminute,moreifyou’vejustbeeninjuredandthere’salotofadrenalinearounddrivingitharderandfaster.Foramanofaverageheightandbuild,thewholecirculationholdsperhapsonlyfivelitersandsoasignificantbleedwillkillinminutes—atleastasfastasanobstructedairwayorinjuredchest.Ilookedattheleg.Therewasplentyofbloodonthefloor,anditappearedtobeoozingsteadily.Ifeltdownforthefemoralarteryinthefrontofhisrightthigh.Thepulsetherewasstillgoodandreasonablystrong.IgrabbedoneofthefiremenandpulledhishanddownontothespotwhereIcouldfeelthepulse,askinghimtopushdownhardoverthearterywithhisthumb,hopingthatthiswouldcloseitoffandslowtherateofbloodloss.ThenIcarriedonwithmysurvey,workingagainfromheadtotoe.

Isitedalineintohisarm,too,andstartedsomefluids.Hewassickandgettingsicker.Thereinthemiddleofthestreet,therewasnothingelseIcouldoffer,nothingelseIknewhowtodo.JustatthepointatwhichtheprotocolIwasfollowingendedandImighthavestartedtoflounder,oneoftheHEMSparamedicswalkingbyputahandonmyshoulderandsaid:“Doesheneedtostayorgo?”

“Heneedstogo,”Isaid.

“Heneedstogo,”Isaid.

—ITISTEMPTINGTOTHINKofthatmomentastheendofthestoryfortrauma:thepointatwhichtheambulancedoorsshutandthevictimisspedalongtothenearesthospital.Intruth,rapidaccesstotreatmentandtheATLSprotocolhavetransformedthesurvivalrateofseriouslyinjuredcasualties.Butthefightdoesn’tfinishthere.

ForDominique-JeanLarreyonthebattlefieldsoftheNapoleonicWars,traumasurgeryreliedlargelyupongettingcasualtiesintoafieldhospitalasfastaspossibleandthenstitchingwoundsandperformingamputationspromptlytoarrestbleeding.Therewerenoanestheticsorantibiotics,andsurvivaldependeduponaddressingtheprimaryinjurybeforeitbecametrulylifethreatening.

Today,forthepatientswhoarriveinourtraumaunits,wecandoalotmore:Wefillthemwithblood,splintlimbs,throwstitchesintherupturedvesselswecansee,scoopoutbleedingspleens,repairpuncturedviscera,andpacklaceratedlivers.Allthiswedowhileholdingtheirphysiologystablewithdrugsandlife-supportmachines.

Innovationinthepursuitofsurvivalhastakenusfurtherstill.Weusebeautifullynuancedphysicstoimage,infascinatingdetail,whatremainshidden.Wecanthreadlongtubesintovessels,snakingthemupfromdistantpointsofentry.Wedeploydevicesthatblockorstenttorrentiallybleedingarteriesandveinsthatcan’tbereachedsafelyorquicklywithaknife.

Oncethepatienthasbeentakenfromthesceneoftheaccidentandresuscitated,openedup,andthehemorrhagestopped,thefightcontinues.It’snotenoughtounderstandthemechanismsofbleedingvessels,crushedviscera,andfracturedlimbs.Thebleedingtapshavingbeenturnedoff,limbsandorganshavingbeensaved,patientscanstillcontinuetodecline.

Inthemostseverelyinjuredpatients,kidneyscanshutdown,heartscanmalfunction,andlungscanfail.Itisthissecondarywaveofillnessthatfollowsinthewakeofmajorinjurythattakestraumaoutoftherealmofthesimple,physicaldisruptionofamechanismandturnsitintoacomplexandformidabledisease.

—WHYDOYOUBLEEDTODEATH?That’sthesortofseeminglyinnocuousquestiontheydishoutatfinals.Butit’slikesomeoneaskingyouhowawheelworks.Youthinkaboutitforabouttenseconds,andthenrealizetwothings:Youdon’tknow

andyouneverknew.Ifthere’snobloodrunninginyourveins,youdie.Yes,butdeath,oratleastcardiacarrest,happenslongbeforethesystemisemptyofblood.Sothequestionbecomeswhatcausesthecardiacarrest.Thatinnocentquestionrestsondeterminingwhatisbehindtheforceandenergyofeveryheartbeat.Andthenyouknowyou’reintrouble.

Nervesrunningfromthebrainsendimpulsestotheheart,moderatingitspaceandforceofcontraction,andattimesofstress,adrenalinecirculatesinthebloodstream,drivingitharderandfaster.Butinthefaceofinjuryandmassivebloodloss,it’snotthemalfunctionofthissystemthatcausesthehearttofalterandstop.Itisthemechanismoftheheartitself.Thehearthasspecializedmusclefibersthatmatchtheforceoftheircontractiontotheamountofbloodenteringit.Ifmorebloodreturnstotheheartjustbeforethestartofaheartbeat,themusclecontractsharderandsopushesoutalargervolume.It’sawayofmakingsurethattheheartejectsthesamevolumeofbloodasentersit.Ifitwereunabletomatchitsinsandoutsinthisway,itwouldrapidlyballoonandfail.

Butwhenlessbloodreturnstotheheart,itbeatswithlessforce.Andifthecirculationissuddenlylosingvolumebecauseofahemorrhage,theheartemptiesfurtheranditscontractionsbecomeweaker.Ifbleedingcontinuesunchecked,thehearteventuallyarrests.

Inthefirstmomentsoftreatingatraumavictim,you’retryingtopreventexactlythat.It’swhyit’ssoimportanttostopthebleedingandmaintainanadequatecirculatingvolumeinthebloodvessels.Oncethefirstphaseofresuscitationiscomplete,afteryou’vefollowedJamesK.Styner’sall-importantATLSalphabettotheletter,muchofyoureffortcontinuestobededicatedtothesametask,stoppinghiddenbleedingwithsurgeryandrestoringvolumewithbloodandfluids.

Butevenwithoutresuscitation,thebodystartstoprotectitselfusingthesamestrategy.Inthefaceofmassivehemorrhage,injuredbloodvesselsspasmandshutthemselvesofftopreventfurtherloss.Elsewhere,vesselsintheextremitiesconstrict,forcingbloodbacktowardthecentral,vitalorgans,temporarilydeprivinglessimportanttissuesbutreturningmorebloodtotheheart.Thisreflexiverecoilofperipheralcapillariesnearthesurfaceoftheskinispartlywhataccountsforthepaleappearanceoftraumavictims.Butthebody’sresponsetotraumagoesbeyondtheheartanditssystemofbloodvessels.

Hormonespourintothebloodstream,mobilizingfuelstoresfromfatandraisingthebody’ssugarlevels.Theproteininmuscle,too,beginstobebrokendownanditsconstituentcomponentsrecycledtoassistinthedefense,likeacountryputtingitseconomyontoawarfooting.

countryputtingitseconomyontoawarfooting.Butthemostcomplexandproblematicaspectofthehumanbody’sresponse

tomajortraumaisthatoftheimmunesystem.Atthesiteofinjury,whitebloodcellspatrollinginthebloodstreamandthecellslininginjuredvesselsandtissuesreleasemessengermolecules.Thesesummonahostofotherimmunecellsthattakepartinremovingdeadanddamagedmaterialandpreparethewayforhealing.Inmoderateinjury,itisabeautifullyorchestratedprocessthatsweepsawaycellsthatarenolongerviableandreplacesthemwithnewones,allthewhilemakingsurethatenoughenergyismadeavailabletocopewiththeincreasedmetabolicdemandofthisrestoration.

Thesemechanismsevolvedovermillionsofyears.Theyarewhatallowedourancestorstohuntandtodefendtheirfamilies—tobepredatorandprey—andthenlimpoffintothebushesandreturnrebuilt.Forminorandmoderateinjury—deeplacerationsandwoundsthatdon’tinvolvevitalorgansoruncontrolledbloodloss—thebody’sresponsehasbeencarefullyhonedoverDarwiniantimescalestoworkinourfavor,assistingoursurvivalandensuringthatourgenescontinue.

Butforsevereinjuriesofthetypethatwouldhavekilledapersonquicklyinthedaysbeforemodernmedicalintervention,noappropriatesurvivalprocesshasevolved.Insteadtheimmuneresponsetotraumaoscillateswildly,causingmoreharmthangood.Theimmuneresponseiseffectivelylikefiringupanuclearpowerstation.Youwanttoencouragethereactiontokickoff,gocritical,andgenerateheat,butyouhavetomoderateitwellenoughtoavoidmeltdown.Underactivationwouldleavethevictimpronetoinfection.Overactivationwouldleadtothemalfunctionofourorgansystems,thebiologicalequivalentofmeltdown.

Thereisnoevolutionaryprecedentforthelimitsofsurvivalwearenowprobing.Bythetimewe’resupportingmultipleorgansystemsonanintensive-careunitinthewakeofmajortrauma,we’veleftevolutionfarbehind.Outatthoseextremes,wedependnotonourphysiologybutuponstate-of-the-artsystemsoflifesupportandthespeedwithwhichtheycanbebroughttobear.Theideathat,intheeventofmajoraccident,ateammightliterallydropoutofthesky,scoopyouupfromtheroad,andpropelyouwithinminutestoahospitalisaconstructofmodernmedicinethathasexistedonlyinrecentdecades.Theedgeoflife,inthatrespect,hasneverbeenmoreheavilyinvestedin.Expectationsofsurvivalinthefaceofhorrificphysicalinjuryandphysiologicalinsulthaveneverbeensohigh.Allofthismeansthattoday,whenfacedwitheventhemostextremetrauma,wearelesswillingtoacceptdefeat.

—WHENTHEBOMBSITEWASCLEARofallthemajorcasualties,wemoveduptoSohoSquaretocheckoverthewalkingwounded.WewalkedalongDeanStreet.Thecafésandbarswereentirelyvacant,theirtablescoveredwithhalf-eatenmealsandhurriedlyleftdrinks.Afterward,wereturnedtothehospital,andIworkedthroughthenight.

ThepubthathadbeenbombedwascalledtheAdmiralDuncan.Itwasabarpopularwithgaymen.Thebomber,atwenty-three-year-oldparanoidschizophrenicandformermemberoftheultra-rightBritishNationalParty,hadplantedanddetonatedtwopreviousdevicesintheprecedingfortnight—oneinBrickLaneandoneinBrixton.ThebombinSohowasthefirstonetoinflictfatalities.

—ONFRIDAY,APRIL30,1999,ANDREADYKESandherhusband,Julian,traveledtoLondon.JohnLight,whohadbeenthebestmanattheirwedding,waswiththem.Andreawasnewlypregnant,andtheywereinacelebratorymood;Johnwastobegodfather.TheywereontheirwaytothetheatertowatchthemusicalMammaMia!butdecidedtostopforadrinkattheAdmiralDuncan.TheywerejoinedbyJohn’sfriendandformerpartner,NickMoore.

Thebombdetonatedat6:37P.M.Morethanahundredpeoplewereinjured.TheblastkilledAndreaandNickinstantly.Johndiedthefollowingday.Thenineothercasualtiesadmittedtointensivecareallrandifficultandprolongedcourses,butallofthemsurvived.

OnJune30,2000,DavidCopelandwasfoundguiltyofthemurderofNickMoore,AndreaDykes,andJohnLight.In2007theHighCourtruledthathemustserveatleastfiftyyearsinprison.

April2003:PassengersonHongKong’sMassTransitRailway(MTR)duringthesevereacuterespiratorysyndrome(SARS)outbreak.(©AFP/GettyImages)

TINTENSIVECARE

hepatternsontheelectrocardiogram(ECG)screentripoveroneanother,degeneratingoncemorefromtheessentialelectricalrhythmoflife,becomingsomethingmorelethal.Thepatientiseighteenyearsold,andIdon’tknowwhat’swrong.Thenurseschargeupthe

defibrillatoragain.Wedelivertheshocktotrytoescapethisdownwardspiral.Thereisapause.Thecellsoftheheartresetthemselves,andthenamorenormalrhythmreturns.

Wehavetakenblood,shotX-rays,andrunCTscansinsearchofadiagnosis.Thereislittletheretoguideus.Wehaveexaminedhimfromheadtotoe.Hischestisclear,heisfreefrominjury,andhiskidneysappeartobeworking—atleastfornow.Buthisbloodchemistryisamess.Lacticacid—atoxicby-productofthebody’smetabolism—isbuildingupfast.Normallyhiskidneysandlungswouldclearitfromthecirculation,buttheyareoverwhelmed.Lyingthereinthebed,unconsciousandventilated,surroundedbytheblinkinglightsofenoughmonitorstoputaChristmastreetoshame,hisheartdrivenbydrugs,hislungsdrivenbyamachine,hehasthephysiologyofamanexhaustedandonthevergeofdeath.TheECGdegeneratesoncemore.Weshockagain.

Hisbellyisslightlyswollen.Perhapsthereisaproblemwithhisgut.Perhaps,somehow,abranchofthecirculationthatsuppliestheloopsofbowelhasbecomeobstructedorcompromised.Thatwouldbemorethanenoughtomakehimcriticallyunwell.Buthe’sreallytooyoungforthattobelikely.WereviewtheCTscanimages.Tooureyestheyareunremarkable.Noneofitaddsup.Wecallinthesurgeons.Theyarereluctanttooperate.Iftheytakehimtosurgery,he’llprobablydieonthetable.Butifwedonothing,hewilldieforsure.Wedebatethedecision,andwhilewedoso,Ishockhimagain.Itisperhapsthetenthdefibrillation.Ihavelostcount.

Thisisintensivecare.Wecansupporthearts,replacekidneys,ventilatelungs.Wecanresuscitate,renderunconscious,andreplenish.Thisisthesharp

lungs.Wecanresuscitate,renderunconscious,andreplenish.Thisisthesharpedgeofallthatcanbedonetosupporthumanphysiologyagainstillnessandinjury.Thisiseverythingwehave,andstillIcannotseehowwecanpossiblywin.Whenisenoughenough?Perhapsthesurgeonsareright.Itis,afterall,absurd—extrudingaman’sphysiologytoitsverylimitsinthisway,wellbeyondanyrealisticexpectationofsurvival.Whyshouldwesetourselvesagainstthesecatastrophes,whenthereareotherfightsthatmightbemoreeasilywon?

Theformidablesystemsofartificiallifesupportatmodernmedicine’sdisposalcreatenewproblems.Thedesiretofindsomethingmorethatwecoulddointhestruggletosavelifeissometimesreplacedbytheneedtounderstandwhentostop.Tohelpunderstandwhywetryatall—andtheeventsthatgavebirthtothefirstintensive-careunits—wemustfirstgobacktoatimeandplacewheremodernmedicalinterventionswouldhaveseemedlikethestuffofsciencefictionandtechnologypresentedlittleobstacletodeath.

—THEVILLAGEOFGRANDGAUBE,onthetinyislandofMauritius,issetbackinlandonlyafewhundredfeetfromtheIndianOcean.In1946itwasaramshacklecollectionofthemostbasicdwellings,separatedfromtheseabyabeachofbrilliantwhitesand.Myfather,AhYoong,andhisfamilylivedinasingle-roomedhut.Hewasnineyearsoldandsharedthefloorspacewithhisparents,histwobrothers,DanielandJohn,andthreesisters,Angele,Pierrette,andTherese.Theroofwasmadeofcorrugatediron,andthewallsweremadeofstonewithbarredopeningsthatservedaswindows.Itwas,inmyfather’sestimation,thebesthouseinthevillagebyfar.

Hisparents,LiMoonKiandTangTinYing,wereimmigrantsfromChina,findingtheirwayfromthesoutheasternChineseprovinceofGuangdong,viatheoceangoingtraderoutes,toMauritius.TheywereHakkapeople—literally“thevisitors”—nomadicovercenturies,movingwherethelandwasgood,neverlimitedbygeographicalboundaries.Whentheageofsteamcame,theyboardedshipsinsearchofprosperity.ThatjourneyendedinMauritius,atinyvolcanicislandmaybethirtymileswideandnotmuchmoreinlength,fringedbywhitebeachesandavibrantcoralreef.TangTinYingwasbyallaccountsawomanoffiercecharacterandintelligence,butshewasilliterate.LiMoonKi,however,wasamongthefewmenofthevillagewhocouldreadandwrite.Thehousedoubledasageneralstore,sellingeverythingfromriceandspicestoliquorandnails.

GrandGaubewasafishingvillage,aramshackleassemblyofhutswith

GrandGaubewasafishingvillage,aramshackleassemblyofhutswithwoodenwalls,thatchedroofs,andcow-dungfloors.Therewereoutsidestandpipesbringingfreshwater,butonlythemostbasicsanitation.

FortheresidentsofGrandGaube,theseawastheirlife.Theytookitsspoilsandwerehostagetoitstemperament.Theywerevulnerabletothetropicalstormsitbrought,particularlyitscyclones.Inthesummerof1945,twocyclonespassednearMauritiusandathirddescendedontheislanddirectly.Thesespiralingwinds,withgustsofoverahundredmilesanhour,carrieddrenchingrainsanddestroyedwhatlittleinfrastructurevillageslikeGrandGaubehad.Afterwardmyfatherandhissiblingscollectedthefishfreshlystrewnalongthebeachandswaminnewlyformedpoolsbroughtbystormandtidesthathadruninland.Butsewagehadspilledintothesewaters,anddiseaseswiftlyfollowed.

ThatsummeranepidemicofpoliobrokeoutonMauritius,causingasmuchdevastationasthecyclones.Theviruscausingthediseasecouldbecarriedinthegutandthenspreadinfeces.Poorhygiene,thedestructionofinfrastructure,andboutsofdiarrhealillnessesfollowingthecycloneallconspiredtoamplifythespread.AteamofBritishepidemiologiststrackeditasitmovedfromvillagetovillage,oftencarriedbyhealthyadultswho’dbuiltupanimmunitytothevirus.

Whatfollowedisanexampleofwhathappenswhenatransmissible,disabling,andpotentiallyfataldiseaseencountersapopulationwithonlythemostrudimentarypublichealthprovisions.Duringthatsummer,thereweremorethanathousandcasesofpoliomyelitisontheisland.Thechildrenwerebyfartheworstaffected.Of851casesidentifiedandrecordedbyepidemiologists,aroundtwothirdswereundertheageoffive,andmorethan90percentwereunderten.Theviruswasaggressiveandunfetteredbymodernmedicine.Almosteverycaseidentifiedbytheepidemiologyteams—nineteenoutofeverytwenty—sufferedparalysisandwitheringofoneormorelimbs.

Inmyfather’sfamily,hisoldersister,Angele,wasthefirsttofallsick.Fordaysshesufferedwithhighfeversanddrenchingsweats.GrandGaubehadnodoctorofitsown.Occasionallyaphysicianwouldpassthroughthevillage,buthewasseenasacharlatanandviewedwithdistrustbymostofitsresidents.AhYoongwassentoutbyhisfathertopicktheleavesofthelilactree,fromwhichacoolbedcouldbemade,insulatingAngelefromthehotfloorinthehopethatthiswouldsomehowreducethefever.Butthefevercontinued,andAngeleappearedtobegettingweaker.

Intheearliestdaysoftheillness,AhYoongwouldtakehisoldersisterbythearmtohelpherwalk.Laterheresortedtocarryingheronhisback.

Eventuallythefeverpassed,butAngelewasleftparalyzed,unabletowalk.Shewasjustnineyearsold.

Shewasjustnineyearsold.

—THEBASISFORTHECONSCIOUSPROCESSthattriggersustomovealimb,speakaword,orregisterathoughtremainselusiveandlikelywillforsometimetocome.Consciousnessisthelastdarkcontinentoflifescience.Weareincapableofproperlydefiningit,muchlessunderstandinghowitworks.

Buttheprocessesitsetsinmotionarebetterunderstood.Whenitcomestomovement,weknowthatthemotorcortexisthepointoforiginofsignalsthattriggervoluntarymovement.

Youcangetanideaofthelocationofthisthinstripofbrainbyputtingyourthumbonyourearlobeandthenstretchingyourindexfingerupuntilitreachesthetopofyourskull.Belowthequarterarcnowmadebyyourfingerandthumb,beneaththelayersofskin,bone,andtoughprotectivetissues,liesanarrowstripofbrain.Itislessthanacentimeterwideandpenetratestoonlyafewmillimetersbelowthebrain’ssurface.Inthismodestlayerliesapopulationofpyramid-shapedcellsfromwhichtheimpulsesthatinitiatemovementarefirstfired.Thosenervecellsareneurons,responsibleforconnectingthoughttoaction,specializedforthetaskoftransmittingsignalsfrombraintomusclebed.

Mostofuscouldhaveagoodcrackatdrawingananimalcell.You’dstartwithanindefiniteoval,andsomewherenearitscenter,you’dplantacirclethatyouwouldshadeinandcallthenucleus.Acoupleofsmallerscribblesaroundthatnucleuswouldgiveyoumitochondria,ribosomes,Golgiapparatus,andotherorganelles.Butthisisonlythebasicscheme.Notallcellsaremadeequal.Andwhenitcomestoneurons,thatsketchdoesn’tquitecoverit.

Thewordcellderivesfromcellula,theLatinwordforaroom.Butthewholethingisbuiltmuchmorelikeawalledcity.Theimportantstuff—theexecutivedecisionmaking—isdoneinthenucleus,thetownhall.Heredenselypackeddouble-strandedDNAiswovenandstored—theblueprintsfromwhichyourbody,andindeedalllife,isbuilt.Thesurroundingclearcytoplasmisdottedwithtinyorganelles,muchsmallerthanthenucleus,whichfunctionlikeacity’sutilitiesandamenities.Herethemitochondriaserveaspowerstations,whileribosomesareindustrialestates,givenovertotheexecutionofmanufacturingordershandeddownfromthenucleus.Elsewhereinthecytoplasm,thereareothermicroscopicstructuresthatplaystructuralrolesortakepartinwastedisposalordefense.

Thepyramidalnervecellsofthebrain’smotorcortexstretchoutovervastdistanceswithinthebody.Theextensionsofthecellarecalledaxons.Forthe

distanceswithinthebody.Theextensionsofthecellarecalledaxons.Forthelongestneuronsinthebody,thoseaxonscangrowtobeoverameterinlength—anenormousdistance,giventheminutescaleofthecellitself.Toputthatintocontext,considerthis:Ifthecellbodyofthemotorneutronwereindeedacity,sayaboutthesizeofLondon,itsaxonwouldberepresentedbyaroadthatranoutintospaceforabouttwentymillionmiles(whichwouldgetyouabouthalfwaytoMars!)

Theneuronsendsitsaxondownthroughthebrain,onintothebrainstem,andthroughthespinalcord,runningandconvergingwithothers,likeindividualtelephonewirescombiningtoformthemaintrunk.Mostofthemeventuallycrossovertotheothersideofthebody(whichiswhyastrokeontheleftsideofthebraincanleadtoparalysisontherightsideofthebody).Inthefrontofthespinalcord,theyend.Thisnervecell,thefirstlinkinthepathfrombraintomuscle,iscalledtheuppermotorneuron.Ithassofarcarriedanerveimpulsefromthebraintowhatisessentiallyajunctionboxinthespinalcord.

Hereinalocationknownastheanteriorhorn,itwillformasynapse,connectingwithafinalneuron,completingthelinkbetweentheeventsinthebrainthatprovidetheimpulsetomoveandthephysicalmeansbywhichmovementisachieved:thecontractionofmuscle.Thissecondnervecell,thelowermotorneuron,runsfromthespinalcord,anditsaxonfinishesembeddedinthesubstanceofaskeletalmuscle.

Itisthejunctionofthesetwoneuronsintheanteriorhornthatisvulnerabletoattackbythepoliovirus.Ifitinvadesanddestroysthecellbodyoftheneuron,thentheentirecellularstructure,fromspinalcordtomuscle,diesbacktoo—forgood.

Thecellsofthenervoussystemaretheoldestinyourbody.Incontrasttoalmosteveryothercelltypeinthehumanbody,theylacktheabilitytodivideandself-replicate.Unlikeskincells,whichenjoyaheftyturnover,ifneuronsbecomeirretrievablydamagedordie,theyarenotreplaced.

Topartiallycompensateforthislackofabilitytoregenerate,thecentralnervoussystemisburieddeepwithinthecoreofthebody,encasedwithinthecolumnofbonethatisyourspineandprotectedinthevaultofyourskull.

Despitethis,itremainsvulnerable,especiallyinthefaceofmodernthreatslikemotortransport.Andthearmoroftheskeletonisnoprotectionagainstinfection.

Duringanattackofpoliomyelitis,manythousandsoftheselowermotorneuronscanbelost.Oncedeprivedoftheirnervesupply,themusclessuppliedbegintowaste,givingthecharacteristicappearanceofwitheredlimbsthataccompaniesparalyticpolio.

accompaniesparalyticpolio.

—WHENYOUTALKTOVIROLOGISTSaboutviruses,theyhaveagrudgingrespectfortheirfoe.Incapableofindependentexistence,virusesrelyuponenteringmorecomplexcellsandhijackingboththeirmetabolicandreproductivemachinery.Theirgenomesaretoorestrictedininformationcontenttoallowthemtomanufacturethemeansoftheirownsurvival.Theyhaveonlythesimplestinstructionset—onethatallowsthemtoattachtoandenteracellandtrickitintomanufacturingfurthercopiesofthevirus.

Butthesesimplestructureshavethecapacitytodestroythehostcellstheyinvadeandthenspreadlikewildfire—firstfromcelltocellandthenfrompersontoperson.Asaconsequence,viralpandemicsarecapableofcausingdeath,disease,andpersonalsufferinginmanymillions.

BythetimetheepidemicinMauritiushadpassed,myfather’soldersister,Angele,waswheelchairbound.Hisyoungersister,Therese,waslessfortunatestill.Inherthepoliovirushadweakenedthemusclesresponsibleforbreathingandthoseinvolvedinswallowing.Shewentontodieofpneumonia.

—IN1952THEPOLIOVIRUSARRIVEDinnorthernEurope.ButthepatternofattackwasverydifferentfromthatseeninMauritius.Poliomyelitis,theinflammationanddestructionofthemotornervesbroughtaboutbythepoliovirus,isalsoknownasinfantileparalysisbecauseinearlierepidemicsitwasalmostinvariablyyoungchildrenwhoweremostseverelyaffected.

ThatpatternofattackanddisabilitycontinuedindevelopingcountrieslikeMauritius,butinEuropepoliohadforsometimebeenconfinedtosmalloutbreaksbecauseofimprovedsanitation,sotherewaslittleinthewayofnaturalimmunitytothevirusamongthewidercommunity.WhentheepidemicarrivedinCopenhageninthesummerof1952,thediseaseranrifeinadultsandchildrenalike.Themanifestationofthediseaseinadultswasfarmoreseverewithamuchhigherriskofparalysisofthemusclesinvolvedinbreathingandswallowing.Thisformofthedisease—hithertorarelyseeninpolioepidemics—wascommonlyfatal.

In1952therewasnodrugorvaccinethatphysicianscouldsetagainstpolio.Whenoutbreakshitmajorcities,theycreatedtragediesofthegrandestproportion.Thousandswereinfectedandmanyhundredsleftparalyzedordead.Cliniciansingeneralbecamenihilisticintheirattitudestothedisease.Medicine,

Cliniciansingeneralbecamenihilisticintheirattitudestothedisease.Medicine,itseemed,hadlittleornothingitcouldoffer.

Buttherewasadistanthope—thattherespiratorysystemcouldbesupportedartificiallywithventilators,asatemporarybridgetosurvival,whilethevirusranitscourse.Forthistheworldofmedicinewouldturntothefledglingspecialtyofanesthesia.

—DURINGANINTERVIEWFORAJOBwithacardiothoracicunit,ananesthetistwasonceaskedbyaratherpompoussurgeonwhatshethoughtherrolewaswithinthesurgicalteam.“Oh,that’seasy,”shereplied.“It’slikeanaircraft.Iflytheplane,andyoudothein-flightentertainment.”Apparentlyshestillgotthejob.

There’smuchmoretotheartofanesthesiathaninjectingadrugandmakingthepatientcountbackwardfromten.Anesthetistsflyhumanphysiologyaspilotsflyplanes.Whileyou’reawakeandconscious,yourphysiologyislargelyunderautomaticcontrol,justlikeapassengerairlineronautopilot.Theintricaciesofyourcardiovascularandrespiratorysystemsareheldneatlyinbalancewithyourkidneys,gut,liver,andtheenormouscomplexityofyourbrain.Yourbody’sautopilot—itssystemofautonomiccontrolandfeedbackloops—isprettygoodatthejob.Inhealthitkeepsthingsrunningonanevenkeel,nightandday,beattobeat,evenwhenyou’reasleep.Evolutionhasallowedthousandsofbiologicalprocessestobeseamlesslyintegratedandorchestratedunderautomaticcontrol,sothatyoucangoaboutyourbusinessanddothestuffofconsciousthoughtwithouthavingtobebotheredbypeskythingslikestoppingtoremembertomakeyourselfbreatheorkeepyourheartbeatingwiththerightrateandforce.

Buttheunconsciousnessofanesthesiaissomethingotherthansleep.It’salittlebitlikerebootingthatautopilotmidflightandgivingtheaircraftovertosomeoneelseformanualcontrol.Inthesamewaythatthecaptainoftheplanetakesovercontroltogentlynavigatearoundbadweather,sotheanesthetistmustwrestcontrolofphysiologyfromthepatientinordertonavigatethehazardspresentedbysurgery,injury,anddisease.

Thisabilityofanesthetiststosupportandreplacethefunctionoforgansystemsartificiallywasvitaltothecreationofthenewspecialtyofintensive-caremedicine.

—THESCALEOFTHE1952DANISHpolioepidemicwasunprecedented.InCopenhagenoverthreethousandpeoplewereinfected,amongwhommorethanathird

showedsignsofparalysis.ThenumberofthesepatientssufferingwithrespiratoryfailurewashigherthaninanyotherEuropeanoutbreak.Copenhagenboastedseverallargemunicipalhospitals,buttherewasonlyone,thefive-hundred-bedBlegdamHospital,thatwasequippedtodealwithinfectiousdiseases.

Towardtheendofthesummer,thepolioepidemicwasinitsfullestthroes.HenryCaiAlexanderLassen,professorofepidemiologyatBlegdam,chartedtheprogressoftheoutbreakandwasshockedbythetidalwaveofdiseaseanddeaththatflowedthroughthehospital’sdoors.Amongthefacility’sstaff,therewasfrankdesperation;thediseaseappearedtodefyanyconventionaltreatment.InthefirstthreeweeksofAugust,thirty-onepatientssufferingwithparalysisofthemusclesofbreathingandswallowingweretreatedatBlegdam.Despitethehospital’sbestefforts,allbutfourdied.Desperateforameasurethatmightturnthetideagainstthevirus,oneofBlegdam’sphysicians,MogensBjørneboe,recalledtheworkofaninnovativeyoungdoctornamedBjørnIbsen,whowasinterestedinanesthesiaandartificialventilation.IbsenwasafreelanceramongthehospitalsinDenmark,andBjørneboehadworkedbrieflywithhimearlierthatyearintreatingandventilatinganewbornsufferingwithtetanus.Thechilddidnotsurvive,buttheinterventionitselfappearedtoBjørneboetohaveworked,atleastbriefly.Ibsenwaspromptlysummoned.

—THREEYEARSEARLIER,in1949,BjørnIbsenhadtraveledtoBostontotrainasananesthetistatMassachusettsGeneralHospital.HespentayearthereandreturnedtoDenmarkwithnewskillsandinsight.Hewasnothingifnotunconventional.Hechoseanesthesiaovermoretraditionalcareers—aboldmoveinaworldthatwasn’tyetreadytoacknowledgethatthiswasaspecialtyworthyoftheattentionofqualifieddoctors.

HereturnedtoCopenhagenin1950tofindhisformertutorsscornfulofhisexperience.TheUniversityHospitalofCopenhagenregardedIbsen’ssojournabroadasthoughitweretimespentinthewilderness.“Youhavebeenawayfromthefountainoflifeforoneyear,”remarkedaprofessorofsurgery.“Letushopeyoucancatchupwithwhatyouhavemissed.”Despitetheseverbalassaults,Ibsenthoughtthattheanesthetistmightfindarolewellbeyondthewallsoftheoperatingtheater.Afterall,theexperienceofresuscitatingapatientbleedingtodeathfromabriskhemorrhageormanagingthelife-threateningsideeffectsofprimitiveanestheticagentsgavetheanesthetistfraternityanappreciationofreal-timeappliedphysiologythatwasotherwiselackingin

appreciationofreal-timeappliedphysiologythatwasotherwiselackinginmedicalpractice.

ButIbsen—havingwitnessedisolatedcasesofpolioandwithfirsthandexperienceoftheslowsuffocatingdeaththatitbrought—wasmostinterestedintheanesthetist’sabilitytotakeoveratemporarilycompromisedorgansystem.

DuringthepolioepidemicinCopenhagen,themostfortunateamongthepatientsweretreatedwithartificialventilatorscalledironlungs,whichassistedbreathingbyhelpingthepatient’schestexpand.Thesedeviceswerehalf-cylindricalvacuumchambers,largeenoughtoaccommodateanadult.Theywereconstructedsothatapatientcouldliesealedinsidewithonlytheheadprotrudingthroughaholeinthetop,sealedaroundtheneckwithrubber.Thepressureinsidethecylinder,andthereforeinsidethepatient’slungs,couldbereducedtobelowthatoftheoutsideair,creatingapartialvacuuminthepatient’schestandsuckingairintohisorherlungsthroughthemouthandnose.Inthiswaytheironlungdevicesmimickedthenormalmechanismofthelungs,usingreducedpressureinsidethechestcavitytosuckairinfromoutside.Thisbecameknownasnegative-pressureventilation.

Ibsenrealizedthatironlungswereeffectivebutcumbersome,expensive,and,whenitcametothehospitalsofCopenhagen,indesperatelyshortsupply.Theirusewasseverelyrationed,andduringthepoliooutbreaks,doctorshadtheunenviabletaskofdecidingwho,amongthedozensofvictims,shouldbegiventhischanceoflifeandwhoshouldbelefttodie.Soscarcewastheresourcethatevenwhentheiron-lungventilatorswereemployed,theywereoftenusedtoolatetomakeadifference.

—WHILETHEWORSTCASESOFPOLIOintheCopenhagenepidemicwereprovingalmostinvariablyfatal,IbsenwasneverthelessconfidentthattheskillsandknowledgehehadacquiredwhileintheUnitedStatescouldsavelives.IbsenbelievedthattheearlyfailuresseenatBlegdamwerepartlyattributabletoclinicians’poorunderstandingofboththediseaseanditseffectonhumanphysiology.

Nooneseemedsurewhythesepatientsweredying.Thesickestpatientsweredrowsyandfebrile,tothepointwheresomeofthedoctorsassumedthatpoliowascausinginfectionandinflammationofthebrain.

ButIbsendisagreed.Thedrowsinessandrapidheartrate,hebelieved,werenottheresultofencephalitiscausedbypoliobuttheconsequenceofhighlevelsofcarbondioxideaccumulatinginthebloodstream.

Inadditiontobringingfreshoxygenintothebody,thelungsarealsoresponsibleforexpellingcarbondioxide.Deficientlevelsofoxygeninthebloodstreamcan,inpart,betreatedbyincreasingtheamountofoxygeninhaled.Theexpulsionofcarbondioxidefromthelungsdependsmuchmoreheavilyupontherateanddepthofbreathing.Ibsenmeasuredthelevelsofcarbondioxideinthebloodstreamsofthesickestpoliopatients.Levelsofoxygenappearedtobenormalinthesepatients,butcarbondioxidehad,incontrast,accumulatedtomanytimesitsnormallevel.

Artificialventilationwastheanswer,Ibsenwassureofit.HehadtakengreatinterestintheworkofDr.AlbertBowerandhiscolleaguesinLosAngeles,whohaddescribedtheirventilationofpoliosuffererswithironlungsandhowthishadreversedtheirprognosisfrom90percentmortalitytonearly80percentsurvivalinlessthanfouryears.IftheDanishpoliopatientssufferingwithparalysisofthemusclesresponsibleforbreathingandswallowingcouldbesimilarlyventilated,thenperhapstheycouldhopeforthesamesuccessrates.

Butiron-lungmachineswerebulkyandhugelyexpensive—aboutthesamepriceastheaverage1950sfamilyhome.BlegdamHospitalpossessedonlythree.

Acheaper,morewidelyavailablealternativewouldhavetobesought.HereIbsenfellbackuponhisexperienceintheoperatingroom.Heknewthatpatientscouldbeventilatedbypassingatubeintothetrachea,connectingarubberbagtotheendofthetube,andthenallowingoxygentorunintotheassembly.Whensqueezed,thebagwouldpushfreshoxygenintothelungs,therebyinflatingthem.Whenreleasedtheelasticrecoilofthelungsexpelledairladenwithcarbondioxidethroughavalve.Thismethodofventilationmovedairintothelungsbyapplyingpositivepressurefromtheoutsideratherthantryingtoreplicatetheworkperformedbytherespiratorysystemingeneratingnegativepressurewithinthechest.Ibsenwassurethatthiswouldworkoutsideoftheoperatingroom,too.Theschemerequiredlittleequipmentandsocouldofferalifelinetodozensofpatientsratherthanthefewwhocouldbeservicedbythehandfulofironlungsthatthehospitalpossessed.ButIbsen’smethodwouldfirsthavetobedemonstratedandprovedbeforehisphysiciancolleagueswouldacceptit.Hewouldnothavetowaitlongfortheopportunity.

JustafewdaysafterIbsenfirstarrivedatBlegdamHospital,hewasreferredthecaseofatwelve-year-oldgirlwhoselimbsandchestwereparalyzedandwhocouldnotswallow.Breathlessandunabletodealwiththesalivainhermouth,shewaschokingonherownsecretions.Hercasewasnearlyidenticaltothatofthetwenty-sevenpatientswhohaddiedinthepreviousmonth.Withoutintervention,itseemedcertainthatshe,too,woulddie.

intervention,itseemedcertainthatshe,too,woulddie.Ibsentookhertotheoperatingroomandpersuadedasurgeontoperforma

tracheostomy,makingaholeintheneck,aroundaninchbelowtheAdam’sapple,whichcouldadmitabreathingtube.

Thesurgeryproveddifficult.Theyhadinjectedalocalanestheticagentintotheskinwheretheincisionhadbeenmade,butthegirlwasagitatedandfoughtagainstthemedicalteam.Thesurgicalwoundbledbackintoherairway,soilingherlungsandaddingtoherdistress.BythetimethetracheostomywascompleteandIbsen’srubberbreathingtubehadbeeninsertedthroughthenewopening,shewasinextremis,withIbsenwrestlingtoretrievethesituation.Hiscolleagues,whohadgatheredtoobservehisefforts,assumedthattheyweremerelywitnessingthefutileeffortsofaphysiciantoreviveyetanotherpatientdyingofpoliomyelitis.Onebyonetheyturnedtheirbacksandlefttheroom.

Ibsenhadtothinkquickly.Thegirlontheoperatingtablebeforehimwassuffocating.ThetubeconnectingherlungstoIbsen’srubberbagwasinplaceandfreeofobstruction.ButshewasnowdistressedandfightingagainstIbsen’seffortstosqueezeairintoherlungs.Withnoairenteringorleavingherchest,theoxygeninherbloodstreamwasdwindlingwhilecarbondioxidewasontherise.Ifshewastosurvive,hewouldhavetostopherfromfightingagainsthimandtakeoverherbreathingcompletely.Ibseninjectedsodiumthiopental,ananestheticagent,andwithinsecondsherbodyhadgonelimp.Nowforthefirsttimeabletosqueezeairintoherlungs,Ibsencouldmakeheadway.AsleepandunabletoresistIbsen’sefforts,shewasfinallybreathing—albeitartificiallyandwithhisassistance.Thecolorreturnedtoherface,andasthecarbondioxidefell,herheartratestabilized.

Ibsen’sphysiciancolleaguesreturnedtotheroom,incredulousthathehadrescuedachildwhoafewminutesearlierhadbeensoclearlyatthepointofdeath.

Thehospitalwastednotime.Ibsen’stechniquewasadopted,andwithineightdays,thewardswerefilledwithpatientsbeingventilatedusingthistechnique.Armiesofmedicalstudentsandnurseswererecruitedtoassistinthetask;standingbybedsides,squeezingbagsinshifts,dayandnight,theyprovidedartificialventilationtodozensofpatientsatatime.

—UPUNTILTHEMIDDLEOFTHEtwentiethcentury,medicinewasmostlyaboutthetreatmentofchronicillness:consumption,cancer,syphilis,arthritis,andthelike.Short,severeillnesswasgenerallyfatal.Survivalwasrarelyattributableto

heroicmedicalintervention.Withtheexceptionofafewgenuinemedicalemergenciesthatcouldbesolvedwithaknife,therewaslittlethattheartofmedicinecouldputinthewayofcriticalillness.Theideathatmedicinemightbeinthebusinessofbuyingthepatienttimebysupportingtheirvitalorgansagainsttheonslaughtofoverwhelmingdiseasewasalmostentirelyalien.ButIbsen’spioneeringworkinthefieldwastohavefar-reachingconsequences.WhatIbsenstartedbyorganizingpatientsintointensivewardsofcareduringtheCopenhagenpolioepidemiccametounderpinthefrontiersofmodernmedicine.Intime,intensivecareallowedustostretchandprotecthumanphysiologywellpastthepreviouslyacceptedlimitsofsurvival—pavingthewayformoreambitioussurgeriesandmoreaggressivemedicaltherapies.

Andpoliomyelitiswasbynomeansthelastviralepidemictothreatentheworld.

—ONMARCH11,2003,CARLOURBANIwasonhiswayfromHanoitoBangkok,attemptingtorelaxafterwhathadbeenafreneticandexhaustingfortnight.

BasedinVietnamwiththeWorldHealthOrganization,UrbanihadbeencalledintoadvisephysiciansattheFrenchHospitalinHanoionFebruary28.ThereaChinese-AmericanbusinessmannamedJohnnyChenhadbeenadmitted,sufferingwithanunusualandseriousflulikeillness.Urbaniwasunsureoftheidentityornatureofthedisease;itbehavedunlikeanythinghehadseenbefore.AsChen’sconditiondeteriorated,Urbani’sconcernatthestrangenessofhisillnessgrew.Withindays,membersofthemedicalteamwhohadbeenincontactwithChenwerealsofallingillandexhibitingthesameconstellationofsymptoms.ItwascleartoUrbanithattheyweredealingwithanewandpotentiallydangerousinfectiousdisease.

Chen,amaninhismidforties,hadahighfeverandwhatlookedlikeseverepneumonia.Butotherorgansystemswerealsoinvolved:Hisbloodpressurewasdropping,andhiskidneyswereshowingsignsofcompromise.Themedicalteaminvestigatedfurther,butnoneoftheusualsuspectswaspresent;bacteriawereabsentfromhisbloodstream,andthecoursewastooaggressivetobeordinaryviralinfluenzainareasonablyyoung,previouslyhealthyman.Thediseasewasamystery.Itwaswithoutaname,aknowncause,orapointoforigin.Withouttheseitwouldremainwithoutatreatment,avaccine,orameansofcontainment.Andif,asseemedlikely,itprovedlethaltoChen,thenUrbaniwouldbelookingatanunknown,fatal,andhighlyinfectiousdiseaseinamanwhohadtraveledhalfwayacrosstheworldaboardasealedjetaircraft,makingcountlesscontacts

halfwayacrosstheworldaboardasealedjetaircraft,makingcountlesscontactsontheway.

ReportsofasevereandatypicalpneumoniasweepingacrossthesouthernprovincesofChinahadbeencirculatingforsomemonths,butdetailsandreliabledatahadbeenfrustratinglyhardtocomeby.Chineseofficialshadinitiallyplayeddownthescaleoftheoutbreak,statingthatthenumberofcasesrantolittleoverthreehundred,withonlyfivedeathsamongthese.Thisimpliedthatthemysteryillnesswasoflittleconcernandwouldmostlikelyburnitselfout.Butthetrueextentoftheoutbreakhadbeendisguised.LatertheworldwouldlearnthatovereighthundredpeoplehadbecomeinfectedinChinainthoseearlymonths,andmorethanthirtyhaddied.ButinFebruary2003,UrbaniandthemedicalteamattheFrenchHospitalinHanoiknewnothingofthis.

UrbanispentthenextelevendaysworkingcloselywiththeFrenchHospitalinHanoi.Hefirsttoldthestaffhowbesttoprotectthemselveswiththeequipmenttheyhadavailable.Atthistime,theyhadlittlemorethangloves,handbasins,andmedicalmasks,butUrbaniimpresseduponthemthevitalimportanceofthesebasicmeasures.Asconcerngrewamongthehospitalstaff,Urbaniprovidedreassurancethroughhiscontinuedpresence.Hereturnedeverydayandworkedlateintothenight.Throughtheseefforts,hebuilttrustandlaterpersuadedthehospitaltotakethedifficultstepofquarantiningthosemembersofstaffwithsymptomsawayfromthewiderHanoipublic.Shortlyafterward,theFrenchHospitalwasclosedtothepublicandarmedguardswerepostedoutsideitsfrontdoors.

Urbani’sinstinctstoldhimthatthiswassomethingverystrangeandverydangerous—somethingotherthanflu.Hepursuedlinesofinquiryrelentlessly,workinglongdaysattheFrenchHospital,takingsamples,runningtests,andmakingsurethatinfection-controlprotocolswereproperlyenforced.Containmentandproperidentificationofthecausativeorganismwerehispriorities.Thewaragainstthisinfectiousdisease,whateveritwas,wouldturnonthesesimplemeasures.

PascaleBrudon,theheadoftheWorldHealthOrganization’sregionalofficeinHanoi,witnessedUrbani’seffortsandwasintouchwithhimthroughout.Shewasconcernedforhissafetyandanxiousthatheshouldtakeproperstepstoprotecthimself.UrbaniunderstoodtherisksheranbutregardeditashisdutytohelpthecliniciansattheFrenchHospitalamidthisterrifyingoutbreak.BetweenthemUrbaniandBrudonsawtoitthattheWHO’sheadquartersinGenevawasalerted.Iftheirinstinctswerecorrect,thenthefalloutfromthisdiseasewouldbefeltallovertheworld.

Overthenextfewdays,internationalexperts,summonedbytheVietnamesegovernmentonUrbani’srecommendation,arrivedindroves.Bythispoint,BrudoncouldseethatUrbaniwasexhausted.Hehadforthatpastfortnightbeenaloneinthefighttoidentifyandcontainthisdiseaseandnowclearlyneededtorest.BrudonsuggestedthatUrbanicouldnowaffordtotakeabreakandattendaconferenceinBangkok,wherehewasduetogivealecture.Fatigued,Urbaniaccepted,andonMarch11,2003,afterhandingovertotheincomingteamsfromtheWHOandtheUnitedStates’CentersforDiseaseControl(CDC),heboardedaplaneatHanoiairport.

Aboardtheflight,Urbanidevelopedafever,adrycough,andaheadache.Inthosehours,confinedaboardthataircraft,hecouldhavebeenundernoillusionsabouthisailment’slikelycause.Aftertheplanetoucheddown,Urbanifoundhiswaythroughtothearrivalshall,whereacolleaguefromtheCDCwaswaitingtogreethim.Fearingtheworst,Urbaniurgedhimnottoapproach.Whiletheywaitedforanambulancetoarrive,thetwomensatapartinsilence.TheparamedicteamarrivedwearingmasksandprotectiveclothingandtookCarlotothehospital.Hediedeighteendayslater.

—INTHESAMEWEEKthatCarloUrbanileftHanoi,JohnnyChen,theforty-eight-year-oldbusinessmanwhomUrbanihadfirstbeencalledtosee,diedinintensivecareafterhavingbeentransferredtoHongKong.

Dayslater,Jean-PaulDerosier,asixty-five-year-oldFrenchanesthetistwhohadtreatedChen,alongwithanursewhohadbeeninvolvedinhiscare,alsodiedofthesamedisease.ByMarch15,authoritieswereawareofforty-threecasesinHanoi.Ofthese,forty-twowerehealth-careworkerswhohadlookedafterJohnnyChen.Theexceptionwasthesonofoneoftheinfectedhospitalstaff.Amongthese,fivehaddeterioratedrapidly,eventuallyneedingintensivecareandartificialventilation.

TheWHOhadalsobecomeawareofnewcasesworldwide,inSingapore,Taiwan,Canada,andHongKong.IntheweekthatCarloUrbaniwasadmittedtoanintensive-careunitinBangkok,theWHOissuedaglobalhealthwarningforthefirsttimeinitsfifty-yearhistory.Thedisease,whoseprecisenaturewasstillamystery,wouldfinallygetaname:severeacuterespiratorysyndrome,orSARS.

BythetimeoftheWHO’shealthwarning,thismuchwasknown:Thediseasewasinfectious,highlytransmissible,anddeadly.Healthworkersonthefrontlineandtheirfamiliesweremostatrisk.

frontlineandtheirfamiliesweremostatrisk.DueinlargeparttotheeffortsofUrbaniintheearlydaysoftheoutbreak,the

originsofSARSwererapidlyestablished.ItemergedthatJohnnyChenhadtraveledfromHongKong;therehehadstayedontheninthflooroftheMetropoleHotel.HereheandseventeenotherguestshadacquiredSARSfromasingleindividual.Dr.LiuJianlun,asixty-four-year-oldChinesemedicalprofessor,hadunknowinglycontractedSARSinGuangdongwhiletreatingpatients.HehadtraveledtoHongKongtoattendhisniece’swedding.ThisjourneyfromthesoutheasternprovincesofChinatoHongKongwasthetriggeringeventintheglobaloutbreakthatfollowed.Room911,theroomoccupiedbyDr.Liu,becamethecenterpieceoftheinvestigation,andtheninthflooroftheMetropolebecamegroundzeroforSARS.

Thevirushadcirculatedinanimalsformanymonths.Virologistschaseditsoriginsbacktocivetcats.InthefoodmarketsofGuangdong,withtheirexoticanimalhusbandry,ithadmovedfromanimalspeciestoanimalspeciesbeforefinallymakingthejumpintohumans.

Preciselyhowitdidthisremainsafundamentalquestionforthesciencecommunity.Thelimitedrepertoireofgenesthattheviruspossessesisabletomutateandreassort.Itislikethebadlycopiedblueprintforacuriousdevice,handeddownfromonegenerationtothenext.Offspringareabletosharenewinnovationsorspontaneouslyimprovise,untilfinallyenoughofthosealterationsalignandsumtoproduceaterribleweapon.Nature,asourvirologistsarefondofremindingus,isthebestandmostefficientbioterrorist.

ButSARSwouldhavelikelyremainedendemicwithinthesouthernprovincesofChina,haditnotbeenforthefatefuljourneyofDr.LiuJianlun.TakingittoHongKong,toaninternationalbusinesshotel,providedthemostefficientvehicleforthespreadofdisease.Atthatnodalpoint,Jianlunwasconfinedandincontactwithdozensoftravelers,allofthempassingthrough,manyontheirwaytootherinternationaldestinations.FromthemomentJianluncheckedintotheMetropoleHotel,SARSwassettogoglobal.

—SARS,ASITSNAMESUGGESTS,firstaffectstherespiratorysystem.Butunlikepolioitdoesnottargetthemechanicsofbreathingbutthesubstanceofthelungitself.Thevirusbindstocellsinthetissuesofitsfragileairsacsandthebranchingnetworkofairways.Thevirusentersandforcesthesecellstostartchurningoutmillionsofnewcopies,likeaprintingpressturnedovertotheproductionof

quickanddirtywarpropaganda.Thecellsarenotentirelywithoutresponse.Theyareabletosignalthattheyarecompromisedandsummontheimmunesystemtoattack.Butthevirusisburieddeepwithinthestructureofthecell,andsodestroyingitmeansdestroyingthecellinitsentirety:collateraldamageinthewiderfightagainstdisease.

Acombinationofthedeathoftheseinfectedcellsandthescarringandinflammationthataccompaniestheimmunesystem’sattackleavesthesubstanceofthelungscompromised.Theoncetissue-thinmembranes,capableofexpandingandcollapsinglikeasuppleballoon,becomemorerigidandlesscompliant.Theexchangeofoxygenandcarbondioxideacrosstheirsurfacesisobstructed,andtheforceneededtoexpandthechestandperformtheworkofbreathingismassivelyincreased.

TothephysiciancalledtoseeapatientdeterioratinginthefaceofSARS,thesignsarealltooclear.Effortlesshealthybreathingisreplacedbyarapid,shallowpattern.Othermusclesnotusuallyinvolvedinexpandingthechestarerecruitedtoovercomethestiffnessbroughtbytheviralinfection.Allofthisadditionalmechanicaleffortneedstobepaidfor.Thebody’sdemandforoxygenincreasesatthesametimeasitsabilitytograbthosemoleculesofoxygenfromtheoutsideairandexchangethemthroughthethickened,diseasedmembranesofthelungworsens.

Hemoglobin,themoleculeinthebloodcellsthatcarriesoxygen,isbrightredinappearancewhenfullyladen.Oncestrippedofthisoxygenload,itbecomesdullerandbluer—accountingforthedifferenceinappearancebetweenarterialandvenousblood.Butifarterialbloodcannotacquireanew,fullloadofoxygeninthelungs,itlosesitsrosyhue.Theskinthroughwhosecapillariesthesebloodcellscourseacquiresashademoreakintothundercloudgray.

Itisthatvision—ofthegray,breathlesspatientwiththethousand-yardstare—whosefirstglimpse,eveninthehalf-lightofahospitalwardatnight,signalsrealtroubleandtheneedforinterventionsthatcanbeprovidedonlybyintensivecare.Whenthesupplyofoxygenisoutstrippedbydemand,criticalillnessanddeathwillinexorablyfollow.Inthesecircumstances,thebridgetosurvivalisprovidedbymodernintensivecare.

—CHARLESGOMERSALLWASattheendofanothershiftasconsultantinchargeoftheintensive-careunitatthePrinceofWalesHospitalinHongKong.Hehadwornhishard-shellmaskallday;itsmetalpinchcliphaddugitselfintohisface,

leavingareddeneddentinthebridgeofhisnose.Butevennow,stridingacrossthecarpark,awayfromthewardandmainhospitalbuilding,hekeptitinplace.Thepastfortnighthadbeenpunishing.TheSARSoutbreakwasnowatitsheight,andtheunitwasunderstrainfromtheconstantflowofcasesinneedofcriticalcare.

Hisfirstweekondutyduringtheepidemichadbeensobering.Asanexperiencedintensivist,hewasfamiliarwithdestructivepneumoniasandderangedphysiologiesandusedtoholdingthelineinthefaceofadversity,butSARShadadifferentcharacter.TheclinicalcoursewassofiercethatatfirstGomersallwonderedifanyofhisinfectedpatientswouldmanagetosurvive.

Thedamagetotherespiratorysystemwroughtbytheviruswassevere.Artificialventilationhadtobeappliedwithcare.Forcingstiffenedlungsopenwithexternalpressurefromaventilatorwasnotwithoutitshazards.Titratingthevolumesandpressuresappliedbythemechanicalventilatorspreciselyagainsttheneedsofeachindividualpatientwasanart.Gettingitwrongcouldrupturedelicatemembranes,causingpneumothoraxandalife-threateningcollapseofthelungs.Ventilatingtoohard,withoverzealousvolumes,couldfurtherinflamethelungsandthesituation.ButitwastheimpactofSARSupontherestofthebodythatpresentedthebiggestchallenge.

—THECELLSOFTHEIMMUNESYSTEMroamthebloodstreamandtissues,likepolicemenpacingthebeat.Theydetectpotentiallyharmfulmicrobes,attackthem,andthenbeckonotherimmunecellstoenterthefray.Whenactivatedappropriately,thissystemputsastoptotroublebeforeithasachancetogetoutofhand.Butthissystemcanbealltooresponsive.Someinfections—SARSamongthem—overstimulatetheimmuneresponse,givingrisetowidespreadinflammationthatinturncanharmthebody,aninappropriateresponsethatcausesmoredamagethantheoriginalinfectionitselfevercouldhave.

Becauseofthis,Gomersall’sSARSpatientsenduredmorethansimplerespiratoryfailure.Thestormofimmuneresponsedamagedkidneysandliversandcausedheartstofail,whichmeantmultiorganfailurealsohadtobesupported.

IntheyearssinceIbsen’sfirstintensive-careunitwasestablished,medicaltechnologyhasmovedontoallowthecarefullynuancedsupportofmanyorgansbesidesthelungs.

Nowthefailingcirculationcanbesupportedwithnoradrenaline,whichraisessaggingbloodpressure.Theheartcanbedrivenwithinfusionsofadrenaline,

saggingbloodpressure.Theheartcanbedrivenwithinfusionsofadrenaline,boostingitscontractileforceandejectinggreatervolumesofbloodneededtoperfusetherestofthebody.Medicinehaslearnedhowtoreplacetheworkofthekidneys,usingdialysismachinesandbloodfilters.Evenamalfunctioninggutcanbeaugmentedwithafeedingtubeorreplacedbyrunningcaloriesandnutrientsdirectlyintoveins.Todayallofthiscanbeachievedartificiallyand,inthemostdangerousdaysofthedisease,withpatientsinastateofanesthesiaandunawareoftheirplight.

ButGomersall,alongwithotherdoctorsandnursesontheintensive-careunit,wasfastbecomingfatigued.Itwasunheardoftohavesomanypatientsdependentonsuchhighlevelsofartificialsupportforsuchaprolongedperiodoftime.Atthispoint,theoutbreakhadbeenragingforweeks,andtherewasnoendinsight.What’smore,SARSwasthreateningthelivesoftheveryfrontlinemedicalprofessionalswhowerestrugglingtokeepitsvictimsalive.

Protectingtheclinicalteamhadbecomeapriority,onethatGomersall’sintensive-careunithadfounditselfinitiallyillpreparedfor.Thehigh-filtrationmasks,soessentialtopreventdropletsladenwithvirusfrompenetratingintothehealth-careworkers’respiratorytracts,wereinshortsupply.Theyalsohadtobetestedforaprecisionfit:apoorlyfittingmaskwasworsethannomaskatall.Thisprocedurecouldtakeuptotwentyminutesforeachperson—afrustratingdelayinthemiddleofthefranticbattleagainstdeathanddisease.

Therewereother,unanticipatedproblems.ItwasthebeginningoftheHongKongsummer.Ambienttemperaturesranatcloseto30°C.(86°F.)withhumidityatnearly80percent.ThepersonalprotectionequipmentcoveredtheICUteammembersfromheadtotoe,leavingonlyafewsquareinchesofskinexposed.Theheatstresswasstifling,evenwiththeunit’sair-conditioningsettoausuallybone-chilling17°C.(63°F.).Butdespitefastidiousattemptstoavoidinfection,theintensive-carestafffoundthateventheircumbersomemasks,gloves,andprotectiveclothingcouldn’tkeepthemsafefromSARS.Inall,fiveoftheirteamcontractedthedisease,andonewaslateradmittedtotheintensive-careunit.Butdespitethedangerstothemselvesandtheirfamilies,thedoctorsandnursesofthePrinceofWalesIntensiveCareUnitcontinuedtoshowupforwork,weekin,weekout.

Gomersallgotintoaroutine.Assoonastheseverityofthesituationbecameclear,hemovedoutofthefamilyhome,awayfromhiswife,Carolyn,andtwoyoungdaughters.Herentedanapartmentnearerthehospitalandtraveledtoworkbycar.Theactofgettinginandoutoftheprotectivegarb,toeat,drink,orgotothetoilet,wastime-consumingandlefthimvulnerabletoinfection.Gomersalltooktowakingearlyinthemorningtobreakfastandtakeonadecent

Gomersalltooktowakingearlyinthemorningtobreakfastandtakeonadecentloadofwatertohydratehimself.Hethenworkedthroughthedaywithouthavingtogetundressedorremovehismask.Onlywhensafelybackinsidehisowncardidhefinallytakethemaskfromhisface.Eachday,whenhegotbacktohisflatandclosedthedoor,hefeltasenseofoverwhelmingrelieftobeawayfromthewardandinhisownspaceagain.There,alone,hewasinnodangerofinfection.Moreimportant,hewasatnoriskofpassingthevirusontoanyoneelse.

Gomersallwouldworkforfivedaysinarowontheunit.Beforehecouldgohome,hehadtomakesurethathewasn’tincubatingSARS.Todothis,hewouldspendtendaysawayfromtheward,teachinganddoingadministrativetasksinhisoffice—stillstayingattheapartment.Attheendofthattime,ifhewasn’tsickandhadn’tdevelopedafever,itwouldbesafetogobacktohisfamily.Gomersallwentthroughthiscycleofwork,self-imposedquarantine,andbrieffamilyreunionthreetimes.

Hegotonlyfourdaysathomebetweeneachshift.Hisfamilywouldstudiouslyavoidtalkingabouttheelephantintheroom.SARSdominatedthenews.HongKonghadbeenparalyzedbyit.ButCharlesdidn’tmuchwanttotalkaboutwhathe’dseen,andCarolyndidn’twanttohearaboutit.Shouldhefallillatwork,CharleshadtoldCarolynthatsheshouldnotcomeandvisit.ToloseoneparenttoSARSwouldbetragic;tolosetwo—assomefamiliesinChinaalreadyhad—wouldbeinsupportable.

Everydaytheteamsfacedthesamesetofproblems:anintensive-careunitfullofpeopleravagedbySARS,hopelesslyunwell,proppedupbyaconstellationofmachinesanddrugs.Theseweren’tmuchmorethanawayofbuyingtimeinthehopethatthediseasewouldabate.Thatisallintensivecareeveris:anextraordinaryeffortonthepartofmedicinetostretchhumanphysiologywellbeyonditssurvivablelimitsinthehopethatthepatientcanstayaliveuntilsomethingchangesforthebetter.

Inmid-June2003,somethingdidchange.ForthefirsttimesincetheSARSepidemicbegan,nonewcaseswerebeingadmittedfromoutsidethehospital.Theonlyinfectionsnowwerehappeningonthewards,betweenpatientsandhealth-carestaff.SARS,forallitsferocity,hadapeculiarpatternofbehaviorthathadlimiteditsspread.Someviruses,influenzaforexample,arehighlytransmissibleveryearlyintheinfection,longbeforethepatientbecomesincapacitatedandunwell.Thisiswhyfluspreadssoquicklyandsowidely.Manypeopleinfectedwithfluremainwellenoughtogoabouttheirbusiness,sheddingvirustotheoutsideworldallthewhile.

ButinmostcasesofSARS,thepeakofcontagiousnessoccursonlyoncethe

ButinmostcasesofSARS,thepeakofcontagiousnessoccursonlyoncethevictimhasbecomecriticallyunwell,usuallyinthesecondweekafterinfection.Bythistime,mostofthepatientshadalreadybeenadmittedtoahospital.Thiswaswhyhealth-carestaffhadbeensobadlyaffected.Thoughtheviruswasbothhighlytransmissibleanddeadlyatthispoint,thislimitedSARS’sspreadintheworldoutsidethehospitals.Bymid-July2003,alittleoverfourmonthsafterCarloUrbanihadfirstbeencalledtotheFrenchHospitalinHanoi,theSARSoutbreakwasfirmlyindecline,andthelastofthetravelrestrictionstoaffectedareas,recommendedbytheWHO,hadbeenlifted.Worldwide,therehadbeenmorethan8,000caseswith916deathsamongthese.BythefollowingMay,nonewcaseswerebeingreportedtotheWorldHealthOrganization.Thechainofspreadfromhumantohumanhadfinallybeenbroken.

Itcouldhavebeenfarworse.CarloUrbani’sheroiceffortsintheearlyidentificationofthediseaseandhisswiftactionsinnotifyingtheWorldHealthOrganization’sheadquartersinGenevaledtoaseriesofeventsthatcontainedoutbreaksandlimitedtheoverallspreadofthedisease.

UrbanifirstreportedhisconcernsinearlyMarch2003.Aftertrackingrapiddisseminationtothreeothercountries,theWorldHealthOrganizationissueditsglobalwarningsafortnightlater.Beforethemonthwasout,MalikPeiris’slaboratoryattheUniversityofHongKonghadidentifiedanewcoronavirus,SARS-CoV,astheprobablecausativeagent,andwithinamonthofthat,aCanadianlaboratorysucceededinsequencingitsgenome.Thisprovidedinformationvitaltothedevelopmentofdiagnostictestsandvaccines.Butwithtraveltoaffectedareasrestrictedandquarantinemeasuresinplace,thevirusburneditselfout.

Thefightagainstepidemicsandglobalpandemicsiswonnotbyhigh-techinterventionsbutbypublic-healthmeasures.Inthiscontext,theworkofintensive-careunitsmayappearaslittlemorethanagesture:thesymbolicfightingofbrushfiresinaworldunderthreatofbeingengulfedbyamassiveconflagration.

Indeed,thepolioepidemic,whichgavebirthtothespecialtyofintensivecare,wasdefeatednotbyventilators,adrenalinepumps,ordialysismachinesbutbyaprogramofvaccination—acampaignsoeffectivethattodaythepoliovirusstandsonthebrinkoferadicationfromtheworld.Sincethen,intensivecarehasretooledandrepurposeditself.Butthequestionremains:Whatisthevalueofintensive-caremedicine—aspecialtythatinvestssomanyresourcesforsuchmarginalgainsinthefaceofcriticaldisease?

Wecanreassureourselvesthatitismorethanjustafutilegesture.Ofthesickestpatientsadmittedtointensive-careunitsduringtheSARSepidemic,three

sickestpatientsadmittedtointensive-careunitsduringtheSARSepidemic,threeoutoffoursurvived.Withoutthebatteryofartificialsupport,nonewouldhavelived.Mortalitiesintheworst-afflictedpatientsofCopenhagen’spolioepidemicof1952fellfrom90percenttolessthan20percentassoonasIbsen’sinnovationswereimplemented.

Todayintensivecareisabranchofmedicinethatallowsotherspecialtiestoundertakemoreambitioussurgeriesandinterventionsthaneverbefore,safeintheknowledgethatintensivistshavesuccessfullyredefinedthelimitsofhumanlifewhenchallengedbydiseaseandinjury.

Attimesofgreatcrisis,thepolioandSARSoutbreaksincluded,intensivecarehasprovidedmedicinewithamuchneededbulwarkagainstillness,ameansofbuyingprecioustime.Italsodoesthisforanygivenpatient,onanygivenday,inanyintensive-careunit.Intensivecareexistsinthehopethattimeenoughmightbeboughtforadiseasetoabateorforclinicianstosuccessfullyintervene.

—WEARRIVEINTHEOPERATINGROOMandadministeranothershockbeforethesurgeonsbegin.Theventilatorisrunning.Thepatient’slungs,too,arenowbeginningtofail—becomingstifferanddemandingmoreoxygen.Theacidosisinhisbloodstreamisworsening,andhiskidneysaredeteriorating.Weincreasetheadrenalineandthenoradrenaline.Thedosesarenowsohighthattheirsideeffectsarebecomingarealproblem.Thedrugsmakehisheartmoreirritable,morepronetofatalarrhythmias.Wecanholdhisbloodpressureup,butwemustdefibrillatemoreoftennow.EachtimetheECGflipsintoashockablerhythm,thedefibrillatorspitsoutaninch-widestripofpaperonwhichthejaggedtraceisprintedinhardcopy,likeaseismographbeatingoutthelinesofanearthquake.Severalfeetofthisstriphavenowcollectedonthefloor.Analarmgoesoff.Inodatthesurgeons.Theystepbackfromthetable.Wefirethedefibrillatoragain.

Thisisabsurd.Soonerorlatertherhythmofhisheartwilldegenerateintosomethingwecan’ttreat,somethingthatelectricitycan’treset.Perhaps,realistically,thatisallwe’rewaitingfor.

Butthenthesurgeonscallout.They’vefoundasectionofdeadbowel,itsarcadeofvesselsblockedbysomething—abloodclotperhaps.Deftly,thesurgeonssnipoutthegangrenoustissueandjoinhealthyendsofboweltogether.Thingsdonotchangeimmediately,butwiththediseasedbowelgoneandnolongerleakingtoxinsintothecirculation,mypatient’sphysiologywillgetbetterratherthanworse.Survivingthenextfewdayswillbenomeanfeat,butthe

ratherthanworse.Survivingthenextfewdayswillbenomeanfeat,butthesurgeonshavegivenusthemeanstoturnthecorner.Theyarethechangethatwehavebeenhopingfor.Wearefarfromoutofthewoods,butatleastthewoodsarenolongeronfire.

Backontheintensive-careunit,inthehoursaftertheoperation,thesupportweneedtoprovidesteadilydecreases.Westilldelivershocks,buttheyarefewerinnumberandlessfrequent.Slowlythepatientisweanedoffthedrugsandtheartificialventilator.Overthenextfewdays,wegraduallyhandcontrolbacktothepatient,shuttingoffourmachinesashisnormalphysiologyreassertsitself.Preciselyhowhisbodyisabletorecoverandknititselfbacktogetheraftersuchaninsultisunclear.Butheisyoung,andtheyoungareremarkablyresilient.

Lessthanfourweekslater,thateighteen-year-oldwalksoutofthehospital.

November2011:MedivingintheRedSeausingavintagescubarigofthetypefirstseeninthe1950s.(©MichaelPitts)

BWATER

race!Brace!Brace!”heshouts,runningthewordstogetherasthoughtheywereone.Ishovemyheadupagainstthewallofthehelicopter,mycrashhelmetclunkingagainstthebulkhead,andfoldmyarmsovermychest,hookingmythumbsundertheshoulderstrapsofthe

four-pointharness.Wehitthewaterindarknessandimmediatelybegintosink.Thewaterisalreadyatmyankles.Irestmyrighthandonmyharness’squickrelease,andwithmyleftIfindthehandlethatwilljettisonthedoor.Onceunderwater,thehelicopterwillsinkametereverysecond.

Ineverusedtounderstandhowitcouldbedifficulttoescapefromasinkingvehicle.Openthedoor,swimoutanduptothesurface.Howmuchofachallengecouldthatbe?Ondryland,Icanholdmybreathforthebestpartofthreeminutes,andI’manOKswimmer.Howlongcoulditconceivablytakeformetogettothesurfacefrom,say,twentymetersdown?Butofcourseyouhavetofactorintheharshrealitiesofthephysicsandphysiologyofyourpredicament.Howlongcouldittake?Veryprobablyforever.

ThisisHUET(pronouncedhew-it),theRoyalNavy’sHelicopterUnderwaterEscapeTrainingfacilityinYeovilton.Itexiststoprovidehelicoptercrewswiththetrainingtheyneedtoescapeavehiclethathasditchedinopenwater.Theworktheydoisvital.Inmorethan80percentofhelicoptercrashesoverwater,thetimebetweenwarningandimpactislessthanfifteenseconds.Ofthese,morethan70percentsinkimmediately,withoverhalfoftheminverting.Themilitary’sexperienceofhelicopteraccidentsintowaterisalsoprettysobering.Ofthoseoccurringindaylight,thesurvivalrateis88percent.Butforsurvivablehelicoptercrashesintowateroccurringatnight,thatnumberisaslowas53percent.

Butwhyisthishappening?Thesearehealthypeople,trainedmilitarypersonnel,andinmostcasesstrongswimmers.Theanswerliesintheverystructureofourbodies.

structureofourbodies.

—WETAKEOURNATURALBUOYANCYforgranted—mainlybecausethevastmajorityofusneverdivebeyondthepointatwhichwearemorelikelytosinkthanfloat.Fromthesurface,forthefirstsevenmetersorso,ittakesabitofefforttodivebelowthewaves.Theairinyourbody,principallythatinyourlungs,servesasakindoffloattokeepyoubuoyant.HeretheupthrustyouexperiencebyvirtueofthegoodoldArchimedesprincipleismorethanenoughtoreturnyoutothesurface.

Butbelowthosefewmeters,therelationshipisreversed.Yourtissuesbecomecompressed,thevolumeofairinyourlungsdecreasesasthepressuremounts,andyoueventuallybecomedenserthanthewateraroundyou:anobjectthatwouldratherdescendintothedepthsthanfloatupward.

Thisstateisdescribedasnegativebuoyancy.It’sastrangetermwhenyouthinkaboutit—likereferringtothestateofbeingpoorasbeing“negativelyrich.”Whatwe’rereallytalkingaboutissinkingasaprobablepreludetodrowning.

—THEWATERISRISINGFASTNOW,alreadyuptomywaist,andeveryfiberofmybodyistellingmethatIshouldunclipthatharnessandpunchthroughthatwindow.Buttodothatwouldbefatal.Freeoftheseat,I’dbeswilledaroundthecabinbytheinrushofwater;findingmywaytotheexitandthenlocatingthemetalbarthatjettisonsthewindowwouldbeimpossible.IfI’mtosurvivethis,Ihavetowait.Thewatercontinuestobubbleintothecabin.It’satmychestnow,andthewholevehicleisoverbalancing,skewedbytheweightoftheenginesandrotorsabove,turningupsidedowninthedarkness.Thewaterisuptomychinasthecabinstartstorotate.Thesearemylastfewbreaths,andstillI’mstrappedintomyseat,resistingtheurgetogetthehelloutofthere.

—HOLDINGYOURBREATH:that’swhatyoursurvivalboilsdowntohere.Itis,onthefaceofit,asimpleactofmindovermatter,adisciplineyoushouldbeabletofindwithinyourself—especiallyifyourlifedependsuponit.

Yetthedesiretobreatheisamongourmostprimitiveurges.We’redesignedtodrawairintoourlungs,toexchangefreshoxygenforthewastegasofcarbondioxide.Ourlivesdependuponthisperpetualtoandfroofgases,anditisworth

dioxide.Ourlivesdependuponthisperpetualtoandfroofgases,anditisworthtakingamomentheretoconsideryourrespiratorysysteminallitsglory.

Whenwedescribethepaththatoxygentakesfromtheoutsideworldtoitsfinaldestinationinourmitochondria,wedosoasthoughithasagencyofitsown.Wetalkofmoleculesofoxygenmovingintoourbodies,diffusingacrossmembranes,arrivingatmitochondria,almostasthoughtheyknowwheretheywanttogo.Butofcourseoxygenhasnofreewillofitsown.Intheactofliving,yourbodymustsolvetheproblemofhowtograbmoleculesofthisgasfromtheatmosphereandbundlethemintocellsinsufficientconcentrationthattheycandothestuffoflife.

Thefirstpartofthatperformanceistheactofbreathing.Yourribsareattachedtoyourbreastboneatthefrontandthebonycolumnthatisyourspineattherear.Attheendofeachexhalation,theyslopesteeplydownwardtowardtheground.Contractingthemusclesinthechestwallthatdotheworkofbreathingliftstheribsup,toanearlyhorizontalposition,increasingthevolumeofthechest.Atthesametimeyourdiaphragm,thelargedome-shapedmusclethatseparatesthechestfromthecontentsofyourabdomen,contractsanddropsdown,furtherincreasingthevolumeofthecavityinsideyourchest.

Yourlungssitinsidethecageformedbyyourribs,adherenttothechestwall.Asthechestmoves,yourlungsmovewiththem.Asthevolumeinyourchestcavityincreases,sotoodoesthatinsideyourlungs.Theincreaseinvolumeleadstoadecreaseinpressureinyourchest.Thatinturnproducessuction,inexactlythesamewayasseparatingthehandlesonabellowsdoes,andairbeginstoflow.

Thatairpassesthroughyourupperairways,thelarynx,andthetrachea,andthendownintoyourbronchialtree.Ialwaysthoughtofthatbranchingnetworkofairwaysasinvertedsprigsofbroccoliratherthantrees.Intermsofmorphology,that’snotfaroff.There’sahollowcentraltrunkthatsproutsbranchesofeverdecreasingcaliber,attheveryendofwhicharesaclikestructurescalledalveoli:thebuds,ifyoulike,attheendofthatsprigofbroccoli.Thecadavericlung,formalin-soakedinthemedicalschool’sdissectingrooms,issolidandheavy;itsairspacesareoccupiedbypungentpreservativefluid.Butinlife,air-filledlungsarelighterthansponge,lightenoughtofloatonwater.

Theanesthetist’sperspectiveintheoperatingroom,thechestlaidopenduringcardiothoracicsurgery,givesamuchtruerimpressionofthoseorgans.Watchingastheyexpandandcollapsewiththerhythmicgrindoftheventilator,youareimmediatelyawareofastructurewhosevolumeisprincipallyair:adelicateorganhorriblyvulnerabletoinjury.

Thatfinestructureexiststoprovideamassivesurfaceareaoverwhichaircan

Thatfinestructureexiststoprovideamassivesurfaceareaoverwhichaircanbebroughtintocontactwithblood.Thealveoli,thosetinyairsacsattheendofthebronchialtree,areeachnomorethanafractionofamillimeterindiameter,buteachlungholdsoneandahalfmillion.Ifyouweretounfurlthemandlaythemoutflat,theywouldformamatoftissuehalfthesizeofatenniscourtatWimbledon.Thatvastareaisrequiredtobringenoughairintocontactwithenoughbloodtokeepyoualive.

Overthesurfacesofthosealveolirunsaspiderlikenetworkofcapillaries,vesselswithwallsasinglecellthick,providingjustenoughstructuretoconfinethebloodcellssqueezingthroughthem,whileofferingtheminimumobstructiontothemoleculesofoxygendiffusingthroughtheirwalls.

Thisisthemostdelicateinterfaceinyourbody.Nowhereelseisthepointofcontactbetweenyourbodyandthematerialfromtheoutsideworldmoreinsubstantialordelicate.Thatiswhyitisburieddeepinyourchestandprotectedwithaformidablecageofribs.Thereisnochoiceotherthantomakeitthatway;ithastobethatextensive,thatfragile,orelsegaswouldnotflowandexchange.

Intheactofdrowning,volumesofwaterreplaceair,swampingthegossamer-thintissuesdesignedtoallowgastopassfromtheairintoourbloodstream.Fortheaverageadult,atotalofaroundaliterandahalfofwaterdrawnintothelungsislethal.

ThiswasalltoovividinmymindwhileIsattrappedinthesinkinghelicopter.

—“WAITUNTILALLviolentmotionhasceased.”Thewordsofmytraininginstructorcomebacktome.Whathereallymeansiswaituntilyou’reunderandupsidedown.Waituntilyou’rereallysinking.

Icanfeelthewetnesscreepingundermychinandthecoldnessofthewater;Istarttotakedeep,gaspingbreaths.Itellmyselfit’sbecauseI’mtryingtodropmycarbondioxide,extendingthetimebeforemybodysensesitslevelsbuildinginmeandtherebylengtheningthetimeforwhichIcanholdmybreath.Butintruththereareotherreasonsformyhyperventilationhere.Thewaterisatmylips.Itiltmyheadbackandtakealastlongbreath.Andthenwe’reunder.

Itisquieterhere,somehowimmediatelylessstressful.Whenmyheadwasabovethesurface,therewasnoiseanduncertainty.Atleastnowyouknowthatyourracetoescapecanbegin.Youcan’tbesurehowlongthethingtooktoinvert,howfarbelowthesurfaceyoumightalreadybe.Thisispartoftheproblem.Withasinkrateofameterasecond,ifittakeslongerthanseven

problem.Withasinkrateofameterasecond,ifittakeslongerthansevensecondstogetoutofthevehiclethenyou’llbenegativelybuoyantonyourexit.Ifit’snightandyouhavenosourceoflighttoguideyou,thequestionbecomes:“WhichwaydoIswim?”

Fromthosewhohaveescapedfromsinkingaircraftatnight,therearestoriesofpeopleswimmingthroughinkyblacknessforwhatseemslikeaneternity,knowingthatiftheyhaveitwrong,ifthey’veheadedthewrongway,theywillswimfortherestoftheirlives.

Underwaternow,thefamiliarburningdesiretobreatheisalreadyuponme.ButI’mfollowingtheinstructions.Istretchoutmyrightarm,andtheshortleverthatejectsthewindowpressesintomypalm.TheblackandyellowstripeswerethelastthingIsawclearlybeforethewashofwatercoveredmyhead.FranticallyIpullthelevertoopenthewindow,andthenholdtheframetomakesureI’mreadytohaulmybodyoutfromthewaterycoffin.OnlythendoIdareundotheseatbelt,fiddlingwiththerotatingcatch,hopingthatitwon’tjam.

Thereleasecomesapartnicely,andIpullonthewindowframe,rememberingwhichwayisup.Ihaulmyselfoutofthehelicopterandbeginmyascenttothesurface.Ibreakthesurfacewithagasp.Ithastakennearlythirtysecondstoescape.That’sfineinthecomfortofthiswarmswimmingpoolandsimulator.ButoutthereinthechilloftheAtlantic,eventhat’sprobablygoingtobetoolongtosavemylife.Tounderstandwhy,weneedtothinkaboutwhatmakesusbreathe.

—THEACTOFBREATHINGISONEofthefewbodilyfunctionswhosecontrolispartautomaticandpartvoluntary.Youmightthinkthatsuchavitalsystemwouldbebetterleftunderthepermanentsupervisionofyourautopilot.

Theonlyothercomparablerhythminyourlifeisthatofyourheartbeat,andthatisalmostexclusivelyunderautomaticcontrol.Yes,youmightbeproudofyourabilitytochillyourselfoutandslowitdownalittle,butwhenwasthelasttimeyouhadagameof“whocanstoptheirheartlongest”?

Youcanchoosethewayyoubreathe;youcanchooserightnowtobreatheharderandfaster.Youcanchoosetostopbreathingaltogether.Butyourbodyknowswhatyou’relike,anditdoesn’tcompletelytrustyou.Itallowsyoutotakecontrolofyourbreathingtemporarily,butneverlongenoughtodoyourselfanypermanentharm.It’snotpossibletostopbreathinglongenoughtokillyourself;infact,ondryland,it’strickytoholdyourbreathtothepointofunconsciousness.

Soonerorlateryourbodyanditsautomaticsystemofmanagementwrests

Soonerorlateryourbodyanditsautomaticsystemofmanagementwrestscontrolfromyou.Detectingwhenenough’senoughisabitofanart.Yourbodyisprettyconservative,withasetofearly-warningsystemsthattriggerbreathinglongbeforeyourbiochemistrygetstooupset.

Toknowthatyou’renotbreathing,thebodyhastodetectthewaythatyourphysiologychangeswhengasexchangestops.Broadlyspeaking,therearetwothingsyoucoulddetect.Althoughthefallinglevelofoxygeninyourbloodwouldbetheobviousthingtouseasanindicatorofdanger,that’snotwhatyourbodydoes.

Thatleavescarbondioxide.Whenyoustopbreathing,thelevelofcarbondioxideinyourbloodrisesfasterthanthelevelofoxygenfalls.Thatmeansthatahighconcentrationofcarbondioxidebecomesatelltalesignthatyouneedtotakeabreath.

Soinpart,theearly-warningsystemfunctionsbysensingtheeffectthatrisingCO2levelshaveinthebody.Carbondioxidemoleculesdissolveinwaterandmakeitmoreacidic.It’sthisaciditythatindirectlytellsthebodythatthemechanicsofbreathinghavebeenhaltedfortoolong.

Butthesystemismorecomplicatedthanthat.Infact,nobodyissurepreciselywhattriggersthebreakpointinourdrivetobreathe:thepointatwhichtheurgetotakeabreathbecomesirresistible.Weknowthatthereisaconstantcentralrhythm,beatenoutbyrespiratorycentersdeepinthebrainstem—clustersofcellsthatkeeptimeinadancethatlaststhroughoutthewholeofourlivesandonefromwhichwemayonlyverybrieflyabsentourselves.Thisrhythmislikeaperpetualbiologicalmetronome.Whentheperformanceofbreathinghalts,itkeepstickingaway,urgingyoutorestart.

Thenthereareenvironmentalfactors.Inswimming-pooltests—withthewaterat25°C.(77°F.)—experimentalsubjectssimulatingescapefromahelicoptercouldholdtheirbreath,onaverage,fornomorethanthirty-sevenseconds.Awayfromthewarmthofanindoorpool,thesituationdeterioratesfurther.

Inwaterbelow12°C.(53.6°F.),thecold-shockresponseisactivated.This,areflextriggeredbythewidespreadactivationofcoldreceptorsintheskin,provokesaninvoluntaryanduncontrollablegasp,forcinganindividualtodrawhugevolumesintothelungswhetherimmersedornot.Thedrivetobreatheitproducesissoprofoundthattheaveragebreath-holdtimeincoldwaterconditionsfallstojustsixseconds.

Wealsoknowthattherearereceptorsthatsensemechanicalstretchinthelungsandthemusclesthatdotheworkofbreathing.Butwhatweighteachof

lungsandthemusclesthatdotheworkofbreathing.Butwhatweighteachoftheseindicatorscarries,howtheyinterplay,andtowhatextentthemechanismsvaryfromoneindividualtoanotherremainamatterofeducatedguesswork.

Itisinterestingthatinthisagewetalkaboutthesearchforagrandunifiedtheoryofphysicsbuthavestilltoachieveawell-unifiedtheoryofthatmostfundamentalofphysiologicalfunctions:whatitisthatmakesusbreathe.Inthisfieldordinarymenandwomenhavebeenconductingtheirownexperimentsandconfoundingthepredictionofscientistsfordecades.

—GIORGIOSHAGGISTATTIWAS,atfirstsight,anunremarkableItalianfisherman.HewasofdiminutiveheightwithskindarkenedbydaysspentlaboringunderMediterraneanskies.Hisbuildwasslight;hispulseandrateofrespirationwereregular.Hisheartsounds,too,werenormal.AnItalianphysician,searchingforsomethingoutoftheordinarythatcouldexplainStatti’sextraordinaryfeat,recordedthesedetails.In1913Stattibecamesomethingofalocalcelebrity,afterdivingtorecovertheanchorofawarshiplostintheharbordepths.Holdingasinglebreathofair,theysayhereachedadepthinexcessofseventymeters.

Skindivingitselfwasn’tanythingnew.TheexploitsoftheJapaneseamashadbeenknownforcenturies:Theseremarkablefemalediversremainedsubmergedincoastalwatersforminutesatatimecollectingshellfish,seacucumbers,andpearls.However,nothinginthehistoryoftheamassuggeststhattheydivedmuchbeyondadepthoftwentymeters—certainlynothingcomparabletothedepthreachedbyStatti.

Intriguingly,Statticlaimedthathewascapableofevendeeperdives.ButnothingabouttheItaliangaveaclueastohowhewasabletoachievesuchfeats.Whentestedonland,hecouldholdhisbreathforonlyfortyseconds.Onlyonefeatureofhisphysiquestoodout:aseeminglyoverinflated,barrel-shapedchest.Theonlyotherevidenceofhisexposuretothegreatpressureofdepthwashisimpairedhearing.Oneeardrumwasentirelyabsentandtheotherdamagedandperforated.Stattiwasbemusedbytheinterestinhissalvagedive.Tohimitwasnothingoutoftheordinary:Hewasafisherman,andthiswasjustsomethingheknewthathewascapableof.Hewasbaffledbythedoctor’squestionsandannoyedatbeingaskedtoholdhisbreathondryland.ToStattiitwasameaninglesstest;forhimeverythingwasdifferentoncehewasinthewater.

—IN1968APHYSIOLOGISTNAMEDAlbertB.Craig,workingatRochesterHospital,

wroteapaperreviewingthepredictedphysiologicallimitsforbreath-holddiving.Withthebodyofknowledgeinhand,itappearedthathumanbeingsshouldn’tbeabletofree-divebeyondaroundthirty-fourmetersfromthesurface.This,scientistshadestimated,wasthedepthbelowwhichtheincreasedpressureofthesurroundingwaterwouldcrushthelungsandreducetheirvolumetothepointatwhichbloodwouldpourintotheirairspaces.

Atheoreticallimitonthelengthoftimeforwhichapersoncouldholdthebreathhadalsobeensetataroundthreeminutes.Thiswasn’tjustanarbitrarynumber.Physiologistshadcalculateditbasedupontheamountofoxygenleftinthelungsofapersonofaveragebuildaftermaximalinspirationandbalancedthatagainsttherestingrateofoxygenconsumptionbythebody.Whenthegraphsweredrawnandextrapolated,thescientistssawthatthelevelsofoxygeninthebloodstreamwouldfalltoapointatwhichunconsciousnesswasinevitableinlessthanthetimeitwouldtaketoboilanegg.

Craigwasawareofmanycasesofdiverswhohaddivedwellbeyondthosedepthsandtimes.Whilesciencehaddrawnneatlinesinlaboratories,delineatingthetheoreticallimitsofsurvival,breath-holddivershadbusiedthemselvesswimmingrightpastthem.It’snotclearwhomthisdelightedmore,thescientistsorthedivers.

—BYTHEMID-1980S,THERECORDbreath-holddivestoodatonehundredmeters.Neoprene,rubberfins,andeyegoggleshadlentthismodernsportoffreedivinganewdimension,butamongphysiologists,itremainedpoorlyunderstood.Inaseriesofinternationalsymposia,thedangersoffreedivingwerehotlydebated:theplummetingoxygenreservesandclimbingcarbondioxidelevels,thetheorizedvolumechanges,andmountingpressures.Butofonethingscientistsweresure.Therewassomedepthbeyondwhichbreath-holddiverswouldnotsurvive.AsCraighimselfsaid,whenqueriedonthesubject,“Ithinkthelimitwillbereachedwhenoneofthesebreath-holddiverscomesupcoughingblood.”

—THEKEYTOTHESESEEMINGLYsuperhumanperformancesliesinthemammaliandivingreflex.Whenunderthewater,nerveendingsintheskinofyourfacesensethatyouareimmersedandkickoffaseriesofadaptiveresponses,whichincludeslowingoftheheartandconstrictionofthebloodvesselsinyourperipheralcirculation.

Thisrestrictsbloodsupplytononessentialorgansandtissuebeds,reducing

Thisrestrictsbloodsupplytononessentialorgansandtissuebeds,reducingtheiroxygendemandandconservingthesupplyfortheheartandbrain.Thisconstrictionofthebloodvesselsisinadifferentleaguefromthegentleblanchingoftheskinthatmight,forexample,happenwhenyouarriveattheairportcheck-indeskonlytorealizethatyourpassportisstillathome.Inthedivingreflex,itappearstobeahardclampingdownofmuchlargervessels,amongthemimportantarteriolesandveins,andthisleadstoamassiveincreaseinbloodpressure.

Wemeasurebloodpressureinmillimetersofmercury(mmHg).Assumingthatyou’refitandwell,yourpeakbloodpressureisequivalenttoacolumnofmercuryprobablynomorethan120mminheight.Ageneralpractitionermightthinkaboutputtingyouonmedicationtocontrolyourbloodpressureifitexceeded140mmHg.Inanaccidentandemergencydepartment,areadingabove180mmHgmightwarrantimmediateintervention.Butforotherwisehealthybreath-holddivers,pressuresabove230mmHghaveregularlybeenrecorded.

Thesehugepressuresreflectthecentralizationofbloodthathappensastheperipheralcirculationshutsdown.Therushofbloodtothebody’scentralcompartmenthasfurtherbenefits.Itisthoughttoengorgethetissuesofthechestwithblood,allowingairspacestobecompressedbeyondthephysiologists’theoreticallydefinedlimitswhileatthesametimeprotectingthemfromdamage.

Thisselectivediversionofbloodisjustonemeasurethatreducesglobaloxygendemandwhileincreasingoxygensupplytotheheartandbrain.Anothermechanismreliesuponthespleen,afist-sizeorganthatsitsjustbelowtheninthribonthelowerleftsideofthechest.Thespleenmainlyactstofilteroldanddamagedredbloodcellsfromthecirculation—likeaqualitycontrolofficermonitoringaproductionline.Italsogarrisonsapopulationofwhitebloodcellsthathelptheimmunesysteminthefightagainstdiseasebyidentifyinganddestroyingbacteriaandcompromisedcells.Butinextremis,whenoxygenlevelsareperilouslylow,thespleencanalsofunctionasakindofoxygenreservoir.Withinitapoolofredbloodcellsisheld—likethetinofmoneyyoumighttuckawayonakitchenshelfforarainyday.Thedropinoxygenlevelsthataccompaniesbreath-holddivingforcesthespleentocontract,spillingitssupplyofrainy-daybloodcellsbackintothecirculationand,intheory,furtherincreasingthesupplyofavailableoxygen.

Havingmademoreoxygenavailableforvitalorgansthroughthesemechanisms,thebrainsendssignalstotheheartinstructingittoreduceitsrate,therebyfurtherreducingdemand.Theheartisamongthemostmetabolicallyactivetissuesinthebody.Reducingitsrateofworkreducesitsownoxygen

activetissuesinthebody.Reducingitsrateofworkreducesitsownoxygenconsumption.Infreedivers,heartratesaslowastwentybeatsperminutehavebeenrecordedduringdeepdives.

Allofthisisanelaborateschemeformanagingsupplyanddemandunderextraordinarilychallengingconditions.Theseinpartexplainwhythecurrentfree-divingdepthrecordstandsat214meters(heldbyanAustrian,HerbertNitsch),withthelongestbreathholdastaggeringelevenminutesandthirty-fiveseconds(heldbyaFrenchman,StéphaneMifsud).

Buttheseextremefeatsdonotcomewithoutriskorpenalty.Asthecirculationshutsdownattheedgesandbecomesmoresluggish,musclesandotherlessvitalorgansystemsareforcedtoworklargelywithoutoxygen.Thisanaerobicrespirationcauseswasteproductstobuildupinthebloodstream,steadilyacidifyingit.Thisislikethebodytakingahigh-interest,short-termloanfromitsmetabolicbank.Infactit’smorelikeborrowingfromtheworstkindofloanshark.Exceptinthisinstance,failuretopromptlyrepaythedebtalwaysleadstodeath.

Theoxygendebtiscalledinattheendofthedive.Aftersurfacing,diverstakelong,gaspingbreathsthatservetoreplenishtheirplunderedreservesandrebalancetheirphysiology.Forthosewhomisjudgethedive,however,oxygenlevelswillfalltothepointatwhichconsciousnesscannolongerbemaintained.Ifthisoccurswithnoonepresenttoimmediatelyassistandreturnthedivertothesurface,deathbydrowningisinevitable.

Butthosewhofree-diveregularlyappeartoundergoaseriesofadaptivechangesthatseemtoreducetheriskoffatalmisadventure.Thedivereflexbecomesmorepronouncedwithtraining:Experiencedbreath-holddiversexhibitlowerheartratesandhigherbloodpressuresonimmersion.Thetoleranceforaccumulatingcarbondioxidealsoimprovesasthebodiesofthesediversresettheirexpectations.Thecellsthatdetectchangesincarbondioxidelevelsinthebloodstreamrespondmorelaconically,sendingsignalstothebrainlessurgentlywhenbreathingstops.Lungsbecomemorecompliant,andtheirvolumesalsoincrease.This,asthedoctorexaminingGiorgiosStattiin1913noted,leadstoamoreexpandedchest.Mostimpressiveofall,experiencedfree-diverstrainthemselvestoresistthereflexiveandprimalurgetobreathe—aremarkablefeatofmindovermatterallowingthemtopushhumanphysiologywellbeyonditsdefaultlimits.

—

UNTILTHEMIDDLEofthetwentiethcentury,divingwasapursuitthatdemandedumbilicalconnectiontothesurface:atubethroughwhichtheatmosphereabovecouldbepumpeddowntoadiver.TheSiebeGormanstandarddivingdress—ahelmetofbrassboltedtoawaterproofcanvassuit,givenballastbyshoesandweightsmadeoflead—becametheiconicimageofthedivingindustry.Thehelmetwassuppliedwithairviaahosefromthesurface,drivenfirstbyhandpumpsandlaterbydieselmotors.Thelinkwiththesurfacecouldnotbebroken.

Later,self-containedunderwaterbreathingsystemswereinvented,whichallowedthedivertoswimwithoutbeingencumberedbyanumbilicalhose.Thousandsoflitersofaircouldbecompressedundermassivepressureandheldinametalcylindersmallenoughtobecarriedonadiver’sback.Avalvemountedonthesetanksreducedthepressureofthecylindersupplytosomethingthatcouldbebreathedsafely.Withoutthis,breathingfromthemwouldbelikeinflatingpartyballoonsfromtheairhoseatagasstation—theuncontrolledrushofhigh-pressuregaswouldsooninjurethelungs.

Aswellasreducingthepressure,valveswerealsousedtoallowairtobesuppliedondemand—sippedfromthetanklikeadrinkfromabottle.Thisself-containedunderwaterbreathingapparatusbecameknownasSCUBAandallowedunderwaterexplorersandworkerstogreatlyextendthetimeforwhichtheycouldremainimmersed.Buthavingsolvedtheproblemofhowtomaintainoxygensupply,diversencounteredanewproblem.Stayingsafeatdepthisaboutmorethantheavailabilityoffreshair.Maintainingyoursupplyofoxygenisonlythefirstchallenge.Withdepthcomespressureandwithpressurephysiologicalalteration.

—ABOVEWATER,YOUARESWIMMINGatthebottomofadifferentocean:anoceanofair.You’renotawareofitsweightaboveyou,butit’stherenevertheless,pushingonyourbody:14.7poundsforeverysquareinch.Wecallthatoneatmosphere—appropriatelyso,becauseitisthepressureexertedbytheweightofthesingleatmospherethatstandsaboveus.

Waterisfardenserthanair.Thekilometersofgasaboveexertapressureequivalenttojusttenmetersofseawater.Everytenmetersthatyousinkintothewateraddsanotherwholeatmosphereofpressure.Soattenmetersthepressureisdoublethatatsealevel.Attwentymeters,it’sthreetimesasgreat;atthirty,it’sfourtimes,andsoon.

Nowwater,ofwhichthemanytrillionsofcellsofourbodyarelargelycomposed,cannotbecompressed,andsoforthemostpart,ourbodiesdonot

composed,cannotbecompressed,andsoforthemostpart,ourbodiesdonotsignificantlydeformaswedescendintothedeep.Butthesameisnottrueofthepocketsofairheldinsoftbodycavitieslikethegutandthelungs.

Volumesofgastrappedinthebodyarereducedaspressurerises.Ifyoublewupaballoonatthesurfaceandmanagedtopullitdowntotenmeters,itwouldhalveinvolume.Attwentymetersbelowthesurface,wherethepressurewouldhavetripled,theballoonwouldhaveshrunktoathirdofitsoriginalsize.

Thereverseisalsotrue.Aballooninflatedunderpressureattwentymeterswillgrowtothreetimesthatsizebythetimeithasfloateduptothesurface.Iftheskinoftheballooncan’taccommodatethatincreaseinsize,thentheballoonwillburst.

Thisisamongthemostimmediatethreatsthatdiversface.Thelungsareeffectivelyclustersofmillionsofairspaces—alveoli—thatbehaveliketinyballoons.Toinflatethematdepth,youneedtotakeabreathofpressurizedairsufficienttoovercometheincreasedpressureofthesurroundingwater.Onceinflated,they’llbehaveexactlylikeballoons,expandingasyourisetowardthesurfacewithwallsthatareinpartsasinglecellthick,sothey’llburstjustaseasilytoo.

Aruptureofthelung’salveolarairsacswillpushairintoplacesthatitdoesn’tbelong.Therealriskisofairexpandingoutoftheseburstballoonsandenteringthebloodvesselsthatrunovertheirsurfaces.Ifthishappens,thebubblescantravelthroughtheveinsofthelungbacktotheheart.Fromtheretheywillbefiredoffaroundthebody,blockingessentialroutesofbloodsupply.Ifthecirculationofthebrainortheheartisinvolved,theeffectcanbeinstantlyfatal.

Apartfromdrowning,thisphenomenonofarterialgasembolismistheleadingcauseofdeathamongdivers.Thiswecallbarotrauma—literally,thewoundofpressure.Itiseasilyavoided.Thetrick,aswithmostthingsinlife,istokeepbreathing.Breathinginandoutduringtheascentreleasestheexpandinggasandstopsthelungsfromoverinflating.Butpanic,followedbyabolttothesurfacewithyourbreathheld,willkillyou.

—PRESSUREDOESN’TCHANGEjustthevolumeofgaswithinourbodies.Itchangesthewaygasesaffectourbodies.Airiscomposedof21percentoxygen,78percentnitrogen,andamixtureoftracegases.Thenitrogenisusuallyinert,andatsealevelpressure,itpassesinandoutofourlungswithoutanynoticeableeffect.Butitdoesn’tremainsoinnocuousunderpressure.Underwater,nitrogen

acquiresnarcoticproperties.Thehigherthepressure,themoreintoxicatingitseffectbecomes.

“Thenarcs,”indivers’parlance,thisphenomenonfeelsalmostexactlylikebeingdrunkandbecomesverynoticeablebelowdepthsoftwentyorthirtymeters.Whileitmightsoundlikefun,it’sdangerousinasituationwheresmallmistakeshavethepotentialtobecatastrophic.Oxygen,too,becomeslessbenignatdepth.Underpressureitcanbecometoxic—particularlytothelungsandthecentralnervoussystem—intheworstcasescausingseizures.Againtheproblemsbecomemoreseverethedeeperyoudive.Butsomeofthemostseveremedicalproblemsassociatedwithdivingoccuronlyafteryou’veleftthewater.

Nitrogenishighlysoluble.Atsealevel,itpassesfromthelungsintothebloodstreamuntilbloodbecomessaturatedandnomorecanbetakenonboard.Whenwegodiving,theincreaseinpressuretemporarilyallowsmorenitrogentodissolve,supersaturatingthebodyanditstissues.Thisinpartaccountsforthenarcoticeffectsseenatdepth.Butoncethediverreturnstothesurfaceandnormalpressure,thisexcessnitrogenmustcomeoutofsolutionasgas.Thisisexactlythesameprocessthatweseeinthefizzingofabottleofcolawhenthecapistwistedoff.Surfacingslowlyislikereleasingthepressureheldinthebottlegraduallyandavoidingtheoverwhelmingsurgeofbubbles.

Weallfizzwhenwesurfacefromadive.Thetrickistolimitthenumberofbubblesandtherateatwhichtheyform.Therearetwowaysofachievingthis.Spendinglesstimeatdepthreducestheamountofadditionalnitrogenthataccumulates.Ascendingslowlyorstoppingonthewayupallowstheshowerofbubblestobecapturedinthecirculationofthelungsandfilteredoutofthebody.Thisisthebasisforthedivingtablesthatdefinehowlongadivermaysafelystayatdepthandtherateatwhichonecanascend.

Withproficiencyandprotocolcomesanillusionofsafety,butthedangersofsubjectingyourbodytoextremesofsubmergencearerealandpotentiallydeadly.

—QALITOISPARTOFaPacificIslandchain,fringedwiththesortofbeachestheyusetoadvertisecreditcards;itissmallenoughthatyoucouldwalkarounditinjustoveranhour.Thesurroundingwaterswerecrystalclearandwarmenoughtodivewithoutwetsuits.Iwaspartofacoralconservationexpedition,basedintheMamanucaislandgroupjustafewmilesnorthofFiji.IhadarrivedamonthorsobeforeChristmas2003,takingupalessthanonerouspostasdivemedical

officer.Wewerecutofffromtherestoftheisland,livinginanabandonedhousesetbackfromthebeach.Forelectricitywedependedonadieselgenerator.Waterwasdeliveredbyshipandstoredinahugeconcretereservoirtotherear.

Weekendsaside,wedivedmostdays.Forthecoralsurveys,weswaminteamsoffour,catalogingthefloraandfaunainlocationswherenoonehadeverdivedbefore.Thedivesthemselveswereconservative;wewereforbiddenfromgoingdeeperthaneighteenmeters,andwewereneverunderformorethanforty-fiveminutes.Therewasnothingparticularlyextremeaboutanyofit.Thewaterwaswarmandcrystalclear.

ItwasafarcryfromthedivesI’ddoneinBritishcoastalwaters,whereyousometimeshadtowearafleecejacketunderyourdrysuit,wereoftenunabletoseeyourhandinfrontofyourface,andattimeshadtograpplewithoceanswell.Comparedtothat,thestuffwedidontheexpeditioninthePacificfeltabsurdlyplacid,littlemorethansouped-upsnorkeling.Andyetthethreatwasalwaysthere.

Intherun-uptoChristmas,wemanagedtosqueezeinacoupleofrecreationaldives.Thesewerethehighlightoftheexpedition—achancetodosomeproperexploratorydiving.Thesurveysweregreat,butbeingforcedtofollowcompassbearingsandrecordaccuratefishandcoralspeciescountsonourslatessomewhatdetractedfromthegrandeurofthespectacle.

Therewasaclutchofnewlydiscovereddivesitesscatteredaroundourislandgroupthattheexpeditionfoundandnamed.Wewereprettyliteralaboutit.ThereefinfrontoftheexpeditionhousewascalledHouse;anotherthatwascarpetedwithseagrassbecameknownasGarden.ThesitewewoulddivethatdaywassimplycalledMagic.

Thedivestartedwellenough.Wecameofftheboatasagroupoffour,splitintotwobuddypairs,andbeganmovingovertheshelf,droppingclosetothesandybottom,driftingslowlyalongalineofseafans.

Irememberbreakingintoabroadsmileaswesettledintoposition.Thereefswarmedwithlife.Itwasexplodingwithcolor,asbeautifulasanythingI’deverseen—“Magic”indeed.Therewasagentlecurrentthatpushedthroughalongsidethecoralshelf,bringingenergyintothesystem:nutrientsandfoodstuffs.Onthistheresidentsofthiscoralneighborhoodfeasted.Everythingwaswellfed,fromtheclownfishandanthiastothebarracudaandsharks.

Therewasnoneedtoswim;thecurrentwasdoingallthework.Isat,neutrallybuoyant,takingitallin.Thesurfaceripplingabove,withthesunlightplayingthroughit,appeareddeceptivelyclose.

Wepassedbyachunky-lookingreefshark,itspowerful,diamond-shaped

Wepassedbyachunky-lookingreefshark,itspowerful,diamond-shapedbodyframedperfectlyagainsttheblue.Itwasn’tonmylistofproperlydangerouspredators.Besides,whywoulditbothertakingusonwhentherewasanendlesssupplyofmorepredictablepreyonthecoralwall?

Thenthecurrenttookusaroundacorner,andthelandscapebegantochange.Ilookeddown.Thereefwasfadingnow,replacedbyasandysurfacestrewnwithmorebarren-lookingdeadcoralandrock.Iwasvaguelyawarethatwe’dbeenpickingupspeedallalong,butthingsreallystartedmovingafterwemadetheturn.

Ipassedoveroneoftherockyoutcroppings,tooquicklyforcomfort,awarethatmypacehadsuddenlyaccelerated.Iturnedtotherestofthedivegroupbehindmeandpunchedtheopenpalmofmylefthandwiththefistofmyright—tryingtosignaltothemthatIwasworriedaboutthecurrent.

Ineedn’thavebothered;they’dalreadyworkedthatmuchoutforthemselves.Allthreewerebelowme,hangingofftherockIhadjustpassed,legsandfinsflutteringinthecurrentlikeflagsinhighwind.Thecurrentwasgrowingsteadilystronger,threateningtotakeusbeyondthelimitsofthedivesite.

Iturnedandtriedtoswimdowntowardthem,descendingagainatatimewhenIshouldhavebeenonmywaybacktothesurface.Ahandfulofmetersseparatedus,andthecurrentcouldn’thavebeenflowingatmorethanacoupleofknots,butitfeltlikerunningintoagale.Iinchedforward,tryingtoreachtherelativesafetyoftherock.Iwaskickingfuriously,mybodyoutatfullstretch,heavinggreatlungfulsofairfrommytank,tryingtomakeground.

Iwasonthevergeofbeingsweptoffbytheflowandseparatedfromtherestofthegroup.Anearlierexpeditionhadnearlylostadiverthisway,pulledawayfromhisbuddiesbythecurrent.He’dbeenfoundmanyhourslater,aloneonthesurface,morethanamileaway,justbeforenightfall.Theywerelucky.Whentheygottohim,he’dallbutgivenuphopeofrescue.

Iwaskeentoavoidthesamefate.Buthereonthisunderwatertreadmill,kickingashardasIcould,otherriskswerebeginningtocreepin.Myairsupplywasfallingfasterthanever—Ihadtokeepaneyeonthat.Butatthebackofmymind,Iwasawarethatallofthisfranticthrashingwassilentlyacceleratingthechangesinmyphysiologycausedbydiving,increasingmyriskofdecompressionillness.

—WHENYOUEXERCISE,yourrateanddepthofbreathinggoup.Atthesametime,thebloodflowtoyourmusclesandthecapillarynetworkaroundyourlungs

increases;yourheartpumpsharderandfaster—chuckingoutlargervolumesofblood—tryingtokeepupwithdemand.

I’dgonefromsippingaroundhalfaliterofairfrommytankwitheachbreathtoperhapsfivetimesthatvolume.Myheartratewasuptoo.Thefivelitersofbloodordinarilyejectedbymyhearteveryminutehadnowincreasedtofourorfivetimesthatnumber.

Allofthiswasanefforttostepupandmeetthedemandsofthisnewexertion,helpingmetoinchclosertothatrock.Whathadstartedasasedentarydrifthadnowbecomeaferocioussprint.Butinboostingtheoutputofmyheartandthevolumesofgasbeingshiftedinandoutofmylungs,Iwas—everysecond—bringinglargerquantitiesofairintocontactwithamuchgreaterflowofblood,furthersaturatingmybodywithnitrogen.Thesimplefight-or-flightresponsethatIneededtogetmyselfoutofimmediatedangerwasaddingfizztothetissuesofmybody,tradingimprovedperformanceinthismomentforproblemsthatI’dhavetodealwithlater.

Ireachedthem,finally,stillbreathinguncontrollablyhard,payingbacktheoxygendebt.Iscrambledtolookatmyairgauge.Ihadalittlelessthanaquarterofatankremaining.

Westillhadtoworkoutwhattodo.Bryn,themostexperienceddiveramongthefourofus,scribbledsomewordsonaslatewhileweheldontohim.“NearWilkesPassage!!!”hewrote.Ishruggedathim,unsureofwhatthatmeant.Hescribbledsomemore.“Shippinglane.”

Wehadtosticktogetherandgettothesurfaceandhopethatwehadn’tdriftedtoofarfromourboat.Weabortedthedive,ascendingintothepoundingflow,stickingclosetooneanother,stoppingtheascentaswereachedthefive-meterdepth,hopingthatthiswouldbeenoughtohelpreleasethenitrogenthatwe’dstoredupinourbodies.

Iimaginedthefrothingofmyblood.Thenitrogenwouldberushingoutofsolutionnow,possiblyoverwhelmingthecapillariesofmylungs.Usuallythethree-minutestopatfivemeterswasjustanaddedprecaution,somethingyoudidtomakesurethatyouwereabsolutelycovered.ButIwonderedthistimeifitwouldbeenough.Westayedaslongaswecouldatfivemeters.Wehadtheluxuryofnomorethanafewextraminutes.Myairwasnearlyfinished,andthecurrentwasstillcarryingus.

Ihadtimeenoughtothinkaboutwherewewere.Ourshallowexcursionofafewmetersintowarm,clearwatersuddenlylookedfarlessbenign.Atthesurface,we’dhavetohopethatthediveboatcouldfindus.Itwasalreadylateafternoon,andthesunwouldsetfast.

afternoon,andthesunwouldsetfast.Thentherewasthedecompression.EvenifIfeltOK,itwouldprobablybe

morethantwenty-fourhoursbeforeIknewwhetherI’dmanagedtodealwiththeadditionalburdenofnitrogen.Thesymptomsofdecompressionillness—thenumbness,thetingling,thepainsinyourchest,thedifficultywithbreathing,thecreepingdisabilities—allofthatcouldevolveatprettymuchanytimewhilethefizzinginmybloodstreamcontinued.

Nothinginmyknowledgeofdivemedicinewasparticularlyreassuring.Wehadstuckwellwithinthelimitsofthedivetables,butabouthalfofallepisodesofdecompressionillnesshappentopeopledivingwithinrecommendedlimits.Ihadjustcompoundedtheissuebyexercisingforacoupleofminutesattopwhack,loadingmytissuesandbloodwithfarmorenitrogenthanIwouldhaveonanyordinarydive.

Thenagginguncertaintiesthatcomewithdivingareeasiertodismisswhenyou’rewithinclosereachofarecompressionchamber.Butouthereitwouldtakethebestpartofadaytogettothemainlandandintoaplacewiththatkindofequipment.Thatjourneycouldsafelyhappenonlyduringdaylight.

Therewasnofallbackpositionhere,nowheretogoifIreallywassick.MybodyhadstartedchangingtheinstantI’denteredthewater,adaptingtothenewenvironment,yieldingtothepressureandthechangesthatthisinflicted.Itsuddenlyseemedridiculoustohavecartedabagfullofdivinggearoutintothemiddleofnowherejusttoscratchthesurfaceoftheocean.

Thegadgetrythatallowedmetodescendafewmetersbeneaththewaterleftmenakedaboveitandfarfromhelp.Whenwebrokethesurface,Ihadneverbeforebeensohappytospitmyregulatoroutandbreatheordinaryair.

Afteramercifullybriefsearch,thediveboatfoundus.WedrovebacktoQalito,arrivingjustbeforesunset,happy—foronce—tobeoutofthewater.Ispenttheeveninginmybedonthebeach,readingmydivemedicinetextbookbythelightofaheadlamp.Havingpushedthemostsublimeedgeoftheenvelopethatsupportshumanlife—usingatwenty-first-centurysportskitI’dboughtinadiveshopinLondon—Iwasleftunderneaththatpalmtreeindarknesshopingthattheenvelopedidn’tpushback,littlebetterequippedthanaphysicianfromthe1900s.IwashopefulthatthistimeI’dgetawaywithit,butinthatmomentitseemedliketremendousfolly.

—HUMANLIFEISSUPPORTEDINONLYthenarrowestmarginaroundourplanet;thewaterthatcoversfullyfourfifthsofitssurfacedoesn’tsupporttheimmersed

explorer.I’mnotjusttalkingabouttheabsenceofbreathableoxygen.Takingairwithusintothedeepdoesn’tallowustoextendourstayindefinitely.Wechangeaswedive,adaptingtothenewenvironment,butthewatercolumnalsochangesus,asdothegasesthatwetakeintoourlungs.We’renotsupposedtostrayfromsealevel.Atleastthat’swhatourphysiologytriestotellus.We’rehopelessinthewaterwithoutsupport—notmuchbetterevenwithourownoxygen.Weshouldstayondryland,somewherewarm.Wearetropicalanimals,afterall.

Abovethesurfaceoftheocean,helicopterplatformsopenupavenuesofexplorationandrescueunthinkableinearliercenturiesandwithanimmediacyunparalleledinanyotherage.BorneathighspeedoutoverthetropicalseasofthePacificortheicywatersoftheNorthSea,werelyuponthatremarkableengineeringtoextendandprotectus.Ittakesmereminutestoseguefromthewarmthandsecurityofanairportterminaltoflightaboveanenvironmententirelyinhospitabletohumanlife.Allthatliesbetweenusandmilesofopenwaterisanaluminumcansuspendedbeneathanabsurdenginethatthrowsairatthegroundinanefforttodefygravity.

Withhelicoptersandcylindersofair,wehaveprojectedourselvesoverandbeneaththeocean,extendingourcapabilitiesinrescueandexploration.Butthoseinnovationsprovideonlythebarestprotectionfromenvironmentalextremes.Mishapsarepromptlypunishedandrarelyforgiven.Augmentedbytechnologyandengineering,wesimultaneouslybecomemorecapableandmorevulnerable.

January31,1977:HorseandriderwatchasthespaceshuttleEnterpriseistowedthroughCaliforniafromtheRockwellconstructionfacilitysitetoEdwardsAirForceBaseforayearofflighttests.

(PhotographbyArtRogers/Copyright©1977,LosAngelesTimes,reprintedwithpermission)

WORBIT

henIdecidedaftermyastrophysicsdegreetoturnaroundandheadbackthroughtherevolvingdoorsofmyuniversitytostudymedicine,myparentscried.Likemanyimmigrantparents,they’dalwaysdreamedoftheirsonbecomingadoctor.

Mybankmanagerwasclosetotearsfordifferentreasons.Iwasrunningoutofcash.Ispentweekendsfilingslidesinaphotographicagency,workedshiftsasadoormanatthestudentunion,andevenhadalaughablyshortandshockinglybadstintasaDJ.Noneofitquitepaidthebills.

ButIhadaplan:NASA.NASAwasamultibillion-dollaragencyinthebusinessoflaunchinghumanbeingsintospace.Iftheyweredoingthat,thentheymustneeddoctors,sotheymusthavepotsofcashtofundpeoplelikeme.

NASA,ofcourse,hadbillionsofdollars,buttheywereallspent—andthensome.Theyhadnograntmoney,and,eveniftheyhad,myBritishpassportwasn’tgoingtohelpmegettoit.AsafederalagencyoftheUnitedStates,NASAisforbidden,underexecutiveorderofthepresident,fromemployingnon-Americans.Mostoftherepliestomyinquiriesmadethatpointnonetoosubtly.

IgaveupontheideaofgettingagrantanddecidedinsteadtosenddozensoflettersaskingtospendsometimeasaninternwithaNASAresearchlab.I’dhavetodoitforfree—butatleastI’dgetupclosetotheplacethathadfascinatedmethroughoutmychildhood.

Here,too,Iwasmetwithabarricadeofpoliterefusals.Thencametheageofthedial-upmodem,andIstartedblizzardingoute-mails.Iwaslucky.Itwasatimebeforepeoplehadfiguredoutspamfilters.Somewhere,somehow,oneofthoseletters,faxes,ore-mailsgotmeanapplicationform—andunbelievably,thatapplicationformwonmeaplaceinanaerospace-medicinecourseatJohnsonSpaceCenterinHouston.

—

—IFYOURISEUPTHROUGHTHEatmospherefromsealevel,thegoinggetstoughlongbeforeyougetanywherenearspace.Anythingabove5,000feetcountsas“highaltitude”asfarasphysiologistsareconcerned.Evenatthismodestheight,themedicalproblemscausedbyaltitudecanbegintodevelop.

Onceyougettoaround29,000feet,justfiveandahalfmilesabovetheground,youreachthehighestpointonthesurfaceoftheplanet:thesummitofMountEverest.Thisappearstobeverynearlythehigh-altitudelimitforunsupportedhumanlife.Acoupleofhundredfeethigherandthemountainwouldbeunscalablewithoutsupplementaloxygen.

MountaineersarrivingatthesummitofEverestdosoonlybarelyalive,havingalteredtheirphysiologyoverweeks,adaptingtothechallengespresentedbytherarefiedatmosphere.Here,withorwithoutoxygen,everystepbecomesataskofHerculeanscale.Summiteersdescribetheexcruciatinglyslowplodalongthelastridgethatstandsbetweenthemandtheirgoal,eachstridepunctuatedbygreatgaspingburstsofhyperventilationastheystruggletorepaytheoxygendebtincurred.Evenafterweeksofadaptation,theirbodiesareonlyjustcapableofthisfeat.Anunadaptedindividual,whohadn’tenduredtheweeksofacclimatization,wouldbeincapacitatedinsecondsbyexposuretothesamealtitude.

Atypicalcommercialjetairlinercruisesataround36,000feet—afewthousandfeethigherthanthesummitofEverest—butthepassengersandcrewwithinarebreathingnormal,low-altitudeair.Itisonlypressurizationofthecabinthatleavesthemabletoenjoyin-flightmoviesandmoanaboutthelackoflegroom,ratherthanlollaroundunconsciousintheirseatsasapreludetodeathfromoxygenstarvation.

Reductionofpressurecausesusproblemsathighaltitude.Withfewermoleculesofoxygenineverybreath,thepressureexertedbytheoxygeninourlungsfallsandsotoodoestherateatwhichitpassesacrossthemembranesofthealveoliandintoourbloodstream.Thisleavesourredbloodcells,andthereforeourtissues,starvedofoxygen.Youcancompensateforthatinoneoftwoways:eitherbypressurizingyourenvironment—ascommercialairlinesdo—orbyincreasingtheamountofoxygenintheairthatyoubreathe.

Commercialairlinesrelyuponpressuretokeeptheirpassengersproperlyoxygenated.Inpreflightsafetyvideos,flightattendantscalmlyshowofftheyellowoxygenmaskthatwouldpopoutoftheceilinganddangleaboveyourseatifcabinpressurizationfails.Partoftheirbriefingurgesyoutobehave

seatifcabinpressurizationfails.Partoftheirbriefingurgesyoutobehaveselfishly,askingthatyouputyourownoxygenmaskonbeforeattendingtoanyoneelse.Butthere’sagoodreasonforthisrule.At36,000feet,intheabsenceofsupplementaryoxygen,asuddenlossofcabinpressurewillincapacitateyouinlessthanthirtyseconds—roughlythetimeitwouldtakeyoutofightarecalcitranttoddler—bywhichtimebothofyouwouldbelefthelpless.

Thingsonlygetworseasyouascend.Pilotsofunpressurizedaircrafthavetocompensateforthereductioninatmosphericpressureastheyclimbhigherbyincreasingtheconcentrationofoxygenthattheybreathe.ThelivesofWorldWarIIbombercrews,flyingataltitudesofupto40,000feet,dependedasmuchontheoxygensuppliedtotheirfacemasksastheydidonavoidingflakbatteriesandenemyfighters.

Thehigheryougo,thegreatertheconcentrationofoxygenyourequireinthegasesthatyoubreathe.Butabove40,000feet,evenpureoxygenisn’tenoughtokeepyoualive.Atthisaltitude,thepressurefallstolessthanafifththatatsealevel.Heretheoxygendoesn’texertenoughpressuretodriveitselfacrossthemembranesofyouralveoliandloadthemoleculesofhemoglobininyourbloodstream.

Tosupporthumanlifeatthesehigheraltitudes,oxygenmustbebreathedunderpressure.Thesemoreadvancedoxygensystemscomprisemasksthatformanairtightsealaroundthefaceandthenforceoxygenintoyourlungsatahugerateofflow.Wearingonefeelslikestickingyourheadoutofthewindowofacarthunderingdownthehighwayandtryingtobreatheagainsttherushofair.Theeffectistoinflateyourlungslikeaballoon,raisingthepressurewithinthemabovetheambientpressureoftheairoutside,facilitatingtheloadingofhemoglobinwithoxygen,andtherebyensuringyoursurvival.Andeventhisonlyworksuptoapoint.

Above63,000feet,youencountertheArmstrongline,anatmosphericlimitabovewhichthepooroxygenationofyourbloodstreamisnolongertheonlyfactorthreateningyourlife.(AlthoughtheArmstronglimitreferstoaspaceflightboundary,ittakesitsnamefromaviationphysiologistHarryGeorgeArmstrong,asopposedtoheofthe“onesmallstep.”)

TheArmstronglimitisessentiallythealtitudeatwhichyoubegintoboil.Letmeexplain.Pressurecookersworkbecausetheboilingpointofwater,andallotherliquids,risesasambientpressurerises.Yourcarrotscookmorequicklyinasealedcookerbecausethepressurizedwaterinsideisabletoreachatemperaturehigherthan100°C.(212°F.)beforeitboils.Thereverseisalsotrue:Theboilingpointofliquidsreducesasthepressurefalls.

AtthesummitofEverest,waterwouldboilatalittleover70°C.(158°F.).At

AtthesummitofEverest,waterwouldboilatalittleover70°C.(158°F.).Ataround63,000feet,theboilingpointofwaterfallsfurther,to37°C.(98.6°F.),thesameasthehumanbody’snormalcoretemperature.Atthis,theArmstronglimit,watercontainedinthetissuesofthebodyspontaneouslybeginstoboil.Bubblesofvaporevolveandexpand,swellingsofttissues,causingthebodytoballoon.It’sinterestingthat—contrarytosci-filore—thebloodinyourarteriesdoesn’tboil.Themuscularwallsofthosevesselsbehavelikeacrudepressurecooker,preventingthewaterinthearterialbloodstreamfromreachingitsboilingpoint.

Butintheveins,thestoryisdifferent.Herethebloodflowsatmuchlowerpressures,andbubblesofwatervaporcananddoform.Withlongerexposuretohighvacuums,thesebubblesgrowandcauseairlock,bringingthecirculationtoahaltandeventuallycausingcardiacarrest.Toavoidthisfate,peopleventuringabovetheArmstronglinemustswaptheiroxygenmasksforpressuresuits,surroundingthemselvesentirelywithanartificialsphereofsurvival.Soastronautswearhelmetsandbulkysealedoutfits,insulatedagainsttheravagesofspace,takingalittlebubbleofEarth’satmospherewiththem.

TheArmstronglimitdefinestheheightabovewhichsimpleaugmentationofphysiologyisnolongerenough.Beyondthis,humanlifedependsentirelyuponartificiallifesupportforsurvival.ThatlayeraroundEarth,justtwelvemileshigh,representsthenarrowestofslivers.IfEarthwerethesizeofasoccerball,thenthezoneinwhichlifeexistsunsupportedwouldbethinnerthanasheetofpaperwrappedarounditssurface.

—SPACEBEGINSATANINDEFINITEPOINT.ForphysiologistsitistheArmstronglimitthatmarksitsthreshold,buttoaircraftengineersitstartsatthevonKármánline,100kilometers(328,000feet,or62miles)abovesealevel.Heretheatmosphereissothinthatordinaryaircraftcannolongerpushagainstittosteerorgeneratelift.Tothephysicist,truespacestartsmanythousandsofmilesaway,wherethestatisticalprobabilityofcollisionbetweentwogasmoleculesbecomesinsignificant.Butforastronautsit’snotaboutaltitudesorpressures.Forthemthefrontierofspaceandallofitsattendantriskbeginsonthelaunchpad,fromthemomenttherocketengineslight.

IarrivedinFloridaatthebeginningofJuly2011,afewdaysbeforethebiglaunch.Atlantisstoodreadyonthepad,waitingtocarryitscrewoffourastronautsintoorbit.Shewasthelastofherkind;hersistersChallengerand

Columbiahadbeenlosttotragicaccidents.DiscoveryandEndeavourhadalreadybeenwithdrawnfromserviceandnowlaystrippeddowninhangars,beingmadereadyfortransport,preparingtotaketheirplaceashistoricalexhibitsinothercities.Thismissionwastobethelastofthespaceshuttleprogram.Afterthreedecadesand135flights,NASAhadcalledahalttotheproject.

Onthemorningoflaunch,theairoutsidewashumid.Tropicalstormfrontshadblownashoreoneafteranotherinthepastcoupleofdays,throwinglightningatthegroundanddrenchingthesoil.TheweatheraroundCapeCanaveralwasalwaysunpredictableinthesummer:Blueskiescouldturntothundercloudgrayinminutes,carryingsuddentorrentsofrainwiththem.

Forthepasttwenty-fourhours,I’dbeengluedtometeorologicalWebsites,tryingtomakesenseofisobarsandradarpictures,watchingfrontsevolveoutatseaandmigrateinland.Iwouldn’tusuallycare,buttodayat11:21A.M.,therehadtobenearlycloudlessskiesaboveKennedySpaceCenterfortenminutes.Whateverhappenedbeforeorafterthatdidn’tmuchmatter.

WithinthosetenminuteslaythelaunchwindowforAtlantis.TheymarkedthefleetingperiodwhenEarthwouldrotatePad39Aintojusttherightposition,sothatwhenAtlantis’sengineswerelit,thethrustwouldcarrythespacecraft—andhercrewoffour—intoorbit,toarriveatpreciselytherightplaceandtimetoallowhertorendezvouswiththeInternationalSpaceStation(ISS).

ThespacestationitselfwastravelingaroundEarthat17,000milesperhour.Thathugevelocitygaveitenoughenergytoremaininstableorbit,allowingittoresisttheforcesthatwouldotherwisebringitcrashingbacktoourplanet.

Tocatchupwiththatplatform,Atlantishadtobecomeamissile,acquiringenoughenergytoacceleratetothesamespeed.ShewouldgetalittlekickfromtheEarth,borrowingsomeoftheenergyofitsrotation.Likeeverythingelseonthesurfaceoftheplanet,thelaunchsitewasn’tstationary.ItwasrotatingwiththeEarthatalittleover900milesperhourfromwesttoeast.

Therocketscouldmakeuseofthat,likealongjumperstartingtherun-uponasupersonicconveyorbelt.Whilethatsoundslikeagoodstart,mostoftheaccelerationthatwoulddriveAtlantistomorethan17,000milesperhourhadtobeachievedthroughthebruteforceofrocketengines.

Theenvironmentofspaceisuniquelyhostile,butwhenitcomestoorbitalspaceflight,thedominantthreattohumanlifecomesfromthevehiclesandtheirlaunchersandthewaytheybehave.Twohundredfiftymiles,roughlythedistancefromthesurfaceofEarthtothealtitudeofthespacestation,doesn’tsoundlikealongway.Butrocketscienceisn’taboutdistance;it’sabout

soundlikealongway.Butrocketscienceisn’taboutdistance;it’saboutdefeatingtheforceofgravityandtheenergyreleasedinaccomplishingthatfeat.

Atlantiswasalreadystandingexposedonthelaunchpad,toweringovertwohundredfeetabovesealevel.Itsfat,orangeexternaltankhadbeenfilledovernightwithhundredsofthousandsoflitersofliquidoxygenandhydrogen.Thosecryogenicallystoredfuels,sealedintheinsulatedtankstrappedtoAtlantis’sbelly,weregentlyboilingoff.

Atthepad,thestackwascreakingandgroaning,strainingwiththecompetingthermalstressesofthefreezingfuelandmuggywarmthoftheFloridaair.Elsewherehoseshissedandvaporspouredforth.Atlaunchthatliquidfuelwouldfeedtheshuttle’sthreemainengines,whichsatinaclusteratAtlantis’srear.

Flankingthetankandtheorbiterwerethetwosolidrocketboosters(SRBs).NearlyfourmetersacrossandaboutaslongasanOlympicswimmingpool,thosecylinderswerefilledwithfivehundredmetrictonsofammoniumperchlorateblendedwithaluminum:anexplosivecombinationstuddedwithoxygenatoms,whoseenergywasjustwaitingtobereleased.Thatmaterialwascombinedwithabindingagent,leavingitinsolidstatewiththeconsistencyofputty.Whenlit,itwouldburnattemperaturescomparabletothoseofthesurfaceofthesunandmassivelyaugmentthrustinthefirsttwominutesafterignition.

Atlantishadstoodwaitingonthepadforseveralweeks,undergoingmeticulousfinalpreparations.Theorbitersreturnedfromspacenearlydead:glidingwithoutpower,bodiesscorched,fuelandenergyspent,enginesthrashedtothelimitsoftheirendurance.Forthehundredsofengineersresponsibleforturningthemaroundagainandreturningthemtoflight,itwasanactakintoresurrection.

TonightwasthefirsttimeinthismissionthatAtlantishadbeenfueled,readyforlaunch.Theperimeterhadbeenevacuatedasfarbackastwomilestoallbutthemostessentialstaff.Atlantiswasdangerousnow;thepotentialenergystoredinthechemicalsofherexternaltankandthesolidfueloftherocketboosterswasenoughtopropelthetwothousandtonsofstackintospaceattwenty-fivetimesthespeedofsound.Thegroaning,thecreaking,andthehissingmayhavebeencausedbyexpandinggasesandgratingmetal,buteventhemoreseasonedengineersregardedAtlantisasthoughitwereananimalslowlycomingtolife,withapersonalityofitsown.

Thecountdownclocktickeddowntozero.WestoodandwatchedasAtlantisroseintothesky.Itfeltwrong.Launchesalwaysdid.Itwasaneventonascalethatdidn’totherwiseexistintheworld.Amassiveobjectracingstraightup,far

fasterthanitshouldbeableto,burningenginesbrightenoughtolighttheentirebankofcloudsintowhichiteventuallyflew,disappearinginseconds.Istood,breathbated,untilthesolidrocketsseparated.

Thecrewonboardknewtherisksoftheirendeavorbetterthanmost.AsyouclimbonthehighestslopesofEverest,therearepointsatwhichyoupassthebodiesofpeoplewhohavediedonthemountain—asoberingreminderoftheconsequencesoftakingsuchrisks.Inasimilarway,astronautsridingaloftareawarethatastheyhearthewords“goatthrottleup,”theyarepassingthepointatwhichChallengerfailed,andtheyknowastheydeceleratethroughMach19onreentry,thatColumbiagotthere—andnofurther.

—THETRICKTOFLYINGISTOthrowyourselfatthegroundandmiss.Atleastthat’showDouglasAdamsexplaineditinTheHitchhiker’sGuidetotheGalaxy.Whilehisdescriptionwasconstructedforcomiceffect,itactuallycaptures—inastrangelyaccurateway—whatastronautsheadingintoorbitactuallydo.Theyclimbintovehicles,firetheirrocketengines,andhurlthemselvesacrosstheEarthsofastthattheyrunoutofplanettofallonto.Onceatthatspeed,theycontinuetofallfreelyaroundtheglobe,heldbythebondofgravity,unabletoescapeEarth’sgriporreturntoitssurface.Thetermorbitsimplydescribestheactoffallingtowardacelestialbodywithouteverhittingit.

Thereis,ofcourse,alittlemoretoitthanthat.Theartofrocketscienceisadisciplinefilledwitheveryone’sworstmath-classnightmares:calculusstackeduponthemechanicsofcircularmotionframedwithinexoticcoordinatesystems.Whenyougetdowntothenitty-grittyofbuildingthethings,there’saloadofprettynastychemistrytobendyourmindaround,too.

Therealityisworsestill.Thestuffonpaperhastobeengineeredtoworkintherealworldwithoutallofthesimplifyingassumptions.Thenutsandboltshavetotravelatmanythousandsofmilesanhourandthenfallgracefullythroughspace,preciselyaspredicted,withoutflaworfailure.Theonlywayyoucouldmakerocketscienceanymoredauntingasaprospectwouldbetoaddhumansintotheequationaspassengers.

Thisisthechallengeofhumanspaceflight.Noamountofadaptationoracclimatizationcanpreparethebodyforexposuretohardvacuum.Noamountofaugmentationofphysiologycanmakethatenvironmentsurvivable.Insteadbubblesoflifesupportmustbeartificiallycreated,maintained,andsealedagainsttheexterior.Thesemustthenbecrammedintactintothearchitectureofaspacevehicle,smallenoughandlightenoughtorespectthegreatenergies

spacevehicle,smallenoughandlightenoughtorespectthegreatenergiesdemandedbyorbitalspaceflightbutspaciousenoughtoaffordatleastrudimentarycomfortforthecrew.Whenitcomestohumanspaceflight,throwingyourselfatthegroundandmissingisonlyhalfthebattle.

—ASAJUNIORDOCTOR,I’doccasionallygetachancetospendsometimeattheCape,workingandresearchingwiththemedicalteamthere.FormallyitwasKennedySpaceCenter,NASA’sspaceport,thepointonEarthfromwhicheveryhuman-ratedAmericanspacevehiclehadeverdeparted.ButtomeitwasalwaystheCape.ItsatafewdozenmilesoutsideOrlandoontheeasternseaboardoftheUnitedStates,asprawlinggovernmentcomplexreclaimedfromwetmarshlandsinthe1960sforthepurposeofdoingsomethingoutrageouswithexplosiverockettechnology.

Fromtimetotime,NASArantrainingcoursesforthecivilianmedicalteamswhomightbecalledupontoattendashuttleaccident.We’dgatherinlecturehallsandreceiveinstructionontheanatomyandphysiologyofthespaceshuttle,howitmightfail,andwhat,intheory,wemightdotohelp.

Theyshowedushowthecrewcouldescapeadebacleonthelaunchpadbyslidingdownatwo-hundred-foot-highzipwire,gettingfromthecrewdecktothegroundinafewshortseconds,crashingintoanet,andthenbailingintoanarmoredcarthatthey’dbeentrainedtooperate.Inanemergency,theyweretoldtoclimbin,drivestraightthroughtheperimeterfence,andkeepgoinginthehopethattheymightoutrunthefireballandblastthatwouldaccompanythesimultaneousdetonationofafewhundredthousandlitersofrocketfuel.

Theyshowedustoothattheshuttlecouldabortaftertakeoffduringitsascent.Redundancywasthenameofthegamehere.Afterafewminutesofflight,themissioncouldtoleratethefailureofoneofthethreeshuttlemainenginesandstillgetintospace,albeitatalowerthanintendedorbit.

Losinganengineearly,beforemomentumhadhadtimetobuild,orlosingmorethanoneengine,wouldbeadifferentmatter.UnabletodevelopthealtitudeorvelocityrequiredtoachievelowEarthorbit,theshuttlecouldperformatransatlanticabort,amaneuverinwhichitwouldditchitsexternaltankandsolidrocketboostersandvaultacrosstheAtlanticOcean,landingsomewhereinEurope.

ThatjourneyacrosstheAtlanticOceanofmorethanfourthousandmiles,whichacommercialairlinerwouldtakeperhapseighthourstocover,wouldbecompletedbyanabortingshuttleinlessthanthirtyminutes.

Therewasanother,evenmoreoutlandishscenariocalledthereturntolandingsite(RTLS).Here,havinglostanengineearlyinthelaunch,unabletomakeittospace,butstillstrappedtoitsexternaltankandtwosolidrockets,theshuttlecould—intheory—beflippedoverandflownbacktoKennedySpaceCenter.Duringthisabort,thesolidrocketboosterswouldbejettisonedaftertwominutes.Then,stillstrappedtotheexternaltankandatthispointheadingtowardEuropeatseveralthousandmilesanhour,theshuttlewouldascendanduseitsmaneuveringthrusterstoflipitselfover,rotatingthrough180degreeslikeapancake,withitsremainingmainenginesstillburning.

Havingperformedtheequivalentofasupersonichandbraketurn,theshuttle’smomentumwouldcontinuetocarryittowardEurope.

FlyingbackwardwithitsnosepointingroughlytowardtheUnitedStates,theengineswouldbefacingthedirectionoftravel,thusslowingtheshuttledown.Atsomepoint,therocketmotorsstillfiringandtheexternaltankstillattached,theshuttle’sprogresstowardEuropewouldbearrested.Momentarilyitwouldcometoastandstillbeforeacceleratingonceagain,thistimebacktowardtheStates.Thecrewwouldthendumptheirexternaltankandattempttoglideunpoweredbacktothesitefromwhichthey’dlaunchedsometwenty-fiveminutesearlier.

Itwasn’tjustfailureoftheenginesthatcouldleadtotheseemergencyaborts.Boththetransatlanticabort(TA)andthereturntolandingsitecouldalsobeusedtogettheshuttlebackonthegroundquicklyifasignificantfailureinthelife-supportsystemoccurred.Therewas,afterall,nopointinparkingavehicleinperfectorbitifthecrewinsidecouldnotbekeptalive.

Apepperingofeuphemismsaccompaniedthesebriefings.Therewasananticipationthatundersuchconditions,boththevehicleanditscrewmightreturnin“suboptimalcondition,”thatthelandingsmightbe“offnominal”incharacter.Behindthistechnicalphraseologylaytheriskthatduringanaborttheshuttlemightcrashonorshortoftherunwayandthecrewmightbeseverelyinjuredintheprocess.

Tocivilianclinicians,theseabortmodessoundedlikethestuffofsciencefiction.Evenamongtheastronautcorps,therewasalittleskepticismaboutjusthowsuccessfularealRTLSabortmightbe.Nevertheless,theydutifullydrilledandtrainedforthescenarios,sittingfullysuitedinsimulatorsforhoursatatime,rehearsingtheirworstnightmares.

Ioftenwonderedwhytheybotheredtodothiswhentheriskofthesetypesoffailureswassolowandthechancesofrecoveringintactafteroneofthemoreelaborateabortswassmallerstill.Butlikesomanyotherthingsinexploration

elaborateabortswassmallerstill.Butlikesomanyotherthingsinexplorationandmedicine,theydiditbecausetheonlyotheralternativewouldhavebeentodonothing—whichforthemwasn’tanoptionatall.

—EVENIFTHELAUNCHGOESSMOOTHLY,thereisstillthepossibilitythatamedicalemergencymightariseduringamission,farfromthesafetyofanyhospital.Becauseofthis,considerableefforthasbeeninvestedindesigningavenuesofescapeandmedicalcontingencyforspacecrews.Peoplehaveevengonesofarastodevisewaysofresuscitatingvictimsofcardiacarrest.Thisisnomeanfeat.Imagine,foramoment,tryingtodelivercardiaccompressionswhilefloatingweightlesslyinorbit.

Thetrick,itturnsout,istostrapthepatienttothefloorofthevehicle,putyourhandsontheperson’schest,braceyourfeetontheceiling,andthenuseyourlegstoprovidethenecessaryforce.Thismethodhasbeentestedonresuscitationdummiesinweightlesstrainingaircraft,anditworkssurprisinglywell.Butifyou’regoingtoplanforthepossibilityofcardiacarrest,thenyou’vegottoconsiderpreciselywhatyou’regoingtodoafterthepatient’sheartstartsbeatingagain.ContrarytowhatHollywoodwouldhaveyoubelieve,peoplewhosurviveanarrestoftheirheartveryrarelysituptheinstanttheirpulsereturnsasthoughnothinghadhappened.Theexperienceoftotalcirculatoryarrest,alongwithwhateveritwasthatstoppedtheheartinthefirstplace,tendstoleaveonecriticallyunwell.Afterward,aperiodofextremeinstabilityandalengthystayinanintensive-careunitisthenorm.Forallitssophistication,theInternationalSpaceStationhaslessmedicalequipmentanditscrewlessexpertisethanarefoundintheaverageambulance.DefinitivemedicalcareisavailableonlybackonEarth.

Itwaspredictedthatduringitsoperationallifetime,therewouldbeatleastonemajormedicalincidentaboardtheInternationalSpaceStationthatwouldrequireevacuationtoEarth.Toallowforthis,NASAstartedworkonanewexperimentalvehicle:theX-38.Standingontheedgeofspace,lookingoutacrossthevastnessofthefinalfrontier,NASAwasstillpreparedtogotoextraordinarylengthsinthehopeofsavingalife.

—THEREISABLACK-AND-WHITEPICTUREfrom1977oftheprototypespaceshuttleEnterprisebeingcarriedalongaCaliforniandesertroadonthebackofahugearticulatedtruck,beingdeliveredtoNASA’sDrydenResearchCenterforflight

testing.Behinditisasnakinglineof1970smotorvehicles.Intheforegroundsitsamanastridehishorse,itsbreathmistinginthecoldFebruaryair.Itisapictureoftheoldworldwatchingthefuturearrive.Thatiswhatwecametoexpectfromthespaceagency.That’swhatNASAdid:Itservedupthestuffofsciencefictiononthebackofaflatbedtruckandtoldyouthatthiswaswhatthefuturewasgoingtolooklike.

IwasremindedofthatimagewhensomeoneshowedmetheplansforNASA’snewX-38backin2001.Itwasawinglessvehicle,shapedlikeashuttlecocksplitinhalfthroughitsnose;awedgetoonarrowtoallowanadulttostanduprightinside,aboutthesizeofaluxuryspeedboat.Itwaswindowlessandprofoundlyalieninappearance.Irememberthinkingthatifitlandedunannouncedinyourbackgarden,you’dbeprettydisappointedifsomethingdidn’tthenslitheroutandsay,“Takemetoyourleader.”

TheX-38wasdestinedtobeNASA’sAssuredCrewReturnVehicle—awayofsolvingtheproblemofwhattodoifanastronautcrewhadareallybaddayinspace.Theplanwastoloaditintothepayloadbayofaspaceshuttle,deliverittothespacestation,andthenleaveitdockeduntilcalledupon.

Intheeventofsomecatastrophicfailureofsystemsaboardthespacestation,theX-38wouldbecomeaspacelifeboat.Thecrewwouldscrambleinside,liedown,strapin,andpunchout.Itwasaremarkabledesign,abletoaccommodateacrewofseven,shapedsothatitcouldbesteeredintheupperatmospherewhiletravelingathypersonicspeeds,andthenendowedwiththeworld’slargestparafoil—asteerablecanopythatwouldslowitsdescenttothegroundtoensureagentlelanding.Butitwasintendedtobemorethanjustafastridehome.Inamedicalemergency,withmembersofthecrewcriticallyillorinjured,itwouldessentiallyperformasaspaceambulance,capableofbeingequippedwithmedicaloxygen,state-of-the-artpatientmonitoring,andevenventilators.

ButascostsmountedandtheInternationalSpaceStationranintofinancialtrouble,NASAwasforcedtomakecuts.TheX-38wasshelved,andNASAreturnedtorelyingupontheSoyuzspacevehicleastheirmeansofescape.MuchsmallerthantheX-38andcapableofaccommodatingonlythreecrewmembersatatime,itwasalifeboatwithnorealmedicalcapability.ButinlowEarthorbit,ithadbecomeincreasinglyclearthatthedominantthreattohumanlifewouldnotcomefromcrewinjuryormalfunctioningphysiology.Therewassomethingthatdoctorsandmissioncontrollersonthegroundfearedfarmorethananymedicalemergency:acatastrophicfailureofthevehiclesthatcarriedandprotectedtheirastronautcrews.

—

—SOYEONDIDN’TPLANONbeinganastronaut.ShelivedinSouthKorea,acountrywithnohumanspaceexplorationprogram.Shewatchedscience-fictionfilmsasachildandfantasizedidlyaboutthepossibilitiesofspace,butherambitionwentnofurtherthanthat.

ShewasinherfinalyearofPhDstudywhentheadvertisementsfirstappearedinnewspapers.SouthKoreawastorunanationalcompetition,castingthenetwideinsearchofthecountry’sfirstastronaut.ThecontesthadallthetrappingsofTheXFactorgameshow:Eliminationswouldberunweekafterweekoverfourmonths,andthecompetitionwouldbetelevised.Totakepart,theonlyprerequisitewasthatyouhadtobeovernineteenyearsold.

Soyeondecidedtoapply,knowingthatshecouldn’tpossiblybesuccessful.Shewasatwenty-eight-year-oldlaboratoryscientistworkingonagraduatedegreeinbioengineeringattheprestigiousKoreaAdvancedInstituteofScienceandTechnology(KAIST),butshedidn’tkidherselfthatshewasanythingspecial.Shefilledintheformanyway.Itwouldbeanexperiencejusttobeintherunning,andawelcomedistractionfromthefinalyearofPhDstudy.BythetimetheclosingdateforentriesarrivedinSeptember2006,thirty-sixthousandSouthKoreanshadapplied.

Themountainofapplicationformswasscreened,excludingthosewithouttherighteducationalbackgroundorqualificationsanddrivingthenumbersdowntosomethingmoremanageable.A3.5-kilometerrunthenservedasanothercoarsefilter,thistimeforstandardsofphysicalfitness.Thelistofhopefulsthinnedoutquickly.Bytheendofthefirstmonthofselection,therewereonly245peopleleft—Soyeonamongthem.

Medicalexaminations,psychologicalevaluations,andinterviewsfilledthemonthofOctober.WhenSoyeonmadeitdowntothefinalthirtycandidates,sheallowedherselfthefaintestglowofhope.

InNovemberandDecembercamesuccessiveroundsoftelevisedelimination.Asthetestscameandwent,Soyeonfoundherselfstillintherunning.Thetasksbecamemoreelaborate.Thecontestantsexperiencedweightlessnessaboardaroller-coasterairlineride,divedinswimmingpoolstosimulatespacewalksandneutralbuoyancy,andunderwentdecompressiontraining.Thesuperficialgloss—thestudiolights,thespectacle,andthetelephonevoting—wasjustthat.Underlyingallofthiswasarigorousprocessoftechnicalselectionofthetypethatanycountrymightusetoselectprofessionalastronauts.BythetimethetenfinalistslinedupbeforethelivetelevisioncamerasonChristmasDay2006,theassembledhopefulslookedmuchliketheshortlistforanyformalastronaut

assembledhopefulslookedmuchliketheshortlistforanyformalastronautcorps:aclutchofscientists,engineers,andpilots.

Thereweretwowinningcandidates,amanandawoman.KoSan,athirty-year-oldresearcherattheSamsungAdvancedInstituteofTechnology,wasthesuccessfulmaleapplicant.Andstandingnexttohim,blinkinginthestudiolightswhenhernamewascalled,wasYiSoyeon.

Thingsmovedquicklyafterthat.SoyeonwastoldtohaltworkonherPhDandgetreadytoreporttoStarCityinMoscowfortraining.Thepacewasbewildering.ItwastheendofDecember,andtheywereduetoreportfortraininginRussiainthreemonths.Atthatstage,shedidn’tspeakawordofRussianandhadn’tyetfinishedherdegree,butnoneofthatappearedtomattertothecompetitionorganizers.ShewasgoingtoMoscow.

Soyeon’sfirstmemoriesofMoscowwerethatitwasgrayandbitinglycold.ThereinStarCity,inparallelwithanoneroustrainingregimen,Soyeonfinishedherdoctoralstudies.ShebecameaconfidentRussianlinguist,enduredsurvivaltraining,andgottogripswiththecultureofRussiancosmonauttraining.Therewasinitially,shefelt,adismissiveattitudetowardherfromthepredominantlymaletrainingstaffinRussia.ButSoyeonwasthick-skinnedandmorethanusedtohandlingthissortofbehavior.ThroughoutherengineeringstudiesinKorea,shehadpursuedcourseswherewomenwereintheminorityandmenwereoftenlessthanprogressiveintheirattitudes.Toher,StarCityfeltlittledifferent.

MoreattentionwaslavisheduponKoSan.AlthoughbothKoreanswerebeingtrained,onlyonewouldeventuallyflytothespacestation,anditappearedtobeaforegoneconclusionthatitwouldbeSanandnotSoyeon.

Afterayearoftraining,whenthetimecameforflightassignment,Soyeon’ssuspicionswereconfirmed.KoSanwasawardedtheprimeslot.YiSoyeonwastobethebackupcrewmemberand,assuch,likelynevertoflyinspace.Shehadlovedherexperiencenevertheless;ithadtransportedandtransformedher.Life,shefelt,wouldneverbethesameagain.MeanwhileKoSanpreparedforlaunch,lookingeverybitthenationalherothatSouthKoreahadsoughttocreate.

TheRussiantrainingteamsarenotoriouslyunforgivingofprotocolviolations.Andthoughthedetailsremainunclear,KoSansomehowmanagedtoangerhisRussianhosts.Withthreemonthstogobeforethemission,hewastakenofftheflightandinhissteadSoyeonwaspromotedtotheprimecrew.

Atfirstshewasincredulous.Shehadneverreallyexpectedtofly,butyetnowhereshewas,theprimecandidate,duetolaunchinlessthanahundreddays.Usuallyadaptable,Soyeonwasworriedthatshecouldn’tadequatelyprepareinthatshorttime.

prepareinthatshorttime.Thisfearcontinuedtooccupyhermindastheemphasisofhertraining

changedfocusandtookonanewseriousness.WhilehavingsupperonedayinStarCity,shereceivedaspecialphonecall—onecominglivefromamoduleinspace.ItwasPeggyWhitson,NASAastronautandcurrentspacestationcommander,whowasalreadyinorbit.Peggyhadheardaboutthelast-minutechangeinthecrewassignmentsandwantedtoreassureSoyeonthatshewasgoodtogo.Duringhertraining,SoyeonhadparticularlylookeduptoPeggy.ShenoticedthatwherevertheAmericanastronautwent,peopleappearedtorespectherauthority.That—Soyeonnoted—wasrareforanyoneandrarerstillforafemalecrewmember.IfPeggythoughtthatSoyeonwasready,thenmaybeshewas.

OnApril8,2008,alittleovereighteenmonthsafterSoyeonhadfirstrepliedtoanadinanewspapercallingforastronauthopefuls,shelaunchedfromBaikonurCosmodromeinKazakhstanaboardSoyuzTMA-12.Theytookahandfulofminutestoclimbmorethantwohundredmilesintospace.Twodayslater,theircapsulecrepttowardtheInternationalSpaceStationanddocked.

Soyeon’stimeonthespacestationfeltlikeasurrealdream.Theassembledmodules,joinedendtoend,gavethecrewafree-floatingspacecomparabletothatoftwocommercialairliners.Fromtheoutside,itappearedlargerstill.Withitssolararraysunfolded,thestationcoveredanareaintheskythesizeoftwoAmericanfootballfields.Inside,thenoiseofitspowerandlife-supportsystemsthrobbingawaywasattimesloudenoughtomakeeardefendersnecessary.Itwasareminderthatthiswasmorethananassemblyofbuildingsfloatinginorbit.Itwasamachineinwhichpeoplelived,onethat,throughenergyandingenuity,createdanartificialislandofhumansurvivalinanotherwiseuniquelyhostileenvironment.

Soyeonbusiedherselfperformingalonglistofexperiments,takingtimeoutduringherten-daystaytobroadcasttoschoolchildrenandthewiderSouthKoreanpublic.ShetooktheopportunitywhenshecouldtostealtimeinhercabinwithitstinywindowthatlookedoutattheblueglobeofEarthbelow.Alltoosoon,itseemed,itwastimetoleave.

Onthedayofdeparture,thecrewcrawledintotheconfinesoftheSoyuzcapsule.Theyhadtoenterinstrictorder.PeggyWhitsonenteredfirst,crammingherselfintotheleftseat.Soyeonfollowed,findingtherightmostchair.FinallyYuriMalenchenko,whowouldcommandtheSoyuzcapsuleonitsflightbacktoEarth,wedgedhimselfbetweenthetwo.Theycompletedtheirchecklists,andthecolleagueswhomtheywereabouttoleavebehindasthenewspacestationcrewclosedthehatchesandsealedthemin.Theretheysatintheirbulkypressure

closedthehatchesandsealedthemin.Theretheysatintheirbulkypressuresuits,containedwithintheirtinybudoflifesupport,suspendedbelowtheInternationalSpaceStation.

TheSoyuzbackedoffcarefullyfromthestation,creepingawayatinchespersecond.Therewerenoforwardwindowsonthecapsule;thecrew’sviewthroughthesmallportholeswasrestrictedandmostlylookedouttotheleftandrightsides.Fromherseat,SoyeoncouldseethevastnessoftheInternationalSpaceStationasitslowlyreceded.Forallitsartificeandfragility,thespacestationwasanislandofsecuritycomparedwiththeirtinyhomeboundcraft.

Thetriohoveredbelowtherelativesafetyofthespacestation,separatedfromthegroundbelowbyadenseatmosphereandtheneedtobleedoffthetremendousenergiestheyhadacquiredatlaunch.Theycontinuedtopullawaycautiously,takingnearlytwoandahalfhourstoputonlytwelvemilesbetweenthemandthespacestation.Thisexcruciatinglyslowchoreographyunderlinedthevulnerabilityofbothvehicleandstation.ThestructureandsystemsofboththeSoyuzandISSwerefinelybalanced.Neitherwasdesignedforhardcollision.

Atasafedistanceandonschedule,theyfiredtheSoyuz’srocketmotors,slowingthemselvesdown,givinggravityachancetocapturethemmorefirmly.TheSoyuzcraftcomprisedthreesections.Atthefrontwastheoval-shapedorbitalmodule,accessibletothecrewonlywhilealoft.Behinditwasacone,thelowerhalfofwhichhousedthepropulsionmodule.Inthetoppartofthatconelaythereentrymodule,atiny,bell-shapedvehicleintowhichSoyeon,Yuri,andPeggywerecrammed.Superficiallyitresembledagiantpawn,takenfromachessboardthesizeofasoccerpitch.

Shortlybeforereentry,thecrewcapsuleseparatedfromtheothermodules.Soyeon,sittingintherightseat,rememberedhertrainingforthisphaseoftheflight.Specificallysherecalledaskingifshe’dbeabletoseetheorbitalmoduleastheyseparatedfromit.Theanswerwasanemphaticno.Herinstructortookherthroughtheseparationprocessagainstep-by-step,explainingthatthemoduleswouldcomeapartlikebeadsonastraightpieceofwire.Ifshecouldseethemoduleafterseparation,itwouldmeanthatsomethinghadgoneverywrong.Andyet,afterthepyrotechnicboltshadfiredandthethrustershadbeguntopushthemapart,shewassureshehadcaughtaglimpseofpartofthatmodulethroughtheportholeaboveherhead.

Concerned,SoyeonreportedthistoYuri.Atfirsthethoughtthatshemustbemistaken.Asthevehiclecommander,hehadbeenmonitoringtheinstruments,andallofthemhadregisteredasuccessfulseparation.Healsoknewthatanearlycatastrophicfailureintheseparationprocesswouldhavetohaveoccurredfor

catastrophicfailureintheseparationprocesswouldhavetohaveoccurredforSoyeontobeabletoseesomethingoftheseparatedorbitalmodulefromherseatposition.YuriandPeggywereamongthemostexperiencedastronautsinRussiaandtheUnitedStates.Soyeon,ontheotherhand,wasarookieandcouldhavebeenmistaken.ButthenPeggyWhitsonsawsomethingthroughherportholetoo,apparentlydriftingoverandaroundtheirvehicle.

Strappedintotheirseats,withalimitedviewoftheexterior,itwasdifficulttoknowwhattheyhadjustwitnessed.Butwhateveritwas,theyknewtheyshouldn’thaveseenit.Worsestill,Soyeonnowthoughtthatshecouldseesomethingflapping,stillattached,againsttheoutsideofthecapsule.

Reentrystartedwiththecapsule400,000feetabovetheEarth.Theweightlessnessoforbitalspaceflightwasreplacedbytheforcesofdecelerationasthecraftslowedagainsttheatmosphere.Soyeonnoticedthattheridewasrougherthanshe’dexpectedittobe;theGloadseemedtobepressingonherchestfasterandharderthanthe4Gshehadanticipated.ShereportedthistoPeggy,whotriedtoreassureherthattheloadwasnormal,andthattheexperienceoftendaysofweightlessnessmightmakeitfeelmoreintense.ButtheGloadclimbedquickly,andsoonevenWhitsonandMalenchenkosensedthatthingswerenotright.

Thethreecrewwerecrammedintothereentrymodule,sharingjust3.5cubicmetersofspace—acoupleoftelephonebooths’worth.Theyknewthatthemodule’ssurvivaluponreentrydependeduponitsabilitytoadoptexactlytherightorientation—withitsheatshieldfacingthedirectionoftravel—asitpassedthroughtheatmosphere.Itwasnotthephysiologicalchallengeofthespaceenvironmentthatthreatenedthecrewhere—itwasthesheerviolenceofreentry.

—ATLAUNCH,AVEHICLELIKESOYUZmustacquireenoughkineticenergytopropelitscrewatover17,000milesperhour.Itdoesthisexactlyasafireworkwould,byliberatingthechemicalpotentialenergyinthelauncherandtranslatingitintothekineticenergyofmotion.Thevehiclecouldintheoryusethesameprocesstoslowitselfdown,butthatwouldrequireanotherrocketmotorofthesamesizethatgotitintoorbitinthefirstplace.Toavoidhavingtocarrythathugemassintospace,theSoyuzslowsdownbylosingenergytotheatmosphereasitpassesthroughit.

It’stemptingtothinkthatitisfrictionthatslowsthecapsule’sprogressduringreentry.Butthat’snotwhathappens.Instead,withthemoleculesoftheatmosphereessentiallyunabletogetoutofthewayasthereenteringvehiclescreamsthrough,ashockwaveofcompressedgasbuildsupinfrontofthe

screamsthrough,ashockwaveofcompressedgasbuildsupinfrontofthecapsule.Muchoftheenergyofmotionislostinheatingthatshockwave.Thefasterthecapsuletravels,thegreatertheheatgenerated.Soyuzisdesignedtostretchthereentryoutoveralongerperiodoftime,slowingdownmoregradually—abitlikethewayaFrisbeewouldsinktowardthefloorcomparedwithacricketball.Buteventhenthefrontofthecapsulereachestemperaturesofseveralthousanddegrees—aboutashotastheouterlayersofthesun.

Humanphysiologyfunctionsverybadlyifthebody’scoretemperaturerisesbyjustoneortwodegrees.Peoplebegintodieofheatstrokeifitrisesbymorethanthree.Theproblemfordesignersofhuman-ratedspacevehiclesishowtofaceawallofheatof,say,3000°C.(5432°F.),andthenparkthreeastronautsbehinditinatinycapsule,maintainingthatpocketanditssystemoflifesupportatnomorethan25°C(77°F.).

Thisoutlandishfeatisachievedintwoways.First,thebaseofthecapsule,facingtheshockfront,iscoveredinathermalshield.Thislayeredsurfacesublimes,transformingfromsolidtogasasitheats,pushingthehotshockwaveinfrontofthevehicleawayasitdoes.Thesecondelementthatallowsthecrewtosurvivetheinfernoisapreciseangleofentry,whichpreventsthecapsulefromheatinguptooquicklyandallowsittoflywiththeheatshieldfacingthedirectionoftravel.

ButSoyeonknewthattheyhadn’tseparatedfromtheirorbitalmodulecorrectly.Whateveritwasthatstillremainedattachedcouldthrowthingsoff,leavingthecapsuleinthewrongorientationasreentrybegan.Ifanunshieldedpartofthecapsulewasfacingforwardastheypushedthroughthedenseatmosphere,theheatwouldveryquicklydestroythemandtheirvehicle.Ifthishadhappened,thenthefirstindicationswouldbeasuddenincreaseintheGloadfollowedbyheatbuildingupinsidethecapsule.

Insidethecapsule,theGmeter,measuringtheseverityoftheirdeceleration,peakedat8.2G—morethantwicethenormalvalue—andSoyeonstruggledtoremaincomposed.

—ITISANOLDADAGETHATthetwohardestfeatsinallofrocketsciencearestartingandstopping.Thesearetheso-calleddynamicphasesofflight,whenthevehicleandcrewaregainingorlosinghugeamountsofenergyoverashortperiodoftime.ItwasafailureofanO-ringsealatlaunchthathadkilledthecrewofChallengerin1986andadamagedheatshieldinoneofColumbia’swingsthat

haddestroyeditanditscrewduringreentryin2003.JustastheheatassaultingSoyuzfromtheoutsidewasatitsfiercest,ared

lampbegantoflashonthecontrolpanel.Itwasawarninglight,tellingthemthatsomethingintheirsystemshadfailedandthatthevehiclewasswitchingtoanemergencybackupprocedure:ballisticreentry.Itmeantthattheywereplunginginelegantlythroughtheatmosphere—likethecricketballratherthantheFrisbee.ButSoyeonfoundthisstrangelyreassuring.TheSoyuzcapsulewasdesignedforthis.Theridewouldberough,buttheyshouldstillarrivesafely.

AfterwhatseemedlikeaneternitytoSoyeon,theviolentbuffetingstopped,andshefeltajerkastheparachutesopenedabovethem.Unsureofwhathadhappened,theycheckedtheirsystems.Itwasatthistimethattheynoticedsomethingthatlookedlikesmokecomingfrombeneathoneofthepanels.InthecrampedspaceoftheSoyuzcapsule,nobodycouldbesureofwhattheywereseeing,butthecloudseemedtohangaroundSoyeon.Withminuteslefttogointhedescent,thecrew’sfearsturnedtothepossibilityoffire.

FireintheconfinesoftheSoyuzcapsulewouldbedevastating.Thecrewdecidedtopowerdowntheelectricalsystems.Thereentryhad,afterall,beenhotterandharderthanexpected;perhapssomethinghadoverheatedandcaughtfire.

Soyeon,however,wasn’tconvinced.AspartofherPhD,shehadworkeddailywithliquidnitrogenandliquidoxygen.Toherthis“smoke”lookedlikethevaporsfromacryogenicsystem.Yuriaskedherifshewasabsolutelycertain.“Yes,”sheinsisted.Reassured,thecrewturnedtheirsystemsbackonashorttimebeforelanding,butbythentheyweremorethantwohundredmilesoffcourse.

Thecapsulehitthegroundhard,bouncingbeforeitcametorestonitssideintheKazakhsteppe,farfromtheintendedlandingsite.Thecrewunbuckledtheirstrapsandcrawledout,wheretheyweremetbyasmallgroupofnomadictribesmen,whoinitiallycouldn’tunderstandwhereSoyeonandhercolleagueshadappearedfromorhowtheyhadarrived.Yuriflickedonasatellitephoneandcalledintheirposition.Itwascold—coldenoughfortheirbreathtofrostintheair—andtheywouldhavetowaitmorethananhourbeforetheirrescuersreachedthem.ButSoyeonwasonceagainbackonEarthandsafe.

—FORORBITALFLIGHT,ITISENGINEERINGandnotcleveradaptationsoraugmentationofphysiologythatsaveslives.Thenatureofspaceflightissuch

thatinitsmostdynamicphases,theresilienceofourphysiologyanditsabilitytoadapttothephysicalextremesoftheEarthareutterlyirrelevant.Therelianceuponartificeissocompletethatanysignificantfailureismetwiththedeathoftheentirecrew.Therehasneverbeenamishapinspaceflightinwhichonlypartofacrewhasbeeninjuredorkilled.Foreveryaccident,thesamehasbeentrue.Eithereverythingworksandeveryonelives,oritdoesn’tandeveryonedies.Thefirstconsiderationonthewaytothefinalfrontierisnotaboutourabilitytoadaptphysiologically.Itisaboutthesafetyoftheevolvedengineeringsolutions.

Thisrecognitionofourincreasingrelianceuponartificialsystemstopreserveandprotectlifeisnotlimitedtotheendeavorofhumanspaceflight.Wepushattheedgeoftheenvelopeofsurvivalinspaceexplorationinthesamewaythatwetakeourbodiestoextremesinmedicine.Evolutionhasfinelycraftedthebalancebetweenourphysiologyandthelimitsofthenaturalworldinwhichwelive.Thatsolutionleavesuscomplexandcapablebutatthesametimefragile.Thechallengesthatwefaceinfutureexplorationandthelimitswewouldliketoprobeinmedicinefaroutstripthespiritedbutlimitedresilienceofthehumanbody.WenolongerexploreinthewaythatScottandhisforebearsexplored,whendeterminationandself-reliancewerethekeyprerequisites.Inthiscentury,explorationwillrelyalmostentirelyuponartifice.

—TENDAYSAFTERTHELAUNCH,Istoodindarknessattheshuttlelandingfacility,swattingmosquitoesandstrainingmyeyesinvaintotrytocatchsightofAtlantis.Thelastmissionofthespace-shuttleerawouldlandatnight,cruellyclosetodaybreak.We’dbeluckytoseeanythingatall,butwehadtocomeanyway.Somewhereabove,thecrewofSTS-135wasonitswayhome.

AdoublesonicboomoverheadheraldedAtlantis’sarrival.Shewascirclingnow,onfinalapproachtoKennedySpaceCenter,fallingunpoweredbacktoEarth,herfuelgone,nearlyallofherenergyspent.Wecaughtaglimpseofherassheflewthroughsearchlightsneartheendoftherunway,beforeshetoucheddownoutofsight.It’snothowIhadimaginedit.Ithoughtthatthelastspaceshuttlewouldlandinablazeofilluminationandtrundletriumphantlyacrossthetarmac,trumpetingtheendofanera.InsteadAtlantisdartedfurtivelyfromcovertocoverinthehalflight,gonealmostassoonasshe’dappeared,vanishingintowhatremainedofthenightlikeamythicalcreature.

IthadbeenhalfacenturysinceYuriGagarinfirstventuredintoorbitaboardVostok1,inamissionlastinganhourandahalf.Inthosefiftyyears,the

RussiansandtheirAmericancounterpartshadlearnedtoworktogetherinlowEarthorbit,transformingitintoastagingpostforstillmoreambitiousfeatsofexploration.Peoplenowpermanentlylivedandworkedinspace.LowEarthorbitcouldbevisitednotjustbytrainedastronautslikeSoyeon,butbypayingcustomers.Itwastimetosetsightsonnewdestinations.

October1997:MefloatingaboardNASA’sKC-135weightlesstrainingaircraft,betterknownasthevomitcomet.

(©KevinFong)

WMARS

henIfirstarrivedatNASAin1997asastudent,itwasallaboutMars.Thehumanspaceflightdivisionbuzzedwithexcitement;therewasasensethattheagencymightreallybeabouttoembarkonanewchapterofexploration—thenextsmallstep.

TherewasakindofMarsundergroundatNASA,acadreoffolkwhohadlonghelddearthehopeofsendingahumancrewtotheRedPlanet.Forthem,lowEarthorbitandtheMoonwerepedestriandestinations.Marswaswheretheactionwasat;exploringitwouldbethedefiningfeatoftheirgeneration:alongoverduereturntothesortofbarefacedambitionthathadfirstmadeNASAfamous.Abadgehadappearedonthelapelsofthefaithful:acheaptinbadgeaboutthesizeofaquarterwiththewordsMARSORBUST!inboldredlettering.

We’veimaginedsendingpeopletoMarssincewellbeforeGagarin’sfirstspaceflight.WernhervonBraun,principalarchitectoftheSaturnVlauncherthatdeliveredNeilArmstrongandBuzzAldrintotheMoon,laidouthisdreamsinthe1953publicationDasMarsprojekt(TheMarsProject),thefirstmaturestudyofwhatitwouldtaketosendhumansacrossthehugevoidofspacethatlaybetweenEarthandMars.

Itwasadesignofstartlingambition.InitvonBraunenvisagedanarmadaoftenspacecraftplowingontowardtheirdestination,crewedbynolessthanseventyastronauts.Inthisplan,heforesawtheneedtoplacenearlyfortythousandtonsofpayloadinlowEarthorbit,providingaplatformofboosterstageswithwhichtolaunchhisMartianflotilla.

VonBraun’splanwas,ofcourse,toofantasticinscaletoeverberealized,butthekernelofthesedesignsunderpinnedmuchofwhatwouldfollow.TheideathatfutureexplorersofMarswouldbehurledawayfromEarthbyabriefbutviolentexplosionatthestartoftheirjourneyandthenlefttofallfreelythroughspacetowardtheirtargetbecametheacceptedtemplateforhumanmissionstoMars.

missionstoMars.Throughoutthetwentiethcentury,Marscontinuedtodriftinandoutofour

thoughts,appearingalmostwithinreachandyetsomehowtantalizinglybeyondourgrasp.VonBraun’sdesignsenvisaged1965asthedateonwhichthefirsthumansmightarriveatMars.AndsinceDasMarsprojekt,morethanathousanddifferenttechnicalstudieshavebeenconducted,mostofthemmakingtheassumptionthatMarslaylittlemorethantwentyyearsinthefuture.ButthatiswhereMarshasremained:alwaysinourfuture.

Spaceisnotasingledestination.Earthorbit,theMoon,andMarsareasdifferentincharacterasthecontinentsoftheEarth.Sotooarethevoyagesandchallengesinvolvedinreachingtheselocations.LowEarthorbitisaboutnegotiatingtheviolenceoflaunchandtheterrorofreentry,aboutunderstandinghowweshouldclimboutofthewellofgravityinwhichwelive,breakingthebondsofattractioncreatedbythemassoftheEarth.

Orbitalspaceflightisafurioussprint,withtheenergiesinvolvedbarelycontrolled,anendeavorinwhichthefrailtiesofhumanphysiologyareswampedbythephysicalityofthepropulsivesystems.Forthepioneersofthisage,theabilityofthehumanbodytoadapttotheextremesofterrestrialenvironmentswaslargelyirrelevant.Dangersweremoreimmediateanddramatic—catastrophicexplosionsthatnoonecouldhopetosurvive.

Marspresentsachallengeofadifferentscaleandcharacter;it’smoreamarathonthanasprint.TheMoonhangsaroundaquarterofamillionmilesawayfromthesurfaceoftheEarth.Itisadistancewecaneasilyconceptualize:thenumberofmilestheodometerinyourcarmightclockupbeforethevehicleseizesandfails.TheMoon,thefarthestpointfromtheEarthanyhumaninthehistoryofourspecieshasevertraveled,liescloseenoughtoinspectwithlittlemorethanthenakedeye,reachablewithinfourdaysofspaceflight.

Marsgetsnocloserthanthirty-fivemillionmilesaway.ItspositionrelativetotheEarthisalwayschanging,stretchingthatseparationtoasmuchasfourhundredmillionmiles.Tocrossthatgulf,astronautcrewswillhavetoenduremissionsdrawnoutovermonthsandyears,spanninghundredsofmillionsofinterplanetarymiles,travelingthousandsoftimesfartherthanArmstrongandtheApollopioneers.

Thesecrews,too,willhavetosurvivetheenergiesoflaunchandthoseinvolvedinrocketingthemawayfromEarthandtowardMars.Butastheyfallacrossthevoidthatseparatesthetwoplanets,theywillalsohavetocontendwiththesilentthreatofspaceanditsenvironment.Heretheabsenceofgravitationalloadtakesonanewdimension,transformingfromanoveltyintoacreeping

loadtakesonanewdimension,transformingfromanoveltyintoacreepingthreat.

—THETERMZERO-GISAMISNOMER.WeightlessnessinlowEarthorbitdoesnotarisebecausethereisnogravity.ThegravitationalattractionoftheEarthdoesn’tsuddenlymeltawaytonothingjustbecauseweventure250milesawayfromitssurface.Atthataltitude,theforceofgravityisonlymodestlydiminished,toaround90percentofitsvalueatsealevel.Ifyouweresomehowabletobuildahouseontheendofapole250mileslongandliveinit,youmighthavetroublenoticingthechange.Adroppedglasswouldstillbreak;climbingstairswouldstillrequireeffort.Theremightbesomethingofaspringinyourstep—youandeverythingaroundyouwouldbearound10percentlighter—butyouwouldn’tfindyourselffloatingaroundfromroomtoroom.Theweightlessnessoforbitisexperiencednotbecauseoftheastronauts’separationfromtheEarthbutbecauseofthewaytheyfallaroundit.

Weightlessnessissomethingwehaveallexperienced;it’sonlythatourexperienceofitisgenerallysobriefastobebarelynoticed.Ifyoujumpupashardasyoucan,youmightstayintheairforalittleoverasecond.Forthattime,youareweightless.

Youcouldprolongtheexperiencesimplybyfallingfarther.Imaginestandinginaliftonthethirtiethfloorofaskyscraperatthemomentthesupportingcablesnaps.Fromthemomentofreleaseuntilthemomentofimpactyou’dbeweightless—arideofaroundthreehundredfeetthatwouldlastalittleoverfourseconds.

Inthesameway,astronautsinlowEarthorbitfindthemselvesfloatingbecausetheyareinsideaspacecraftthatispermanentlyinfreefallaroundtheEarth.

—STRAPPEDINTOMYSEATaboardamodifiedAirbus,I’mwaitingtowatchhowtheFrenchdoweightlessness.ThisisaspecializedflightundertheauspicesoftheEuropeanSpaceAgency’sDGA(Directiongénéraledel’Armement)Essaisenvol(literally,“testsinflight”),conductedbypilotswhospecializeinflyingaircrafthighintotheskyinaparabolicarcandthenplungingthemintoasteepdive,pullingoutjustintimetoavoiddisaster.Atleast,that’sthetheory.

Thereisaflurryofactivitybeforethestartoftheparabolas.Inplaceofairstewards,wehavefrequentflyersintangerinejumpsuits,theretolendahandifthingsgetrough:the“orangeangels.”Peoplegetready,tweakexperiments,and

thingsgetrough:the“orangeangels.”Peoplegetready,tweakexperiments,andpositionthemselves,preparingforthenextstomach-lurchingmaneuver.“Oneminute,”comestheGallicvoiceovertheintercom,startingthecountdown.Thescurryingbecomesmorefrantic.

“Twentyseconds...tenseconds...pullup!”comesthesamedisembodiedvoice.Thewordsarespokenlevelly,withnohintofexcitement.Thepersonutteringthemisatthecontrolsoftheplane.

Forthenexttentotwelveseconds,wearepushedintothefoamcoveringtheflooroftheaircraft.Weexperienceclosetotwicethenormalgravitationalload.Theburdenofmy168-poundframeissuddenlydoubled.IfeelasthoughI’mmadeoflead.

Thisisnothingcomparedtotheloadsthatfighterpilotsexperienceduringfastturns,butit’smorethanenoughtocreatediscomfort.It’snotjusttoughingouttheextraweight;thismaneuverisperfectforconfusingthehelloutofthedelicatesystemofaccelerometryinyourinnerear.

“Thirty,”callsthepilotinthesameleveltoneofvoice,narratingtheangleofclimbnowinsteadoftime.Weareonourwayuptothetopoftherollercoaster.That’sexactlyhowitfeels—thenervousness,theanticipation,theexcitement—andthat’snotfaroffwhatitis.Onlythisrideis25,000feethighandwillrepeatitselfthirtytimesinthenextcoupleofhours.

“Forty,”comesthevoice.“Inject.”Andthen,inoneofthemosteffectiverapidweight-lossprogramstheworldhaseverknown,Igofrombeing336poundstoweighingnothing.

Theyrefertothepointatwhichtheplanebeginstofallawayfromyouasrapidlyasyouarefallingtowarditasinjection.Itdoesindeedfeelasthoughyou’vebeeninjectedintoanalternatereality,oneinwhichthenormallawsofphysicshavebeenbrieflysuspended.Aroundyoupeopleandthingstumbleweightlessly,withnorespectfortheconceptsofupordown.Theeffectsofgravityaresuspendedhere.Allthosedreamsyoueverhadofflying?Wellthisaircraftmakesthemcometruefortwenty-threesecondsatatime.

TheAirbusdriftsoverthetopofitsparabolicarc,itsliftbalancedperfectlyagainstitsweight,thrustthrottledtomatchdrag.

“Thirty...twenty...pullout.”Afterhangingeffortlesslyinmidaironesecond,I’msmashedbackintothe

deck.Thephrase“backdowntoEarthwithathud”couldhavebeeninventedfortheexperienceofparabolicflight.

Glancingoutside,Iseethewingtipsflexedtwometersoutoftheirnormalposition,likeatensionedbow.Morealarmingstill,asteadytrickleoffuel

position,likeatensionedbow.Morealarmingstill,asteadytrickleoffuelescapesalongthewingedges.Swallowinghard,Iturnbacktothecabin.

The1.8-Gloadpourson.People’sfacesappeartoagevisiblyasgravitytakesontheskin’selastinandwins.I’mlyingonthedeck,stillmanagingasmile,whenIcatchsightofoneoftheotherpassengers,headburiedinhisarm,sweatingbeads.

Oneoftheorangeangelsaskshimifhe’sOK.Heshakeshisheadvigorously.He’smanhandledtotherearoftheplane.There’safumbleforasickbagandthefamiliarsoundofretching.It’snotfornothingthattheycallthistheVomitComet.

—INOURDAILYLIVES,gravityisthatpedestrianphysicalforcethatkeepsusgluedtotheground.Wedon’tthinkofitassomethingthatshapesourlives.Ourbodiesaresetuptoallowustomovewithinitsfieldofattractionwithouttoomucheffort,somuchsothatwebarelynoticeit.Youhavetogooutofyourway—climbaclifffaceorjumpoutofaplane—beforeitstartsdemandingyourattention.Butweareconstantlysensingtheeffectsofgravityandworkingagainstthem—largelyunconsciously.

Weare,forexample,equippedwithantigravitymuscles—thosegroupsthatworkagainsttheEarth’sforceofattractiontokeepyoustandingupright.Togetanideaofwhichgroupstheseare,imaginebeingonaparadegroundwithasergeantmajorbarkingatyoutostandtoattention.Prettymucheverymuscleyouwouldtensetoavoidtheprodofhisbatonisantigravityinfunction.

Ofthesethequadriceps,buttocks,andcalves,alongwithagroupofmuscles—theerectorspinae—thatsurroundthespinalcolumnandkeepitstandingtall,arethemostimportant.Withoutthemthepullofgravitywouldcollapsethehumanbodyintoafetalballandleaveitcurledclosetothefloor.

Thesemusclegroupsaresculptedbytheforceofgravity.Theyareinastateofconstantexercise,perpetuallyloadedandunloadedaswegoaboutourdailylives.Itisbecauseofthisthatthequadriceps,themassoffleshthatconstitutesthebulkofyourthighsandworkstoextendandstraightentheknee,arethefastest-wastinggroupinthebody.

Yourbones,too,areshapedbytheforceofgravity.Wetendtothinkofourskeletonasprettyinert—theretoproviderigidity,littlemorethanascaffoldonwhichtohangthefleshorasystemofbiologicalarmor.Butatthemicroscopiclevel,itisfarmoredynamic:constantlyalteringitsstructuretocontendwiththegravitationalforcesitexperiences,weavingitselfanarchitecturethatbestprotectsthebonefromstrain.

protectsthebonefromstrain.Thebiologicaladaptationstogravitydon’tstopthere.Whenyou’restanding

up,yourheart,itselfamusclepump,hastoworkagainstgravity,pushingbloodverticallyinthecarotidarteriesthatleadawayfromyourhearttowardyourbrain.

Evenyoursystemofbalanceandcoordinationappearstorelyinafundamentalwayupontheconstantforceofgravity,withtheotoliths—theorgansoftheinnerearthatsenselinearacceleration—usingitasasortofcalibratinginput.

LifeonEarthhasevolvedoverthepastthreeandahalfbillionyearsinanunchanginggravitationalfield.Inthatcontext,itshouldn’tbeasurprisethatsomuchofourphysiologyappearstobedefinedby,ordependentupon,gravity.Takegravityaway,andourbodiesbecomevirtualstrangerstous.

—ASAMEDICALSTUDENT,youdon’ttakethecontentsoftheinnerearveryseriously.Theorganswithindetectaccelerationandaudiblestimuli,gatheringinformationaboutmotionandsound.Buttheyarenotconsidered“vital,”inthesensethattheyarenotrequiredtokeepthehumanbodyalive.Asaresult,theessentialroletheyplayindeliveringafinelycalibratedsenseofmotionisoftenoverlooked.However,likeallofthebestthingsinlife,youdon’treallyappreciatewhatyou’vegotuntilyouloseit.

Thesystemofaccelerometersinyourinnerear,theotolithsandsemicircularcanals,areengineeredtoprovidethefinestdetailaboutmovementintheever-changingworldaboutyou,creatingtheillusionthatyouareessentiallyastableplatformthroughwhichtheworldcanbeobservedasthoughitwereafilmmadewithaSteadicam.Itisasystemthatsharesitsinputsandoutputswiththeeyes,theheart,thejoints,andthemuscles.

Considerforamomenttheactoflookingatstuff.Holdafingerupinfrontofyoureyes.Nowshakeyourheadleftandrightasthoughyouarevigorouslysayingno.Theimageofyourfingerremainsremarkablystable,doesn’tit?Nowtrykeepingyourheadstillandwagglingyourfingerbackandforthatthesamerate.Thistimetheimageislessstable;plentyofblurcreepsin.

Keepinganimagestableandclearinyourvisualfieldisaprettydifficulttasktoachieve.Firstyouhavetofocustheimageontothelayeroflight-sensitivecellsatthebackofyoureyecalledtheretina.Now,yourretinaisn’tthesameallover.Attherear,nearthecenter,isaclusterofdenselypackedcells,conelikeinshape,thataccountforlessthan1percentoftheareaoftheretina.Thistinybut

shape,thataccountforlessthan1percentoftheareaoftheretina.Thistinybutall-importantareaiscalledthefoveaandisresponsiblefortaskssuchasreadingorstudyingapicture.Thishighdensityofspecializedcellsresolvesthecriticaldetailofasceneanditscolors.Therestoftheretina,bycomparison,ispopulatedbyrods—goodinlow-lightconditionsbutrubbishatsubtlety.Uninterestedinnuance,they’retherechieflytopickupmovementintheperiphery,toidentifyatargetonwhichyoushouldfocusyourattentionmoreclosely.

Thosereceptorsreporttoaspecializedpartofthebraincalledthevisualcortex.What’sinterestingisthat,althoughthefoveaaccountsforlessthanahundredthofthesurfaceareaoftheretina—onevoiceamongahundred—thevisualcortexdedicates50percentofitsmasstolisteningtothesuperdiscriminatingfovea.

Allthiseffort,andwe’restilltalkingaboutastationaryeyeballfocusingonastationaryobject.

Nowlet’sstartshakingthingsupabit.Imaginethatthethingyou’relookingatisnolongerstationarybutisinsteadmoving.Asitmoves,youhavetorotateyoureyeballstokeepitsimagefocusedintherightspot.Onceitreachesthepointatwhichyoucan’ttrackitwithyoureyesanymore,youstarttomoveyourhead,too.

Nowyouhavetwospheres,capableofrotatingindependently,carryingalenssystemthatistryingtokeeptheimageofamovingobjectsharp,onanareaatthebackoftheeyethatisonlyafewmillimetersacross.

Itistheslavingtogetheroftheaccelerometersinyourinnerear,themusclesthatrotateyoureyeball,andthosethatturnandtiltyourheadthatallowsyoutoachievethisremarkablefeat.

Nowimaginethatthesystemdoesn’tworkandthatthestableimageoftheworldyoutakeforgrantedisreplacedbyagentlyoscillating,nausea-inducingscenefromwhichthereisnoescape.Ifyou’veeversufferedfromseasickness,imaginetheworstpossibleepisodeofthat,onashipthatyouareneverallowedtoleaveandunderwhichtherollingseaswillnevercalmdown.That’swhatitfeelslikewhentheorgansoftheinnerearmalfunction.Andthatcanbecausedbydisease,drugs,poisons,and—asitturnsout—theabsenceofgravity.

—WEIGHTLESSNESSMAYSOUNDLIKEFUN,butthemajorityofrookieastronautsfeelsickinthefirstforty-eighthoursofspaceflight.Antiemeticmedications—thosedrugsthatacttocombatfeelingsofnausea—areamongthemostcommonly

prescribedduringNASAspaceflights.Theundesirableeffectsdon’tstopthere.Deprivedofgravitationalload,bonesfallpreytoakindofspaceflight-

inducedosteoporosis.Thebalancebetweenthepopulationsofcellsresponsibleforlayingdownboneandthoseforremovingboneislost,andsobonesbecomelessdenseandmorepronetofracture.Andbecause99percentofyourbody’scalciumisstoredintheskeleton,asitwastesaway,thatcalciumfindsitswayintothebloodstream,causingyetmoreproblems.

Hypercalcemia—apathologicalstateinwhichthelevelsofcalciuminthebloodareraised—isfamousforcausingatetradofclinicalproblems.Constipationistheleastofthese,followedbypainsinthelongbones.Moreseriously,renalstonescanform,blockingtheroutefromyourkidneystoyourbladder,causingexcruciatingpain.Andfinallythereisthepossibilityofpsychoticdepression.Medicalstudentsrememberthislistas:bones,stones,abdominalgroans,andpsychicmoans.Allfourareproblematicwhenyoucouldbetwoyearsandmorethanfourhundredmillionmilesfromyourclosestfamilypractitioner.

It’snotjustyourbonesthatwasteaway.Musclesdotoo—theantigravitygroupsatanalarmingrate.Inexperimentsthatchartedthechangesinthequadricepsofratsflowninspace,morethanathirdofthetotalmusclebulkwaslostwithinninedays.Moreinterestingstill,astronauts’musclefiberswitchesfromslowtwitch—theefficient,fatigue-resistanttypesuitedtomarathonrunning—towardthefast-twitchvarietythatasprintermightprefer.

Meanwhile,theheartanditssystemofvessels,deprivedoftheneedtoworkagainsttheforceofgravity,becomedeconditioned.Spaceflightenforcesasedentaryexistenceonotherwisewell-exercisedphysiologicalsystems,slowlytakingathletesandturningthemintocouchpotatoes.

Forthecardiovascularsystem,thefinelytunedreflexesthatonEarthconstantlycopewithchangesinposturesharplydeteriorateduringextendedspaceflight.Pictureyourselflyingonthesofa,watchingback-to-backmovies.Thedoorbellrings,andyouspringtoyourfeet;yourcardiovascularsystemisforcedtomakeasuddenalteration.Havinggonefromlyingtostanding,thebloodinyourbodynowsuddenlytriestopoolinyourlowerlimbs,reducingthevolumethatreturnstotheheartandasaconsequencetheforcewithwhichitbeats.Inaddition,thebloodthatwaslazilyflowingbetweenyourheartandbrainalongyourcarotidarteriesisnowtryingtotravelverticallyagainstthepullofgravity.

Combinedandunopposed,thesechangeswillleaveyourbraindeprivedofanadequatebloodsupplyandyouunconsciousonthefloor.

adequatebloodsupplyandyouunconsciousonthefloor.Allthatstandsbetweenyouandthatfateisareflexthatsensesthedropin

pressureinthecarotidarteriesandtellsthebraintoincreasetherateandforceofcontractionoftheheart,whilesimultaneouslyconstrictingperipheralbloodvesselstorestorebloodpressure.Thisprimitivereflexisall-important.Withoutit,you’denduplyinginacrumpledheapeverytimeyoustooduptoosuddenly.

Thisiswhatweseeinastronautsreturningfromlongmissionsaboardthespacestation.Askedtostandstillanduprightfortenminutes,asignificantfractionareunabletodosowithoutfeelingfaint.Thiswecallpostflightorthostaticintolerance—aninabilitytomaintainanuprightposture.

Theimpairmentsdon’tstopthere.Thereareother,lesswell-understoodalterations.Redbloodcellcountsfall,inducingasortofspaceanemia.Immunitysuffers,woundhealingslows,andsleepischronicallydisturbed.

Inshort,mostastronautsreturnfromlong-durationspaceflight—missionsofmorethansixmonths—inatemporarilydiminishedstate:sleepdeprived,theircardiovascularsystemdeconditioned,theirmusclesandbonesweakened,andtheirhand-eyecoordinationimpaired.Asblissfulastheexperienceoffloatingaroundmightappear,iterodesthebody’sabilitytofunctionwhenchallengedagainbytheforceofgravity.

WhenastronautcrewsarrivebackonEarth,theyaremetbyasupportteamthatincludesnursesandphysicians,andtheyarespiritedawaytorecuperatefromtheexperience.Andeventhen,withallthecarethattheassembledterrestrialrecoveryforcescanmuster,therearestillincidents.Returningcrewmembershavebeenknowntovomitatcelebratorybanquets,collapseinshowers,orruntheirvehiclesofftheroadbecauseoftransientdisorientation.

Others,forgettingthattheyhavereturnedtoaworldruledbygravity,dropexpensiveequipmentorfragilegifts,havinggotusedtotheideathatreleasedobjectsfloatratherthansinktothefloor.Backathome,oneastronautreportedlygotoutofbedtochangehisinfantson’sdiaperandstoodforawhilewonderinghowhemightVelcrothebabytothecotwhilehesearchedforsomewipes.

Theproblemsofspaceflightareprincipallythoseofreadaptationtoaworldinwhichgravityistheshapingforce.Reacclimatizingtothat,bothphysicallyandpsychologically,isachallenge.OnreturntoEarth,astronautsarecarefullymonitoredwhiletheirbodiesreadapt.ButonamissiontoMars,they’darriveandbeentirelyontheirown.

ThecrewsthatarriveatMarswoulddosoaftersixtoninemonthsofflightandwouldexperiencemanyifnotalloftheseproblems.Theretheywouldhavetoperformthemostchallenginglandinginthehistoryofhumanspaceflight.ThecommunicationdelaybetweenEarthandMarsmightbeuptotwentyminutes.In

communicationdelaybetweenEarthandMarsmightbeuptotwentyminutes.Inthatmomentoftouchdown,theywouldbetrulyalone.Assumingtheylandsafely—andrememberthataround50percentofeverythingwe’vethrownatMarshascrashedordisappeared—they’dthenhavetoleavetheirvehicletowalktothepre-preparedhabitat.Thathabitatmightbeuptohalfakilometeraway.

Andthat’sassumingtheyevenmakeitthatfar.

—IT’SWORTHBRIEFLYCONSIDERINGwhatittakestogettoMars.Thetermspaceflightissomethingofamisnomer.Human-ratedspacecraftdon’treallyflythroughspace.Theirrocketmotorsfireforonlyafewbriefminutesatthestartofthejourney,throwingthevehicleanditsoccupantstowardtheirintendedtarget,likeamedievalballistahurlingamissileatthewallsofacastle.Thespacecrafthavetheirownrocketmotorsandthrusters,butthesearefarlesspowerfulthanthelauncherthatsetthemontheirway.Oncethey’retraveling,onlysubtlecoursecorrectionscanbemade.Soastronautsontheirwaytotheirdestinationareengagedinanactivitythatmightmoreaccuratelybedescribedasspacefall.

Whilethevehicleanditscrewarebusyfallingacrossspace,Marsisouttheresomewhereinthedarkness,tearingarounditsellipticalorbitatalittleoverfiftythousandmilesperhour.Mars’sjourneyaroundtheSuntakes687days.Earthcompletesitsorbitin365.25days,movingataroundseventythousandmilesperhour,whichleavesthetwoplanetsconstantlychangingtheirrelativepositionsinthesky.

Thishasconsequences.Itmeansthatyoucan’tdecidetogotoMarsanytimeyouwant.Youhavetowaitforpreciselytherightopportunity,launchingfromlowEarthorbitatexactlytherighttime,sothatMarsistherewhenyouarrive.Andthesameistrueuponyourreturn.

Despitetheserestrictions,thereareasmanydifferentrecipesforgettingtoMarsastherearefortheperfectchickennoodlesoup.Missionarchitectshavetojugglepropulsionsystems,trajectories,vehiclevelocities,andatmosphericentrystrategiesandtradetheseagainstpayloadmassandcrewsizeinanattempttodesignsomethingrealisticintermsofriskandcost.Theyhavetodecide,forexample,betweenexoticdeep-spacemaneuvers—whichmightusetheorbitalenergyofVenusasaslingshottopropelvehiclesontheirwaytoandfromMars—andmoreprosaicbutpotentiallysaferjourneys.

Butintheend,allofthemissiondesignsboildowntotwobroadscenarios:

Butintheend,allofthemissiondesignsboildowntotwobroadscenarios:thosethatseeyouarriveandstayonMarsforafewweeksandthosethatleaveyouonthesurfaceoftheRedPlanetformorethanayear.Thesearetheso-calledshort-stayandlong-staymissionarchitecturesforMars.

Fortheshort-staymissions,crewswouldtravelforclosetoninemonthstogettoMars.ButoncetheretheycouldthentakeadvantageofanearlyopportunitytoreturntoEarth,whichwouldarisebetweenthirtyandninetydaysaftertheirarrival.This,afterhavingspentclosetoninemonthsinflight,wouldbelikeflyingfromLondontoNewYork,millingaroundinthegiftshopatJFKforanhour,andthenflyingstraighthome.Butithastheadvantageofshorteningthetotalmissiondurationtolessthantwenty-fourmonths.

Forthelong-staymissions,youcangettoMarsalittlefaster,closertosixmonthsthannine,butinthiscase,theellipticalmovementsoftheplanetsmeanyoudon’tgetachancetocomehomeagainforsomethinglikeeighteenmonths.

Thatmeansyou’dspendatleastayeartravelingandayearandahalformoreonMars.Thatmissionwouldapproachthreeyearsinduration—allofwhichwouldbespentweightlessorworkinginthereducedgravityofMars.

Thereareanumberofformidableproblemsthataccompanymissionsofsuchduration.Thefirstislifesupport.Howdoyouinventasystemthatcankeepacrewoffouralivefornearlythreeyears?Forspacestations,breathableoxygenisgeneratedbyelectrolyzingwater:usingacurrenttodecomposeitintohydrogenandoxygen.Thisrequiresasteadysupplyofwater,whichisconvenientlyresuppliedfromEarthviatheRussianProgressvehicles:automaticallypiloted,space-agedeliverytrucks.Thecarbondioxidethatwouldotherwiseaccumulateisscrubbedoutusingchemicalsieves—canistersoflithiumhydroxidethatreactwiththeCO2andremoveitfromtheatmosphere.ThesetooneedtoberesuppliedaboardtheProgressvehicles,alongwithfoodforthecrew.

ButthereisnoeasywaytoresupplyateamtravelingtoMars,andsoanumberofingenioussolutionstothisproblemhavebeenproposed.Oneinvolvesagrow-your-ownapproachtolifesupportandnutrition.

OneoftheexperimentsunderwaywhenIfirstvisitedJohnsonSpaceCenterin1997wasexactlythis.Plantsrespirephotosynthetically,bytakingincarbondioxideandgeneratingoxygenandwater.Itturnsoutthatifyougrowtenthousandwheatplants,youcangeneratemorethanenoughoxygentobreathewhileremovingthehumanwastegasofcarbondioxide.Betterstill,youhaveapartialsourceofnutrition.Forawhile,theSpaceCenterhadateamoffourvolunteerslockedupinahermeticallysealedtube,subsistingpretty

volunteerslockedupinahermeticallysealedtube,subsistingprettyindependentlyonthisself-regenerating,hydroponicallygrownlife-supportsystem.Andthat’sallgreat—untilyoufactorinthepossibilityofcropfailure.

Anothersolution,discussedataEuropeanSpaceAgencyhumanspace-explorationsymposium,wouldbetogrowvatsofalgae,whichmightbeeasiertosustainthanwheatandwouldalsoprovideasourceofprotein.Betweenthatandthewheatplants,youcouldgethalfwaytoadietofpizzalikefood—breadcoatedwithflavoredalgae—andmassivelyreducetheweightandvolumeofthefoodandlife-supportapparatusrequiredforaMarsmission.

Afterthatconference,Irememberlisteningwide-eyedinthebarwhileanexcitableFrenchmanwhospecializedinthefieldofregenerativelifesupporttoldmehowitmightwork,goingsofarastoexplaintherecyclingofurineandtheuseoffecesasasourceoffertilization.

“Yousee,”heshoutedabovethedinofthebar,“thesepeoplewhogotoMars,theywillliterally’avtoeattheirownshit.”

—IFTHATHASN’TPUTYOUOFFthetripalready,thenconsidertheradiationhazards.Asfarasanyonecantell,thebackgroundradiationyouwouldbeexposedtowhiletravelingbetweenEarthandMarsshouldbewithinsafelimits—unlessthere’sasolarflare.

ThesegianteruptionsofplasmafromthesurfaceoftheSunareaccompaniedbyanintenseshowerofhigh-energyparticlesthatrainthroughspace.FortheastronautsandcosmonautsoperatinginlowEarthorbit,withinthecageofprotectionprovidedbytheEarth’smagneticfield,thispresentslittleproblem.ThechargedparticlesarecaughtandtrappedbythelinesofEarth’smagneticflux,depositingtheirenergymoreorlessharmlessly,wellawayfromthehumancrews.

ButforavehicleventuringoutsidetheEarth’simmediateneighborhood,thereisnosuchprotection.Asolarflareislikeaneutronbombgoingoffnexttoyou.Energeticparticles—chargedheliumnuclei,neutrons,protons,andthelike—wouldpassthroughyourbody,wreakinghavocandirreversiblydamagingcells.SuchanexposurewouldbeliketakingtheDNAblueprintsofeachcell,shootingcannonballsthroughthem,andthentryingtobuildsomethingbasedontheinformationthatremains.Theresultingstructureswouldbedangerouslyunstableandpronetomalfunction.

Thefastest-proliferatingcellpopulationswouldbeworstaffected:hairfollicles,skin,andtheliningofthegut.Therapidlydividingcellsofthebonemarrow,too,wouldfallvictim.Withbloodcellsdecimated,thesuffererwould

marrow,too,wouldfallvictim.Withbloodcellsdecimated,thesuffererwouldbeleftanemic,shortofplateletstohelpclotbloodandbolstertheimmunesystem.Thisexplainsthefamiliardepictionofacuteradiationsickness:hairfallingoutinclumps,diarrhea,bruisedskin,andbleedinggums.Withoutashield,itwouldbeimpossibletosurvivesuchanexposure.

Tomakemattersworse,solarflaresarisesporadically,andwe’reaboutasgoodatpredictingthemasweareatforecastingtheBritishweather.Andthere’snostraightforwardwayofcombatingtheireffects.Buildingashipcoatedwithleadwouldn’thelp—evenifyoucouldfindawaytoliftthatmassintoorbit.LeadandotherheavymetalsaregreatatshieldingagainstX-rayradiationandlighterparticles,butwhenitcomestohighlyenergeticheavyparticles,theyareworsethanuseless.Massiveparticles,arrivingatclosetothespeedoflight,wouldsmashintotheatomsofametalshieldandscatterthemlikeacueballhittingabilliardpack.Thesescatteredatomswouldthengiverisetosecondaryradiation,asdeadlyastheparticlestheyweresupposedtoshieldagainst.

Onepossibilityliesinbuildingasortofbombshelterinthespacecraft,anareamoreresistanttotheradiationstormsbroughtbyasolarflare.Thisyoucouldshield,notwithlayersofmetal,butwithajacketofwater.Itturnsoutthatwaterisverygoodatattenuatingsolarparticleradiation.Butthisisprettyspeculative.WhenitcomestotheradiationhazardsofahumanmissiontoMars,ifyouasktheexperts,theytellyouthatwesimplydon’tyetknowenough.

—EVENIFWEFIGUREOUTAwaytonegotiatetheradiationandbuildalife-supportsystemthatisatleastpartlyregenerative,wekeepgettingbacktothemostelementalproblem:havingtocontendwiththeabsenceofgravity.Thelongestmissioninhumanspaceflighthistorywas437days,17hours,58minutes,and16seconds;itwascompletedbycosmonautValeriPolyakovaboardtheRussianspacestationMirbetween1994and1995.Byallaccounts,hearrivedbackonEarthinreasonablygoodhealth,butitisfarfromclearthatthiswouldbetrueofallspaceexplorers.

Polyakovisinanexclusiveclub.Aroundfivehundredpeoplehaveflownintospace.Ofthese,onlytenhaveflownformorethantwohundreddaysandonlytwoformorethanayear.

Mostofourexperienceinthefieldofastronauticsinvolvesmissionsoflessthantwoweeks’duration.Theimpairmentsseenincrewmemberswhohaveflownforbetweenthreeandsixmonthsaresignificantandtendtovaryfromindividualtoindividual.

individualtoindividual.Arangeofcountermeasurestocombattheeffectsoflongermissionsis

availabletoastronautcrews.Theseincludemedications,specialdiets,andregimensofresistiveexercise.Andwhiletheyhavegonesomewaytomitigatingtheconsequencesofhumanspaceflight,noneappearsuniformlyeffective.

Itisbecauseofthisthattheideaofgeneratingartificialgravityhassurfacedtimeandtimeagain.Theconceptisnotnew.Theearliestrocketscientistsrealizedthattheircrewswouldexperienceweightlessnessandthatthismightbeproblematic,eveniftheycouldnotpredictallofitseffects.

In1923HermannOberthproposedasolution:avehicletetheredtoacounterweightthatwouldspinendoverendlikeatwirlingbaton,subjectingtheoccupantstoanartificialgravitationalloadasitwent.It’sthesameloadwefeelonspinningfairgroundrides,theforcethatpinsusagainstthesideofthecar.

Sofar,sogood.Buttheproblemwithartificialgravityliesnotintheunderlyingphysicsoftheideabutwithengineeringarotatingvehiclecapableofthefeat.Heredesignisnarrowlyconstrainedbythebiologicalfrailtiesoftheastronautcrew.

Theforceofartificialgravitygeneratedbyarotatingvehicledependsupontheradiusofthevehicleanditsrotationrate.Togenerateenoughforceitmusteitherbesmallandspinextremelyquicklyorbelargeandspinmoreslowly.

Everybodydiffersintheirtolerancetofairgroundrides;somepeoplecanbespunathead-snappingrateswithoutapparentilleffectwhileothersfeelsickjustwatchingthethinggoaround.This,again,isdowntotheapparatusoftheinnerear:detectingrotationalaccelerations,tryingtomakesenseofwhatishappening,andexpressingdispleasurethroughthevomitingcenterifitcannot.Butiftherateofrotationiskeptslowenough,tofourrevolutionsaminuteorless,everybodyintimecanadapttothemotion.

Withthatrequirementfixed,theradiusofrotationnecessarytoproduceaforceof1G—equivalenttotheloadyouwouldfeelatthesurfaceoftheEarth—canbecalculated.Itleavesyouwithavehiclearound125metersacross—coincidentallyaboutthesamesizeastheLondonEye.Ifthethoughtofsomethingofthatsizewhackingaroundfourtimeseveryminuteseemsdaunting,imaginebuildingavehicleofthatscaleandthenlaunchingitintospace.

NASAdidmorethanimagine.Inthe1990s,KentJoostenandateamofengineersatJohnsonSpaceCentercameupwithabroad-brushdesignforanartificial-gravityvehiclethatmightactuallywork.ThisreturnedtoHermannOberth’soriginalideaofatetherbetweenacrewhabitatandacounterweight.InJoosten’sdesign,themoduleanditscounterweightwereseparatedbyan

Joosten’sdesign,themoduleanditscounterweightwereseparatedbyaningenious,ultralight,liquid-crystalpylonstructure.ThiscouldbecompressedandstoredduringlaunchfromEarthandthendeployedafterthevehiclehadarrivedinorbit.ThewholethingwouldthentumbleendoverendallthewaytoMars,withthecrewlivinginamoduleaboutthesizeofafour-bedroomhouseunderconditionsthatapproximateterrestrialgravity.

Joosten’sartificial-gravitystudyrepresentsthemostmaturetechnicalapproachtothesubjectsofarseen.Thereare,however,anumberofsignificantproblemstobeovercomebeforesuchavehicledesigncanberealized.Itpresentsanentirelynewparadigminourconceptofwhathumanspaceflightis,andthishasinpartcontributedtoareluctancetoembraceorfurtherinvestigatetheidea.

AmongthehundredsofstudiesthathaveconsideredhowbesttogettoMars,nearlyallofthemhaveinvolvedsmaller,simplervehiclesofthetypethattookustotheMoon.Butthereisawaytodeliverartificialgravityinsidesuchspacecraft,evenifthevehicleitselfcan’tbespun.

Inourdailylives,ourbodiesdonotexperienceconstantgravitationalload.Whenwestompupanddownstairs,ourjointsbecomeshock-loaded,withregionsofourskeletontransientlyexperiencinguptothreeorfourtimesthegravitytheywouldatrest.Whenweliedowntosleep,thelongaxisofourbodyismoreorlessperpendiculartotheforceofgravity,andourskeleton,cardiovascularsystem,andantigravitymusclesareleftunloaded.Thisquasi-weightlessstatequitecloselyresemblestheweightlessnessofspaceflight.Indeed,whenresearcherswanttomimictheeffectsofmicrogravityhereonEarth,theysimplysendabunchofpeopletobed.

SoonEarthourphysiologyismaintainedbyonlyintermittentexposuretogravitationalload—thestandingupandstompingaroundwedoduringtheday.Andeventhatisn’tconstant.Fromthisrealizationgrewtheideathatwemightprescribegravitylikeadrug,givingitinshortbutlargedoses.Cuetheshort-armcentrifugeasacountermeasuretotheeffectsofweightlessness.InsteadofbuildingaspacecraftasbigastheLondonEyeandrotatingitslowly,youcouldbuildamuchsmallerspinningdevice,rotateitveryquickly,andpackthatinsideaconventionalspacecraftmodule.

Ifyoudothemathonthis,acentrifugewitharadiusofthreemeterswouldhavetospinaroundfortytimesaminutetogeneratealoadofabout3Gatitsedges.Thisbizarreregimenofloadingmightneverthelessbeenoughtoprotectthebodyfromweightlessness.Betterstill,itcanbeadministeredinshortdoses;aslittleasanhouradaymightbesufficient.Andwiththisknowledgeinhand,

aslittleasanhouradaymightbesufficient.Andwiththisknowledgeinhand,NASAwentoutandbuiltone.

—SOMEWHEREINANASALABORATORYinGalveston,theceilingspinsaroundabovemyhead,revolvingfortytimesaminute.Ikeepmyheadstraight,eyesfixedonthescreenmountedabove,aboutthreefeetfrommyface.

Deepwithinmyinnereararetinycellswithhairlikeprotrusionsthatwaftinagellikebladesofgrassstandingvertically,setinaplateofjelly.Partofmyvestibularsystem,theseexisttodetectaccelerationintheworldaroundme.Themorethejellyleansover,themorethebladesofgrassbend,andthistriggersthefiringofthehaircells.Rightnowthey’restrugglingtomakesenseofwhatI’mbeingputthrough.

Thesetofhaircellsinmysemicircularcanals,theorgansthatdetectrotation,arescreaming,firingconstantlywiththewhirlingofmybody.Mybraingotboredoflisteningtothatquitesometimeagoandhasdecidedtoignoretheirmessages,leavingmefeelingalmostcomfortable.Butit’saprecariousstate.ThereisprofoundconflictbetweenwhatI’mseeingandwhatI’mfeeling.Myvomitingcenter—whichiswiredintothesameboxoftricksthatsensesacceleration—isatthisinstantjustaboutmanagingtostayquiet.Ihavetokeepmyheaddeadcentertomaintainthatstatusquo.IfIstartjerkingitaround,I’llbevomitinginseconds.

I’mwearingaheadsetwithamicrophone.Aresearcherinthecontrolroom,watchingthecamerafeed,asksmeifI’mstillOK.ItellhimthatIam.AnothervoicefromthecontrolroombombardsmewithafewmorequestionsandthenasksmeifIwouldn’tmindturningmyheadtotakealookatapieceofequipmenthe’sworriedaboutonmyright-handside.ItellhimthatI’mnotfallingforthatone.Somewhereoff-mike,there’sanevilchuckle.

I’vebeenherenowforhalfanhour;therearestillanotherthirtyminutesleft.Iamlyingonmybackonthisexperimentaldevice:acentrifugesmallenoughtobeaccommodatedinthemoduleofaspacecraftonitswaytoMars.

Itlooks,atfirstglance,likeaninstrumentoftorture.Apairofarms,eachonejustaboutlongandwideenoughtoaccommodateanadultlyingsupine,sproutfromacentralcolumn.Thereareharnessesandstrapstostopyoufromflailingaroundandprobesandmonitorsdesignedtoextractinformationfromyou.Thewholethingcanrotateatastomach-wrenchingrate.IfTomásdeTorquemadainventedafairgroundride,itwouldlooksomethinglikethis.

Theapparatusistheretointerrogatehumanphysiology,todeterminehowitwillrespondtothisinsult.ECGelectrodesaregluedtomychest,anautomated

willrespondtothisinsult.ECGelectrodesaregluedtomychest,anautomatedblood-pressurecuffinflatesperiodically,andaprobemonitorstheoxygeninmybloodstream.

Thisisadeviceforgeneratingartificialgravity—oratleastanartificialgravitationalload.Theforcesgeneratedwhenthemachinerotatesforcemeout,tryingtoflingmetowardthewallsoftheroom.I’mstoppedfromdoingsobyaplateatmyfeet.Asthecentrifugespinsup,Igetheavieragainstthatplate.Atfulltilt,theforceonmybodybelowmywaistisbetweentwoandthreetimesthatofnormalgravity.Inmyupperbody,wherethespeedoftravelisslower,theloadisless.Itmeansthere’sagradientofforcealongmybodythatbuildssteadilyfromheadtotoe.ThisgivestheillusionthatI’mlyingwithmybackarched,makingmefeelasthoughI’mengagedinsomesortoflimbodancemaneuver.

AsIsettledownintoit,Ibegintofeelmorecomfortable,comfortableenoughtobegintogetbored.IfIdon’tmovemyheadaround,thewholeexperienceisquitedoable,almostrelaxing.Avoicecracklesintomyheadset.

“How’reyoudoing?”askstheresearcher.ItellhimI’mfine.“Wecansticksomethingonthescreenifyou’regettingbored.”HefumblesaroundinthecontrolroomandslidesaDVDintotheplayer.AHarryPotterfilmspringsintoviewonthescreenaboveme,andallofasudden,whirlinginthedarknessinfrontofasmallglowingscreenfeelsnomoreabnormalthanwatchinganin-flightmovieonalong-haulflight.AndIbegintothinkthatthiscouldbeanOKwaytogettoMarsafterall.

—ARTIFICIALGRAVITYISONEOFTHOSEthingsthatpeopletendtodismisswithasnortiftheydon’tknowmuchaboutit.Itremainsunclearhowlonghumanscanbedeployedinspacewithoutsufferingseriousmedicalconsequence,butitisunlikelythatwecanendureweightlessnessindefinitelyandmaintainacceptablehealth.Ifwearetocontinuetopushoutintospace,thenatsomepoint,artificial-gravitymachines—compacttorturechambersorgianttwirlingbatons—willhavetoplayarole.Thisisanaturalprogression.Wetakeeverythingelsewithusintospace:ourlight,ourheat,ourfoodandwater;weeventakeouratmosphere.Atsomepoint,itseemscertainthatwe’lltakegravitywithustoo.

There’salotofworktobedonebeforethatcanhappen.Weareunsureoftheprescription,ofhowhardandhowfastyouwouldneedtospincrewmemberstoprotectthemfromtheravagesofweightlessness.NeitherdoweknowhowmuchprotectionthelessergravityofMarswillprovide,ifany.

protectionthelessergravityofMarswillprovide,ifany.Itisunclearwhatsuchasystemmightdototheinnerear.Earlyresultsfrom

NASA’sArtificialGravityPilotProjectsuggestedthattheheartandmusclesmightbeusefullyprotectedinthisway.Itwouldbesurprisingifbonedidn’tbenefittoo.Buttheinnerearanditsorgansofaccelerometryareadifferentstory.Thisstrangerotationalinputmight,overtime,leadtomaladaptivechangesthatmightworsentheirfunction.Ontheotherhand,itmightprovehighlyprotective.Sadly,itdoesn’tseemthatwe’llfindouttheanswersanytimesoon.

In2009,justastheartificial-gravityprojectwasreadytoenteramorecomprehensivephaseofinvestigation,aseriesofbudgetcutstorethroughNASA.Thestrategythatwouldhaveseentheshort-armcentrifugeinvestigatedthoroughlyonthegroundandthenmadereadyforflightaboardthespacestationwascanned.Itisn’tthelastwe’veseenofthis;asoneoftheinvestigatorsquipped,“Artificialgravityisanideathatcomesaroundandaround....”

Aboutthesametime,anewvisionwasset,onethatprioritizedareturntotheMoonoverafirsthumanmissiontoMars.AndonceagaintheRedPlanetrecededintothefuture.

Simeis147:Asupernovaremnantsomethreethousandlight-yearsfromEarth.Thesearetheremainsofastarthathasreachedtheendofitslife,afterithasbeendestroyedbyamassivethermonuclearexplosionatitscore.Theenergyofthatcatastrophiceventisenoughtoallowheavier,moreexoticelements—ofthetypeuponwhichlifedepends—tobecreated.This,inmanyrespects,iswherelifeintheuniversebegins.

(©DigitizedSkySurvey2/DavideDeMartin)

IFINALFRONTIERS

n1917,PrivateHudsoncutanunimpressivefigureontheWesternFront.Hewassmallbutwiryinbuildandbyhisownaccount,fivefeetfourinchestall.Overloadedwithhisfullcomplementofequipment,hestruggledtoclamberinandoutofthetrenches,evenwhentheGerman

gunsweren’ttrainedonhimandhispals.OnhisfirstdayonthefrontlinesoftheGreatWar,hehadanearlylethal

mishapwithahandgrenade.Standinginthesafetyofhisowntrenches,heandasmallteamofmenwerepracticinghurlingthedevicesfarenoughawaytoavoidshrapnelinjuries.

Theseventeen-year-oldpulledoutthepinandhurledthesmallmetalpineappleashardashecould.Butitstrayedoffcourse,collidingwiththetopoftheparapetwallandrebounding.Itfellathisfeetwiththefuseinsideburningdown,countingoffthesecondsbeforeitreachedtheexplosive.Therewasamomentofpanicbeforeheandtherestofthebombingpartyscatteredintothezigzagmazeofthetrenches,safelyoutofthewayoftheblast.

StumblingacrosstheshellholesoftheWesternFrontandfumblingtheoccasionalexplosivedevice,theyoungJamesHudsonwasneverthelessatthepeakofhisbiologicalfitness.

Physiologicallyhewouldneverbebetterthanhewasinthatwar.Damagesufferedbyhisbodythroughdisease,accident,orthewearandtearofeverydaylivingwasaddressedpromptlyanddefinitively.

Thestemcellsofhisbodywerecapableofstunningfeatsofregeneration;hisimmunesystemwasrobust;hisbodyboastedhugephysiologicalreserves.Hecouldrunfaster,fightharder,andsurvivelongerinthefaceofadversitythanatjustaboutanyothertimeinhislife.Buthewasalreadyinhisseconddecadeoflifeandabouttoenterhisthird.Andtheprocessofagingwouldsoonbegintogaintraction.

Thechangeswereatfirstimperceptibletotheyoungprivate;theywould

Thechangeswereatfirstimperceptibletotheyoungprivate;theywouldhavebeenmeasurableonlyinthelaboratorybythemostdiscriminatingtests.Laterthatwouldchange.

ButPrivateJamesHudsonwasabornsurvivorineverysense.HewentoverthetopintheterriblebattlesofMons,Arras,andlaterYpres,stayingaliveagainstincredibleodds.HealsoescapedthesweepingpandemicofSpanishfluthatfollowedtheGreatWar—adiseasethatclaimedthelivesofuptoahundredmillionworldwide.

Throughouthislife,hecontinuedtodefyeveryexpectation,livinginthreedifferentcenturies,watchingaworldtransformbeyondallrecognition.Andinthefinalyearsofhislife,aftermorethanacenturyofadventuresandnearmisses,hefinallyfoundhimselfadmittedtoMountVernonHospital,underthecareofamedicalteamwhoseranksIhadjustjoinedasajuniordoctor.

—WHENMOUNTVERNONHOSPITALwasbuilt,inthemiddleofthenineteenthcentury,itwastuberculosisthatstoodasthegreatunmetchallenge.Itwasadiseasewelldescribedbutpoorlyunderstood.Physicianscoulddolittlemorethanobservetheconsumptivehorroroftheinfectionasittookholdinlungsandspreadtohearts,bones,muscles,andbrains.

MountVernonspecializedinitstreatment.Builtonthetopofahill,boastingwardswithopenbalconies,itrepresentedthecuttingedgeinVictoriantuberculosistherapy:essentiallylittlemorethanaplantoexposepatientstolargevolumesoffreshair.

Overitslife,thehospitalwasrepurposedmorethanoncetomeetthechanginghealth-careneedsofthepopulation,asscienceandtechnologycontinuedtoredefinethefightagainstdeathanddisease.Itreceivedthecasualtiesofbothworldwars,becomingafull-fledgedgeneralhospitalwithanaccident-and-emergencyunitduringtheSecondWorldWar.Eventually,withtherationalizationofhealthcareinLondonanditssurrounds,itlostitsA&Edepartmentandbecamea“coldsite”fortherehabilitationofelderlypatientsandthetreatmentofcancer.BythetimeIarrived,thehospitalwasoveracenturyold,anditseemedfittingthatinitstwilightyears,partofitsraisond’êtrehadbecomethecareoftheelderly.

Arrivingfreshfromnearlythreeyearsofacutemedicine,withnightsspentansweringcrashcallsandpoundingdowncorridors,itlookedtomeatfirstlikethemedicalequivalentoflimbo.Amazeofsmallroadsranfromthenineteenth-centurybuildingsatthecoretomoremodernunitsattheperiphery.Theseaside,

centurybuildingsatthecoretomoremodernunitsattheperiphery.Theseaside,thesitedidn’tlookasthoughithadchangedmuchinthelasthundredyears.

Theelderly-carerehabilitationunitwashousedinatwo-storyprefabricatedbuilding,onethathadbeenbuiltatsometimeasatemporarymeasurebuthadsinceacquiredamorepermanentrole.Itwasaplacethatreceivedpatientstransferredfrombiggergeneralhospitalswithmoreurgentpressuresontheirbeds.Thejobofthisessential—butessentiallyforgotten—corneroftheNationalHealthServicewastorestoreitspatientstosomethingoftheirformergloryinthehopeofgettingthemhomeoncemore.

Thenightswerequiet,andthejobofferedabreakfromthecutandthrustofintensivecareandA&E,achance,Ithought,tofocusonmakingpreparationsformydreadedpostgraduateexams.

IntheeveningswhenIwasoncall,Iwouldtourthewardsjustbeforemidnight,scribblingtheoddprescription,checkingononeortwopatientswhomwewereworriedaboutbeforeturningin.Therewasasideroomonadisusedwardwithahospitalbedandplastic-coveredpillowswhereyoucouldputyourheaddownwiththereasonableexpectationthatyou’dgetsomesleep.

Thepracticeofelderlycareatfirstfeltveryalien.Asaformerphysicsstudent,IwasalwayslookingforawaytoreducetheproblemsIfacedonthewardstosomethingsimpler,forsystemsthatwouldcollapseneatlyintoafewlinesofequationandaphysiologicalprinciple.Butheremedicinewasfarlessalgorithmic.Therewere,yourapidlycametorealize,noquickfixesoreasyanswerstothemedicalproblemsthataccompaniedadvancedage.

PartofwhatIhadlikedaboutastrophysicswastheabstractionandthesimplicityofthesystemsunderstudy,systemssoinvariantinpropertythatyoucouldaskquestionsofbewilderingcomplexityandhaveareasonableexpectationofgettingdecentanswers.

Inmedicineitwastheotherwayaround.Thehumanbodyappearedsounfathomablethatwecouldonlyeverhopetoanswertheverysimplestquestionsaboutthepeoplewhomwetreated.Wedidstufflargelybecauseitworked.Whilestatisticalmethodsoftentoldusthatourtherapiesweredoingsomegood,weweren’talwaysabletoexplainwhy.

Thefieldofanesthesia,withitsemphasisontheintegratedphysiologyofthehumanbodyanditsattemptstoexplainacutechangesattheleveloffirstprinciple,wasaboutasclosetothereductionistapproachofphysicsasIwasevergoingtoget.Andinthepracticeoftraumatoo,onewasusuallydealingwithinsultstophysiologiesotherwiseuncomplicatedbydisease:asingle,albeitmassive,perturbationinanotherwisestablesystem.Tosomeextent,allofthishadfeltvaguelyfamiliar.

hadfeltvaguelyfamiliar.Butwhenitcametothecareoftheelderly,thechallengebecameextreme.

Heretheunderlyingphysiologyofagedpatientsappearedtohavebeeneroded,leavingthemwithlessinthewayofreserves,foreverteeteringonthebrinkofinstability.Superimposeduponthiswerelayersofchronicillnessesandsideeffectscausedbydozensofdrugs—manyofwhichhadundesirableinteractions.

Ontopofallofthiswereconsiderationsaboutthepropershapeofanindividual’slife:thestateoftheirhome,thestrengthoftheircircleoffamilyandfriends.Fortheelderly,thetruebenefitofeveryinterventionhadtobeunderstoodandweighedcarefullyagainsttheconsiderablerisksitpresented.Thephysiologyoftheseindividualswasfragileandunforgiving.

Havingeverknownonlyacutemedicinewithallitsurgency,therehabilitationoftheelderlywaslikelearningtherulesagainfromscratch.ThebiologyoftheyoungerpatientsIhadgottenusedtolookingafterwaslessnuancedandcertainlyfarmorerobust.

Asheroicasthetraumacallshadappeared,theywereincomparisonlikeagoal-linescrambleinagameoffootball:urgentandplayedoutinsecondsbutalwayswiththepossibilitythatyoumightrecoverfromyourmistakesrightupuntilthelastinstant.

Beingadoctorspecializinginthecareoftheelderlywasmuchmorelikeplayingchess.Asinglepoorlyconsidereddecisioncouldprovecatastrophic.Thingshappenedslowlyandinsmallmoves.Sometimestheadvanceofapawnwasallthatwasneeded.Sometimesretreatwasacceptable—evennecessary.

Therearemanystereotypesconcerningoldage,butIquicklylearnedthatpeoplegrowmore,ratherthanless,differentfromoneanotherastimepasses.

Therehabunitwasbuiltontwolevelswithperhapsthirtyinpatientbedsupstairs,dividedbetweenawardtothesouthforthewomenandonetothenorthforthemen.Inthethirdbedfromthedooronthemen’ssidewasMr.Hudson,whohadbythispointreachedtheremarkableageof103in2001.Nowfrailandafflictedwithpneumonia,hewasneverthelesssharpinmindandspirit.Butthefactofhissurvivalwasperhapslesssurprisingtohimthanitwastous,hiscaregivers.ForiftherewasonetrickthatJamesHudsonhadlearnedinoveracenturyofliving,itwashowtobeattheodds.

—WHILETHETWENTIETHCENTURYbroughtlifesavinginnovations,italsogaverisetoanarrayofincreasinglyviolentwaystodestroyourselvesandeachother.

OnFebruary12,1898,agentlemanbythenameofHenryLindfieldbecame

OnFebruary12,1898,agentlemanbythenameofHenryLindfieldbecamethefirstrecordedfatalityfromanautomobileaccidentwhenhelostcontrolofhistwo-seaterandsmashedintoatreeoutsideofPurley.Hehadbeendrivingdownhillattheheadyrateof17milesperhour.

Almostexactlyamonthlater,JamesHudsonwasborninamewshouseinLondonclosetoPaddingtonStation.AlthoughthehousewaswithinspittingdistanceofSt.Mary’sHospital,hewasdeliveredathome,toacoachmanandhiswife,atatimewhenmorethanoneineverytennewborninfantsdiedatorshortlyafterbirth.

Hearrivedintheworldattheendofthenineteenthcentury,beforehighwaysoranythingthatresembledmodernmedicine,beforetheWrightbrothersorEinstein’sgreattheories,atatimewhenEvereststoodunclimbed,heartswereconsideredinoperable,andthemapsoftheworldstillboastedavastunchartedcontinentofsnowandicetothesouth.

Intheyearofhisbirth,Londonwasacityofcobbledstreetsandhorse-drawncarriages.Therewasnoambulanceservice,welfarestate,orNationalHealthService.Healthcarewassomethingthatonlythoseofmeanscouldafford.Everybodyelsedependeduponsimplecharity.

Inatimebeforevaccinationandantibiotictherapy,infectiousdiseasewastheleadingcauseofdeath.Asthetwentiethcenturyapproached,achildcould,onaverage,expectlittlemorethanforty-fiveyearsoflife.Aroundtwooutofeverytenchildrenborninthattimeweredeadbeforetheageoffive.Nearlyathirddidnotsurvivebeyondtwenty-fiveyears.ButthatwasnottobeJames’sfate.

YoungMasterHudsonleftschoolattheageoffourteen.Abrightanddeterminedboy,hetookupanapprenticeshipinadentist’sofficeinTonbridge,hopingthathemightonedaygainentrytoamedicalschool.

TheGreatWarintervened—andHudsonborewitnesstotheterrifyingefficiencywithwhichmechanizedsocietycoulddestroylives.Butnoneofthisbrokeeitherhimorhisstride.AyearafterWorldWarIended,heenrolledatGuy’sHospitalasastudentofdentistry,andby1928hehadhisowndentalpractice.

Workingwithinahospitalasadentalsurgeon,Hudsonbegantonoticeanincreaseinthenumberoffacialinjuriesandfracturedjawsasaresultofautomobileaccidents.Henotedtoothatwithhisdentaltrainingandknowledgeoftherelevantanatomy,hewasbetterequippedtodealwithsuchpatientsthanmostgeneralsurgeonswere.

Heandseveralofhiscolleaguescampaignedfortheestablishmentofanewspecialty—onethatembraceddentistryandsurgeryinasinglefield,onespecificallyforinjuriesandoperablediseasesoftheheadandneck.Thisbecame

specificallyforinjuriesandoperablediseasesoftheheadandneck.Thisbecamethefieldofmaxillofacialsurgery.Theboywhohadstartedlifeinanapartmentaboveablockofstablesattheendofthenineteenthcenturybecameaconsultantsurgeonandoneofthefoundersofanewsurgicalspecialty.

—ALIFETIMELATER—ANDNEARLYSIXTYYEARSsincethebirthoftheNationalHealthService—Iworkmywayaroundthewardfrompatienttopatient,pushingthetrolleyofnotesasIgo.Fromtheendofthebed,JamesHudsonappearsfrail.Tuckedupinachairwithablanketonhislap,heisthinandbespectacled,withwhitehair.Thesaggingofhisfeaturesrepresentsthedisappearanceofelastin,aproteinthatgivesskinitsyouthfulappearance.Thelinesofskincellsthathavemarchedforwardoversomanydecadescontinuetodoso,onlythesedaystheyareslightlylesswellmade.

Thefibersofhismusclestoohavechanged,shrinkingback,losingmuchoftheiryouthfulbulk.Their“cut,”thelinesofdefinitionthatdemarcateeachmusclegroupclearly,hasfaded,thankstoadecreaseinhislevelsoftestosterone.Andsotoohasthetestosterone.Thesameapparentwearinessofhisbody’sproductionlinethatisresponsibleforthechangesinhisskinhasaffectedeverysystem.

Hisspokenwordsareclearbutnoticeablylessforcefulthanthoseofhisyoungervisitors.Themusclesthatshapehisvoice,likethoseofhisskeleton,havebecomeweakerwithtime.Thevocalcordscannotbeheldsoconsistentlyinposition.Theywavernowinthesamewaythatthemusclesofhisarmmightifheweretoliftaheavyweight.Andthelungfulofairthatheexpelsinordertomakethosesoundsisalsosmaller.Nowthattherecoilofhislungsislesspowerful—likehisskin,theirelasticitytoohasbeeneroded—breathingoutismoreofaneffort.Thecapacityofhislungsthemselveshasshrunk.

TheevidenceofMr.Hudson’sgreatagegoesbeyondthatwhichIcanseeandhearfromtheendofthebed.Hisbiochemistryisderanged.Hiskidneysarelessimpressive:lesscapableoffilteringthevolumesofbloodthatcoursethroughthem,morevulnerabletoinsult.Thetoxinsanddrugsthattheyaresupposedtoremoveareclearedmoreslowlythesedays.

Hisheartbeatswithlessforce,emptiessmallervolumeswitheverybeat.Theelectrocardiogram,whichtracesthespreadofelectricitythroughthatvitalorgan,showstheoccasionalmissedbeat.

Whenherisesfromhischair,hecannotpullhimselfuptohisfullheight.Theweakenedbonesofhisspinalcolumnhaveovertheyearsgivenwaytothe

weakenedbonesofhisspinalcolumnhaveovertheyearsgivenwaytotheforcesgeneratedbyimperfectposture.Thespineitselfcurlsgentlyforwardnow,causingapermanentstoop.

When—withassistance—hegetstohisfeet,youcannothelpbutworry.Themusclesofposturalcontrol,thosethatkeephimupright,arelesscapablenow.Theylaborunderthecontrolofthebrain,whichisunconsciouslyandperpetuallymakingcorrectionstokeephimonhisfeet.Butthatforemantooislesscompetentthanitoncewas.

Theintricatesystemofaccelerometryinhisinnerear—thatwhichinyouthandhealthcantellanOlympicfigureskaterwhentoemergefromapirouette—isnowpronetoplayingcrueljokes,occasionallyprovidingillusionsofmotionwhenitisabsent,leavinghimunsteady.Andthebonesonwhichhisfleshandmusclearehungarelessdense,morepronetofracturewhenexposedtosuddenforce.

Thisisthephysiologyofgreatage,andthefrailtythataccompaniesitisundeniable.Butforalloftheabove,at103Mr.Hudsoncontinuesmuchashemusthavedoneformostofhislife.Heistheoldestmemberofhisgolfcourseandamanwho,untilamonthago,stilldroveacar.

—ITISENTROPYTHATWEAREupagainsthere.Entropyisthatproperty,commontoallsystemsaliveordead,thatseesthemtendfromastateofordertooneofchaos.Andoncetheprocessesofrenewalandreplenishmentthatmaintainusinouryouthbegintorundown,weareleftopentoitsravages.

Youcanthinkofthebiomoleculesthatcomprisethecellsandtissuesofyourbodyasthoughtheywerethousandsoftrillionsofspinningtopsarrangedonavasttabletop.Intheirinitialstate,theyallstandneatlyordered—upright,spinningfast,andresilienttoperturbation.Butgradually,astheybegintospindown,theyslowandbecomemoreunsteady.

Thosetopscanberespunandpreventedfromfallingover,withawhip.Orthoseteeteringonthebrinkofcatastrophecanberemovedcompletelyandreplacedwithafreshlyspuntop.Whippingandreplacingthespinningtopsareprocessesanalogoustotherepairandregenerationofbiomolecules.Itisthisperpetualinputofenergytothebiologicalsystemthattemporarilystavesofftheconsequencesofentropy.

Inyouth,theprocessofentropyisheldincheckbythebody’sintrinsicsystemofrepairandregeneration—asystem,ifyoulike,thatisconstantlyreplacingmanytrillionsofmoleculesandwhippingthemintoshape.Butjustasachildeventuallygetsboredwiththetoy,sothebodyeventuallybeginsto

achildeventuallygetsboredwiththetoy,sothebodyeventuallybeginstoabandontheprocessesofrepairandregeneration.

Unabated,theentropyofthebiomoleculesofwhichthebodyiscomposedmanifestsitselfastheprocessthatweexperienceasaging.Accordingtothismodel,thestateofyouthisakintoaforestofspinningtopsstandingstable,fastandfullofenergy.Oldageseesthemslowingdown,growingunsteady,oscillatingwildly—readyforapassingbreezetoknockswathesofthemover.

Entropydoesnotcausedisease,norisitdisease,butitleavesanorganismvulnerable.Anddiseasetakesholdwherethesystemisweakest.Forhumansthatisthecardiovascularsystemandthosecellpopulationsmostpronetocancer.

Havingmadegreatstridesagainstcommunicablediseaseintheopeningdecadesofthetwentiethcentury,wearenowupagainstthelimitssetbyentropy.

Inasense,wehavetranscendedthefateofotherorganisms,leavingbehindtheeternalwaramongspeciesandmicroorganismsthatoperatestokillsuchlargefractionsofapopulationinearlylife,and—barringaccident—wearelefttobehavemoreliketheobjectsinthephysicalworldaroundus,windingdownasentropytakeshold,lefttofailthewayastarmight.

—MR.HUDSON’SCHESTisfullofcrackles.Hiscoughisworsetoday,hisbreathingmorelabored.Thepneumoniathatfirstbroughthimtothehospitalhasreturned.Iamunsurewhatthekindestinterventionmightnowbe.

Atthestartofthetwentiethcentury,thecontinentofoldagewasadestinationthatstoodrarelyvisitedandlargelyunknown.Fornearlytheentiretyofhumanhistory,averagelifeexpectancylanguishedaroundthirtyyearsofage.Thisgrimstatisticremainedfairlyconstantthroughoutrecordedhistory,aboutastrueoftheancientGreeksasitwasoftheVictoriansofthenineteenthcentury.

InthetimethatJamesHudsonhaslived,lifeexpectancyintheUnitedKingdomhasnearlydoubled.Theoldestpersonwhohaseverlivedwasnineteenyearsolderthanheisnowwhenshediedattheremarkableageof122yearsand164daysin1997.

JeanneCalment,borninthe1870s,livedforherentirelifeintheFrenchcityofArlesand,asayoungwoman,oncemetVincentvanGogh.Itishardtomakesenseofherlongevity.Shesmoked,atechocolate,drankport,andaccordingtoreports,wasn’tparticularlyfussedaboutexercise—hardlythebehaviorofanindividualattemptingtostaveofftheinevitablerunningdownofherphysiologicalprocesses.

physiologicalprocesses.Therearebutahandfulofpeoplealivetodaywhohaveapproachedthisgreat

age.Fewerthanoneinathousandcentenariansreachestheageof110.CouldMr.Hudsonpassthisextremefrontier?Statistically,thechancesappearslim.Butweareinterraincognitahere,livingatatimewhenweareseeingremarkablefeatsofsurvivalandlongevityoccurmoreandmorecommonly.

Weareincreasinglyawarethatapatient’schronologicalageisnotthesamethingasphysiologicalageandthatit’samistaketounderestimatethosewho’vepassedtheirallottedthreescoreyearsandten.Afterall,JohnGlennflewintospaceaboardthespaceshuttleDiscoveryatage77.JeanneCalmentherselftookupfencingforthefirsttimeatage85.Andat102yearsofage,Dr.JamesHudsondescribedhimselfinthenationalcensusasmerely“semiretired.”Ashisdoctor,IhavenodirectwayofknowinghowwellpreservedMr.Hudsonis,onlythatheisresilientenoughtohavemadeitthisfar.

MypatientisarguablylesslikelytodieonthisdaythanhewasonanydayatArras,Mons,orYpres,andonlyslightlymorelikelytodietodaythanhewasinhisfirstyearoflife.ButMr.Hudsonisanindividual—moredifferentfromthepopulationuponwhichthatstatisticisbasedthanhehasbeenatanytimeinhislife.Hehasseenunthinkablerevolutionsinhealthcare,science,andtechnology.Hehasseentheseeminglyimpossibleachievedoverandoveragain.Andforhim,theonlyconstantthroughallofthattimehasbeenthefactofhissurvival.

Tuckedupinbedfightingpneumonia,heisstillinmanywaysthesamepluckyprivatefromtheWesternFront—keepinghisheaddown,knowingonlythatthisiswarandthatallwarsarehard.

—“NOBODY,”ASSENATORANDASTRONAUTJohnGlennonceputit,“hasyetfoundacureforthecommonbirthday.”Butforthosefortunateenoughtoliveinthedevelopedcountriesoftheworld,thecontinentofoldageis,aftertwomillionyearsofhumanevolution,suddenlyopentoall.Equippedwithonlyaverageluck,assistedbytheadvancesthatmodernlivinghasbrought,thevastmajorityofuswillreachit.

Wemayfinddifficultyinperceivingoldageasathingofexploration,butthatitis—andoneinwhichallofustodaycanparticipate.Neitherdoweregarditinthesamewayaswedootherunexploreddestinations:withexpectation,hope,andcuriosity.

Butlifeisanexploration,andJamesHudsonisamongthegreatestexplorersofanyage,livingacrossthreecenturies,witnesstosomeofthemostsignificanteventsofthetwentiethcentury.Tohimitwasallanadventureandonetobe

eventsofthetwentiethcentury.Tohimitwasallanadventureandonetobeenjoyeduntilthelastpossiblemoment.

—ENTROPY,DISEASE,ANDTHECOMPLEXIONofourgeneseventuallycatchupwithusall,eventhosewhohavewalkedupontheMoon.OnAugust25,2012,NeilArmstrongdiedinahospitalinthecityofCincinnati,Ohio,havingfailedtofullyrecoveraftercardiacsurgery.Hewaseighty-two.Earlierthatmonth,hehadsteppedontoatreadmillandwalked,whiledoctorsmonitoredthedanceofelectricityinhisheartthroughelectrocardiogramleads.

Theyperhapsnoticedsmallupswingsanddepressionsinthewaveformsscribbledoutbeforethem,symptomaticofconstrictionsinthearteriessupplyingthemuscleofhisheart.Theywouldhavegoneontomapthosetributariesingreaterdetail,delineatingthenumberandseverityofthenarrowings,beforedecidinguponaplan.ThatplanwasforArmstrongtoundergoacardiothoracicoperationinanefforttobypasstheblockagesinhiscoronaryarteriesandrestorethesupplyroutestohisheart.

BypassoperationswerepioneeredinthesamedecadeinwhichProjectApolloreachedtheMoon.Thistypeofsurgeryremainsamongthemostinvasivethatmedicineoffers—carvingintothechest,isolatingtheheartfromitssurroundings,andestablishingthepatientonaheart-lungbypassmachine—anditcomeswithattendantrisks.ThisArmstrong’ssurgicalteamwouldhavelaboredtoexplain,weighingthealternatives,makingclearwhatmightbewonandlostintheendeavor.

PreciselyhowyoustratifyrisktoamanwhocommandedthefirstcrewtolandontheMoon,orhowArmstronghimselfperceivedit,Idonotknow.Despitehisearlieroccupation,Armstrongwasnoadrenalinejunky.Unnecessaryriskswere,inhisopinion,bestavoided.

Famouslyhebelievedthathumanspaceflightoughttoinvolvenomoreriskthanmakingamilkshake.Thoughbackinthesummerof1969,asthelunarmoduleEaglesanktowardtheSeaofTranquility,runninglowonfuel,itsonboardcomputershavingcrashedrepeatedly,spaceflightstillhadalongwaytogotocatchupwiththesafetyrecordofthemilk-shakeindustry.

Theearlydaysofhumanspaceflightandheartsurgerywerewatchedbytheworldinwide-eyedwonder.Therisksinvolvedinthesepioneeringendeavorsweresogreatastobeimpossibletosensiblyquantify.Deathswereexpected.

Todaytheriskofcatastrophicfailureduringthelaunchofahuman-ratedorbitalspacevehiclestandsatperhaps2or3percent,almostthesameriskas

orbitalspacevehiclestandsatperhaps2or3percent,almostthesameriskasthatinvolvedincoronaryarterybypasssurgery.Despitetheserisksbeingsignificant,bothhave,tosomedegree,cometobeviewedbythepublicasbeingwithinacceptablelimits.Theyhavebecomealmostroutine.

ThesurfaceoftheMoon,liketheanatomyoftheheart,hadbeenstudiedforcenturies.Bothhadstoodformillenniainfullviewandyetunexplored.TheMoonwasreachedbyanastronautcrewlaunchedacrossthevoid,wrappedinafacsimileofEarth’satmosphere.Thatsameapproach—ofswaddlingphysiologyinsystemsofartificiallifesupport—wasthekeytosuccessfulcardiacsurgery.

InthefewdecadesthathaveelapsedsinceScottandAmundsenfirstmarchedtotheSouthPole,wehavecomealongway.Ourexpectationsoftheinsultswemightsurvive,inthepursuitofgeographicalconquestaswellasontheoperatingtable,havebeentransformed.Lifehasneverbeensafer,neverlonger-lived.

Butlookcloserandthepicturegetsmorecomplex.Explorationisnecessarilyaprocessoftrialanderror,oftakingrisks.Itappearsclearwhatwehavetogainbyadvancingsoboldlyasclinicians.Butwe’regrowingmorecircumspectaboutphysicalexploration,particularlythatwhichseesusstaringoutintospaceatthefinalfrontier.We’vebeguntowonderifweshouldcontinuetoboldlygo.

—THEAGEOFHUMANSPACEFLIGHTWAS,withoutdoubt,broughtintobeingbythenucleararmsraceofthemidtwentiethcentury.Inthe1960s,withtherespectivenucleararsenalsoftheSovietUnionandtheUnitedStatesofAmericastandingreadytobringabouttheirmutuallyassureddestruction,humanspaceflightbecameasurrogatebattlefieldforawarthatcouldn’tbefoughtinanyotherway.

WiththeSovietUnionaheadateverypointinthespacerace,therewerehardtruthsfortheUnitedStatestoface.ButthereplytoSputnik,Laika,andGagarinwasArmstrong,Aldrin,andCollins.AnddespiteRussia’searlierpreeminence,thelunarlandinginJuly1969somehowgavetheUnitedStatesvictoryinthisbizarrestruggle.

ProjectApolloanditslunarexplorationmissionswereconceived,built,andlaunchedbeforeKennedy’sfamousdecadewasout.Thisfeatappearstogrowmoremiraculousastheyearsrollby.Themission-controlroomthatdrovethosefirstforaystoanotherworldwasstockedwithsliderules,pocketprotectors,andBakelitetelephoneswithrotatingdials.Tocontemporaryeyes,ithardlyseemspossiblethatthetechnologyofthetimewasuptothetaskofdeliveringmentothesurfaceoftheMoon.Inthatregard,itisanachievementthatstandsoutsideitstime,afeatofanachronism.

Butperhapsactsofexplorationneverfullymakesensetorationalpeople.

Butperhapsactsofexplorationneverfullymakesensetorationalpeople.Theyare,afterall,aboutventuringbeyondwhatisknownandsafeandtobecountedon.Inthisregard,maybethegreatestfeatsofexplorationmustalwaysfeelanachronistic.

—AFTERHALFAMILLENNIUM,westillrememberFerdinandMagellanandthestraitslinkingthePacifictotheAtlantictowhichhegavehisname.Wemightremember,too,theextraordinaryvoyagethatsawhisflotillaofshipsbecomethefirstexpeditiontocircumnavigatetheglobe.Thelegacyofdiscoveryiswhatwecelebrate.Whatwerecalllessclearlyistheexpedition’slegacyofloss.

ForMagellan,settingsailfromtheSpanishportofSanlúcardeBarramedain1519withafleetoffiveshipsandacrewof237,theoceansoftheworldmusthaveseemedasunknown,presentingatleastasmuchthreattolifeastheoceanofspacethatliesbetweenEarthandMarstoday.

Theexpeditionenduredfamine,disease,mutiny,andconflict.MagellanhimselfwasslaininthePhilippines,intheshallowsaroundMactanIsland,beforethecircumnavigationwascomplete.Whentheexpeditionfinallyreturnedtoportin1522,exactlythreeyearsafteritsdeparture,onlyoneship,theVictoria,and18oftheoriginalcrewof237remained.

Todayhistoryrecognizesthisashavingbeenanimportantfeatofexploration,anecessarysteptowardstillgreaterfeatsofnavaldiscovery.ButtoMagellan’screwandthepeoplewholivedandworkedintheSpanishportintowhichtheVictorialimpedatthestartofthesixteenthcentury,itcouldhardlyhaveseemedso.

—INRETELLINGTHESTORYoftwentieth-centurymedicine,weoftensuperimposeanarrativeofsteadyprogress,whenintruthphysicians,surgeons,andscientistsdidlittlemorethanstumbleahead,asallexplorersdo,solvingandcreatingproblemsastheywent.

BothCharlesBaileyandDwightHarkenenduredmanyfailuresintheearlydaysofclosed-heartsurgery,resultinginthedeathsofaverylargepercentageoftheirfirstcohortofpatients.Thesefirsteffortsatheartsurgerywereviewedasbizarreandextremeformsofintervention.SotoowasArchibaldMcIndoe’spracticeofsubjectingdisfiguredairmentodozensofoperations,waltzingsquaresoffleshacrosstheirbodiesinthehopeofreconstructingsomethingoftheirfaces.BjørnIbsenonlynarrowlyconvincedhiscolleaguesofthevalueof

theirfaces.BjørnIbsenonlynarrowlyconvincedhiscolleaguesofthevalueofartificialventilationinaddressingthedevastatingeffectsofpoliomyelitis.

FacedeitherwiththescarsoftheBattleofBritainorthesuffocatingdeathofthepolioepidemics,bothMcIndoeandIbsencouldhavesafelychosentodonothing.Inbothcases,thethreatsaddressedbytheirinnovationwererapidlyneutralizedbyothermeans.Aircraft,evencombataircraft,becameimmeasurablysaferthroughimprovedengineering.Poliowasaddressedeffectivelywithprogramsofvaccination.WithintwentyyearsoftheCopenhagenepidemicthatgaverisetotheworld’sfirstintensive-careunits,thespecterofthisparalyzingillnesshadallbutdisappearedfromdevelopedcountries,andtodaypolioisverynearlyeradicatedfromtheworldatlarge.

Buttheintensive-careunitsthatBjørnIbsenlaboredtocreateweresoonrepurposedtotreatallsufferersofcriticalillness—withinthreedecades,wecouldartificiallysupportlungs,hearts,kidneys,andeventhegut.Andintensivecarecametounderpintheheroicfeatsofsurgerythatwehavecometoexpectinthemodernage,DallasWiensandhistransplantedfaceamongthem.

Plasticsurgeryalsounderwentsomethingofatransformation.Thedevastationanddisfigurationwroughtbyfiresbecamethankfullyrareroverthecourseofthelasthundredyears.Itsravageshavebeenreplacedbytheinvasionofcancer.Anditisherethattheartofplasticsurgery,forgedinthefireofwar,nowfindsitselfmostkeenlyapplied.Noneofthesedestinationswasarrivedatthroughcarefulplanning.Butwhenyoustrikeoutintonewterritory,yourarelyknowwhatyou’regoingtodiscover.

Together,dozensofdiscreteeventsinthehistoryofmodernmedicinecametogethertoensureAnnaBågenholm’ssurvival.Fromflyingambulancesandcardiac-bypasscircuitstointensive-careunitsandreconstructivesurgeries,allofiteventuallybecameacontinuouschainofsurvivalthattookayoungdoctorfromdeathbeneaththeiceofafrozenriverinNorwaytoresuscitationandsurvivalinahospitalinTromsø.Anna’ssurvivalwasoneoftheunintendedconsequencesoftheexplorationofearlierepochs.Inpart,thatanswersthequestionofwhyweshouldexploreatall.Tobeabletoexplore,wemustcontinuetosurvive.Butthereverseisalsotrue.Tosurvive,wemustexplore.

Weadvanceinscience,medicine,andexplorationinfitsandstarts.Thereisnorealplan—atleastnotonethatanyonehaseverstucktoforverylong.Wehappenuponourdiscoverieslargelybyaccident,makingthemostofthemasandwhentheyarise.Wemeetdisasterinthesameway.Weexploresimplybecausewemust.Andthatiswhatmakesushuman.

ACKNOWLEDGMENTS

Therearemanywithoutwhomthisbookwouldnothavebeenpossible.Foremostamongthem:WillFrancisforchasingmeforsomanyyearstowritesomethingandhisoppositenumberintheUnitedStates,P.J.Mark,forhissterlingeffortsinmakingthistransatlanticversionhappen.IoweadebtofgratitudetoVirginiaSmith,myeditoratPenguinPress,chieflyforherpatience,butalsoforinsight,comments,andsuggestionsthathavehugelyimprovedthetext.Aswellasprovidingfirst-classeditorialinput,sheandKaitlynFlynnhavebeenmytutorsinthestrangelanguageofAmericanEnglish.ImustthankKaitlynalsoforherfantasticattentiontodetailandforherroleinpolishingupthefinalversionsofthetext.

Imustfinallysayahugethank-youtothemanypeoplewhohavehelpedmealongtheway.ItoccurredtomethatauthorandevolutionarybiochemistNickLane,havingbashedtheideaoftheimportanceofmitochondriaandbioenergeticsintomyheadoverbeersintheJeremyBenthampub,playedamoreimportantrolethanperhapsheknew.AndI’mparticularlygratefultothosewhoread,commented,andcorrected,amongthemMikeHerd,AdamRutherford,MarkPaul,VikiMitchell,andNeilNixon.AndnoneofthiscouldhavehappenedwithoutSueRider,whoisalwaystheretryingtomanagethechaosthatistherestofmylife.

Perhapsthebiggestsacrificewasmadebymywife,Dee,andourboys,whohavegivenupweekends,evenings,andholidaysfortoolongtoletmegettotheendofthis.SpecialthankstotheWellcomeTrust,theBBC,andparticularlytomycolleaguesandfriendsatUniversityCollegeLondonHospitalforallowingmetocontinuetoexploreandofcoursetomyparentsforencouragingmetodosointhefirstplace.

SOURCESANDFURTHERREADING

Althoughthisbookcoversacenturyofchangeintheworldofexplorationandmedicine,itisn’tconstructedasahistoricaltreatiseanymorethanitisintendedtobeatextbookofmedicineforaspirantphysicians.

ThenarrativeswithinarestoriesthatIwasawareofbutdidn’treallyknow.Theyaretheretoprovideaninsightintotheincrediblethingsthatweareabletodoinmedicineandexplorationtodayandthewaysinwhichwearrivedatthispoint.

Buttheyareastartingpointratherthanadestination.Forthosewantingtoexplorefurther,I’veincludedthereferencesbelow,whichwereusedassourcematerialbutwhosedetailsitwasnotalwayspossibletodiscussinthedepththeydeserve.

ICE

ImetAnnaandTorvindwhilemakingaHorizondocumentaryfortheBBC.Anna’scaseisonethathasbecomethestuffoflegendamongthemedicalfraternity,onethatwehaveoftenusedtoillustratethefactthatinthefaceofhypothermia,itisworthpersistingwitheffortsatresuscitation.ButIhadneverinallofthattimereferredtotheoriginalLancetpublication.TorvindandAnnaweregoodenoughtocometoLondonandlectureataseminarIhadorganizedattheRoyalSocietyofMedicinein2011.Theretheytoldtheirstoryinitsfulldetail,anditisuponthataccount—andourconversationduringthedrenchingonthewaytodinnerafterward—thatthesubstanceofthematerialinthischapterisbased.

MythanksalsototheDezhbodfamilyforpermissiontoincludetheirstoryandfortalkingwithmeaboutit.Esmailhasrecoveredwellfromhissurgeryandhasreturnedtowork.Hiseldestdaughterisatcollegeandhopingtogotomedicalschoolupongraduation.

Itisworthnotingthatcardiac-arrestsurvivalrateshaveimprovedsignificantlyinthefifteenyearssinceIfirstgraduatedfrommedicalschool.I’mhugelygratefultoDr.JerryNolan,consultantanesthetistandchairmanoftheResuscitationCouncil(UK)foransweringnumerousqueries.Changesintreatmentprotocolsandnewtechniques,includingtherapeutichypothermia,havebroughtsignificantbenefits.Andwhilesurvivalfollowingcardiacarrestremainstheexceptionratherthantherule,juniordoctorstodaythankfullyhavefarlesscauseforpessimism.

Berdowski,Jocelyn,etal.“GlobalIncidencesofOut-of-HospitalCardiacArrestandSurvivalRates:SystematicReviewof67ProspectiveStudies.”Resuscitation81(2010):1479–87.

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OxfordUniversityPress,2008.Solomon,Susan.TheColdestMarch:Scott’sFatalAntarcticExpedition.NewHaven,CT:YaleUniversity

Press,2001.———,andCharlesR.Stearns.“OntheRoleoftheWeatherintheDeathsofR.F.ScottandHis

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FIRE

HundredsofservicemenwereinjuredandthentreatedbythestaffoftheQueenVictoriaHospitalinEastGrinsteadduringtheSecondWorldWar,andthousandshavebeentreatedtheresince.TomGleave’sstoryisbutoneamonghundredsofthesameera,thoughasthefirstandonlychiefguineapigandoneofthefoundingmembersoftheGuineaPigClub,hisseemedwellworthretelling.Theeventsoftheairbattlethatledtohisinjurieshavebeentoldseveraltimes:inatelevisiondocumentarymadeforwhatwasThamesTelevision(TheGuineaPigClub,directedbyRobertFleming),ininterviewsforradiodocumentaries,andinhisownbook,publishedin1941andtitledIHadaRowwithaGermanafterhisfirstwordstohiswifewhenshesawhisdisfigurementandaskedwhathadhappenedtohim.Theaccountsvaryalittlefromretellingtoretelling,possiblybecausetheoriginalsource—Gleave’sownbookoriginallypublishedanonymouslyduringthewarandvettedbytheMinistryofInformation—modifieddetailstoavoidgivingawaysecretsabouttheHurricane’svulnerabilities.Ihavedonemybesttopiecethedifferentstrandstogether.TogetapropersenseofjusthowflimsyandflammabletheHurricane’sfuselagewas,IvisitedHawkerRestorationsinSuffolkandsawahandfulofreconstructedHurricanes—oneofwhichhadbeenflownbyGleaveincombat.

IamgratefulfortheassistanceofTomCochraneandBobMarchant,respectivelyhonorarysurgeonandhonorarysecretarytotheGuineaPigClub,fortheirwisdomandrecollections.Mr.CochranerightlypointsoutthatArchibaldMcIndoestoodontheshouldersofthegiantswhoprecededhim,notablythoseofhiscousinHaroldGillies,whosepioneeringworkinthefieldofplasticsurgeryismorefullydescribedinthe1920stextbookPlasticSurgeryoftheFace,authoredbyGillieshimself.

MythanksalsotoTomEdrichandBohdanPomahačfortakingthetimetotalkwithmeatlengthaboutDallasWiens’sdifficultsurgeryandforreviewingthewrittenmaterial.

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HEART

ThestaffoftheBritishLibrarywasparticularlypatientwithmewhileIresearchedthischapter.ThecaseofGreyTurner’swoundedsoldierwasdetailedinacasereportfortheLancetin1940,withamoreformaltreatiseonthesubjectofgunshotwoundsoftheheartin1941fortheBritishMedicalJournal.HislecturetosurgeonspreparingforserviceduringtheFirstWorldWarpredatesthesepublicationsbysometwenty-threeyears.

IwasveryfortunatetobeabletospeakwithDr.AldenHarken,sonofDwightHarkenandalsoasuccessfulcardiothoracicsurgeon.Hisrecollectionsoftheearlydaysofcardiacsurgeryandtherivalrieshisfatherhadtocontendwithwereparticularlycolorful,andIamverygratefulforthetimehewasabletospare.

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Risks,andRealities.”ScandinavianJournalofSurgery96,no.1(Winter2007):4–10.Symbas,PanagiotisN.,andAlexanderG.Justicz.“QuantumLeapForwardintheManagementofCardiac

Trauma:ThePioneeringWorkofDwightE.Harken.”AnnalsofThoracicSurgery55,no.3(March1993):789–91.

Waisel,David.“Norman’sWar.”Anesthesiology98,no.4(April2003):995–1003.———.“TheRoleoftheSecondWorldWarandtheEuropeanTheaterofOperationsintheDevelopment

ofAnesthesiologyasaPhysicianSpecialtyintheUSA.”Anesthesiology94,no.5(May2001):907–14.Willan,RobertJoseph.“GeorgeGreyTurner.”AnnalsoftheRoyalCollegeofSurgeonsofEngland9,no.4

(October1951):274–76.

TRAUMA

TheStynerfamily’sstoryisaprimeexampleofatalethatmanymedicsknowofbutveryfewknowproperly.ItwasagenuinehonortohavebeenabletotalkwithDr.JamesK.StynerabouthisincrediblestoryandthebirthoftheAdvancedTraumaLifeSupportcourses.Dr.Stynerwasgeneroustoafaultwithhistimeandpointedmeatanewlypublishedaccountofthatfamousday’sevents,authoredbyhissonRandalStyner.Thatbook,titledTheLightoftheMoon(2012),givesamuchfulleraccountofthehorroroftheplanecrashandthedeterminationthatledtotheestablishmentofanewstandardintraumacare.WhenJimandIfinallyspoke,Ithankedhim,belatedly,forgettingmethroughtheworstofthatterribledayinSoho.

AmericanCollegeofSurgeons.AdvancedTraumaLifeSupportManual,6thed.Chicago:AmericanCollegeofSurgeons,1997.

Baker,MichaelS.“MilitaryMedicalAdvancesResultingfromtheConflictinKorea,PartI:SystemsAdvancesThatEnhancedPatientSurvival.”MilitaryMedicine177,no.4(April2012):423–29.

Brøchner,AnneCraveiro,andPalleToft.“PathophysiologyoftheSystemicInflammatoryResponseAfterMajorAccidentalTrauma.”ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine17(September15,2009):43.

Buncombe,Andrew,etal.“TwoDead,81InjuredasNailBombBlastsGayPubinSoho.”Independent,May1,1999,www.independent.co.uk/news/two-dead-81-injured-as-nail-bomb-blasts-gay-pub-in-soho-1096580.html.

Cooper,GrahamJ.,andDavidE.M.Taylor.“BiophysicsofImpactInjurytotheChestandAbdomen.”JournaloftheRoyalArmyMedicalCorps135,no.2(June1989):58–67.

Elster,EricA.“TraumaandtheImmuneResponse:StrategiesforSuccess.”Trauma62,no.6suppl.(June2007):54–55.

Frykberg,EricR.,andJosephJ.TepasIII.“TerroristBombings:LessonsLearnedfromBelfasttoBeirut.”AnnalsofSurgery208,no.5(November1988):569–76.

Holt,Richard.“SohoNailBombertoServeatLeast50Years.”DailyTelegraph(London),March2,2007,www.telegraph.co.uk/news/uknews/1544276/Soho-nail-bomber-to-serve-at-least-50-years.html.

Hull,J.B.“TraumaticAmputationbyExplosiveBlast:PatternofInjuryinSurvivors.”BritishJournalofSurgery79,no.12(December1992):1303–6.

Katz,ArnoldM.“ErnestHenryStarling,HisPredecessors,andthe‘LawoftheHeart.’”Circulation106,no.23(December3,2002):2986–92.

King,Booker,andIsmailJatoi.“TheMobileArmySurgicalHospital(MASH):AMilitaryandSurgicalLegacy.”JournaloftheNationalMedicalAssociation97,no.5(May2005):648–56.

Lee,ChristopherC.,etal.“ACurrentConceptofTrauma-InducedMultiorganFailure.”AnnalsofEmergencyMedicine38,no.2(August2001):170–76.

Ng,RoyL.,etal.“TheSohoNailBomb:TheUCHExperience.”AnnalsoftheRoyalCollegeofSurgeonsofEngland83,no.5(September2001):297–301.

Rignault,DanielP.“RecentProgressinSurgeryfortheVictimsofDisaster,Terrorism,andWar.”WorldJournalofSurgery16,no.5(September–October1992):885–87.

Skandalakis,PanagiotisN.,etal.“‘ToAffordtheWoundedSpeedyAssistance’:DominiqueJeanLarreyandNapoleon.”WorldJournalofSurgery30,no.8(August2006):1392–99.

Styner,JamesK.“TheBirthofAdvancedTraumaLifeSupport(ATLS).”Surgeon4,no.3(June2006):163–65.

Tsukamoto,Takeshi,R.SavanhChanthaphavong,andHans-ChristophPape.“CurrentTheoriesonthePathophysiologyofMultipleOrganFailureAfterTrauma.”Injury41,no.1(January2010):21–26,313.

Vasagar,Jeevan.“SohoBombVictimsTellofDevastationasPubTornApart.”Guardian(Manchester,UK),June8,2000,www.guardian.co.uk/uk/2000/jun/08/uksecurity.jeevanvasagar.

INTENSIVECARE

Intensivecarecanclaimtohavehadmanyorigins.TheHistoryofBritishIntensiveCare,publishedaspartofaWellcomeTrustWitnessestoTwentiethCenturyMedicineproject,detailsmanycontributingfactorsbesidestheeventsofCopenhagenin1953.However,BjørnIbsen’seffortsduringthatpolioepidemicstillappeartohavebeenkeytotheproliferationoflarger,better-organizedunitsdedicatedtothecareofcriticallyillpatients.

ThestoryoftheepidemicthatsweptthroughMauritiuswasunknowntomebeforewritingthisbook.InterviewingmyownfatheraboutlifeinthefishingvillageofGrandGaubeledtogenuinelyunexpectedpersonaldiscoveriesabouthisearlylifeandthedevastationthatpoliobroughttothefamily.

HereImustalsothankDr.NicholasHirsch,aconsultantanesthetistattheNationalHospitalforNeurologyandNeurosurgerywhohadahandintrainingmewhileIwasajuniordoctorandwhoseenthusiasmforthehistoryofanesthesiaandintensive-caremedicinesparkedmyown.

ImetCharlesGomersallwhilewewerelecturingtogetheronadisaster-managementcoursefortheEuropeanSocietyofIntensiveCareMedicine.TheSARSepidemicbecameaneventthatmostclinicianslearnedaboutonlyinabstractionthroughresearcharticles.Thenumberofdeathsworldwidewasmercifullysmall—thankslargelytotheeffortsofCarloUrbaniandhiscolleagues—butthatstatisticbeliesthefranklyheroicexperienceofahandfulofintensive-careunitsandhospitalsthroughouttheworld,whichborethebruntoftheoutbreak.IamgratefultoProfessorGomersallfortakingthetimetospeakwithmeaboutthoseevents.

Abraham,T.Twenty-FirstCenturyPlague:TheStoryofSARS.Baltimore:JohnsHopkinsUniversityPress,

2005.Andersen,ErikWainø,andBjørnIbsen.“TheAnaestheticManagementofPatientswithPoliomyelitisand

RespiratoryParalysis.”BritishMedicalJournal1,no.4865(1954):786–68.Berthelsen,PrebenG.,andMatsCronqvist.“TheFirstIntensiveCareUnitintheWorld:Copenhagen

1953.”ActaAnaesthesiologicaScandinavica47,no.10(November2003):1190–95.Chan-Yeung,Moira,andWaiChoYu.“OutbreakofSevereAcuteRespiratorySyndromeinHongKong

SpecialAdministrativeRegion:CaseReport.”BritishMedicalJournal326,no.7394(April2003):850–52.

Cyranoski,David.“ChinaJoinsInvestigationofMysteryPneumonia.”Nature422,no.6931(April3,2003):459.

Fleck,Fiona.“CarloUrbani”(obituary).BritishMedicalJournal326,no.7393(April12,2003):825.———.“HowSARSChangedtheWorldinLessThanSixMonths.”BulletinoftheWorldHealth

Organization81,no.8(January2003):625–26,www.scielosp.org/scielo.php?script=sci_arttext&pid=s0042-96862003000800014.

Gomersall,C.D.,etal.“ExpandingICUFacilitiesinanEpidemic:RecommendationsBasedonExperiencefromtheSARSEpidemicinHongKongandSingapore.”IntensiveCareMedicine32,no.7(July2006):1004–13.

———,etal.“TransmissionofSARStoHealthcareWorkers.TheExperienceofaHongKongICU.”IntensiveCareMedicine32,no.4(April2006):564–69.Epub2006Feb25.

IbsenB.“TheAnæsthetist’sViewpointontheTreatmentofRespiratoryComplicationsinPoliomyelitisDuringtheEpidemicinCopenhagen,1952.”ProceedingsoftheRoyalSocietyofMedicine47,no.1(January1954):72–74.

———.“FromAnaesthesiatoAnaesthesiology.PersonalExperiencesinCopenhagenDuringthePast25Years.”ActaAnaesthesiolScandSuppl.61(1975):1–69.

Li,T.S.,etal.“SevereAcuteRespiratorySyndrome(SARS):InfectionControl.”Lancet19,no.361(April2003,9366):1386.

McFarlan,AllanM.,GeorgeWilliamsonAuchinvoleDick,andH.JohnSeddon.“TheEpidemiologyofthe1945OutbreakofPoliomyelitisinMauritius.”QuarterlyJournalofMedicine,newseries,15(July1946):183–208.

Parashar,U.D.,andL.J.Anderson.“SevereAcuteRespiratorySyndrome:ReviewandLessonsofthe2003Outbreak.”InternationalJournalofEpidemiology33,no.4(August2004):628–34.Epub2004May20.

Peiris,JosephS.M.,etal.“CoronavirusasaPossibleCauseofSevereAcuteRespiratorySyndrome.”Lancet361,no.9366(April19,2003):1319–25,http://image.thelancet.com/extras/03art3477web.pdf.

———,etal.“TheSevereAcuteRespiratorySyndrome.”NewEnglandJournalofMedicine349,no.25(December18,2003):2431–41.

Reilley,Brigg,etal.“SARSandCarloUrbani.”NewEnglandJournalofMedicine348,no.20(May15,2003):1951–52.

ReisnerSénélar,Louise.“TheDanishAnaesthesiologistBjörnIbsen,aPioneerofLong-TermVentilationontheUpperAirways.”Dissertation,DepartmentofMedicine,JohannWolfgangGoetheUniversity,FrankfurtamMain,2009.

———.“TheBirthofIntensiveCareMedicine:BjörnIbsen’sRecords.”IntensiveCareMedicine37,no.7(July2011):1084–86.doi:10.1007/s00134-011-2235-z.

Reynolds,L.A.,andElizabethM.Tansey,eds.HistoryofBritishIntensiveCarec.1950–c.2000.WellcomeWitnessestoTwentiethCenturyMedicine,vol.42,QueenMary,UniversityofLondon,2011.

Richmond,Caroline.“BjørnIbsen”(obituary).BritishMedicalJournal335,no.7621(September27,2007):674.

Sample,DonaldW.,andCharlesA.Evans.“EstimatesoftheInfectionRatesforPoliomyelitisVirusintheYearsPrecedingthePoliomyelitisEpidemicsof1916inNewYorkand1945onMauritius.”JournalofHygiene55,no.2(June1957):254–65.

“SARSinHongKong:FromExperiencetoAction”(extract).AustralianHealthReview26(2003),no.3:22–25.

Wong,Tze-wai,etal.“ClusterofSARSAmongMedicalStudentsExposedtoSinglePatient,HongKong.”EmergingInfectiousDiseases10,no.2(February2004):269–76.

Yu,I.T.,andJ.J.Sung.“TheEpidemiologyoftheOutbreakofSevereAcuteRespiratorySyndrome(SARS)inHongKong—WhatWeDoKnowandWhatWeDon’t.”EpidemiologyandInfection132,no.5(October2004):781–86.

WATER

Dr.C.J.Brooks’slong-runninginvestigationintothefactorsthatconspiretomakehelicoptercrashesatseasodifficulttosurvivearetouchedupononlybrieflyatthestartofthischapter.IhadthepleasureofrunningintoDr.BrooksataconferenceaboutriskmanagementinLondonlastyear.Hetellsmethatwhenhetravelsonhelicopters,hetapesapieceofstringfromtheexitdoor,alongthefloor,totheseatinwhichhe’ssitting,tomakesurehecanfindhiswayoutofthevehicleintheeventofanemergency!

MyfriendDr.MikeTipton,athermalphysiologistatPortsmouthUniversity,answeredmanyqueriesIhadhereandelsewhereinthebookaboutthehumanbody’sresponsestotheextremesofhighandlowtemperatures.HewassohelpfulthatIhavealmostforgivenhimformakingmeendurethecold-shockresponsefirsthand,inachillypoolofwaterthatdoublesashislaboratoryforphysiologicalexperimentation.

Brooks,C.J.,TheHumanFactorsRelatingtoEscapeandSurvivalfromHelicoptersDitchinginWater.Neuilly-sur-Seine,France:AdvisoryGroupforAerospaceResearchandDevelopment,August1989,http://oai.dtic.mil/oai/oai?verb=getRecord&metadataPrefix=html&identifier=ADA215755.

———,etal.“CivilianHelicopterAccidentsintoWater:Analysisof46Cases,1979–2006.”Aviation,Space,andEnvironmentalMedicine79,no.10(October2008):935–40.

Cheung,StephenS.,N.J.D’Eon,andC.J.Brooks.“Breath-HoldingAbilityofOffshoreWorkersInadequatetoEnsureEscapefromDitchedHelicopters.”Aviation,Space,andEnvironmentalMedicine72,no.10(October2001):912–18.

Craig,AlbertB.,Jr.“CausesofLossofConsciousnessDuringUnderwaterSwimming.”JournalofAppliedPhysiology16(1961):583–86.

———.“DepthLimitsofBreathHoldDiving(anExampleofFennology).”RespirationPhysiology5(1968):14–22.

———.“HeartRateResponsestoApneicUnderwaterDivingandtoBreathHoldinginMan.”JournalofAppliedPhysiology18(1963):854–62.

———,andWilliamL.Medd.“OxygenConsumptionandCarbonDioxideProductionDuringBreath-HoldDiving.”JournalofAppliedPhysiology24(1968):190–202.

———,andDonaldE.Ware.“EffectofImmersioninWateronVitalCapacityandResidualVolumeoftheLungs.”JournalofAppliedPhysiology23,no.4(October1967):423–25.

Fahlman,Andreas.“ThePressuretoUnderstandtheMechanismofLungCompressionandItsEffectonLungFunction.”JournalofAppliedPhysiology104,no.4(April2008):907–8.

Ferretti,Guido,andMarioCosta.“DiversityinandAdaptationtoBreath-HoldDivinginHumans.”ComparativeBiochemistryandPhysiologyPartA:Molecular&IntegrativePhysiology136,no.1(September2003):205–13.

Golden,Frank,andMichaelTipton.EssentialsofSeaSurvival.Champaign,IL:HumanKinetics,2002.

Koehle,MichaelS.,MichaelLepawsky,andDonaldC.McKenzie.“PulmonaryOedemaofImmersion.”SportsMedicine35,no.3(2005):183–90.

Levett,DennyZ.,andIanL.Millar.“BubbleTrouble:AReviewofDivingPhysiologyandDisease.”PostgraduateMedicalJournal84,no.997(November2008):571–78.

Lindholm,Peter,andClaesE.G.Lundgren.“ThePhysiologyandPathophysiologyofHumanBreath-HoldDiving.”JournalofAppliedPhysiology106,no.1(January2009):284–92.

Parkes,MichaelJ.“Breath-HoldingandItsBreakpoint.”ExperimentalPhysiology91,no.1(January2006):1–15.

Qvist,Jesper,etal.“ArterialBloodGasTensionsDuringBreath-HoldDivingintheKoreanAma.”JournalofAppliedPhysiology75,no.1(July1993):285–93.

Rahn,Hermann.“Breath-HoldDiving:ABriefHistory.”Narragansett,RI:NationalSeaGrantLibrary,2004,http://nsgl.gso.uri.edu/nysgi/nysgiw85001/nysgiw85001_part1.pdf.

Schagatay,Erika,etal.“SelectedContribution:RoleofSpleenEmptyinginProlongingApneasinHumans.”JournalofAppliedPhysiology90,no.4(May2001):1623–29;discussion,1606.

ORBIT

YiSoyeonliterallyrocketedtofameafterherselectionandflightasSouthKorea’sfirstastronaut.Ifirstnoticedherataspace-medicineconferenceinHouston.Weldedtohersmartphone,displayingboundlessenthusiasm,andconstantlypostingTwitterupdates,shewasneveryouraverageastronaut.Shekindlyagreedtoletmeinterviewherforthisbookandwasgoodenoughtocheckthestoryoverafterwardtomakesureofthedetail.

Ihavewatchedthreeshuttlelaunches.Allofthemmakeyouholdyourbreath.Itwasaprivilegetobethereforthelaunchandlandingofthelastshuttlemission—STS135—inJuly2011.Amongallofthepotentialinsultsthatcouldbehurledatthehumanbody,theenergiesinvolvedinlaunchalwaysmademyfocus,onthemedicalproblemsandthephysiology,seemprettyirrelevant.

I’dalsoliketothankmyfriendDanTani.Dan,aformerNASAastronautwhooncewasgoodenoughtocallmefromthespacestation,hastalkedpatientlywithmeandatlengthabouttheadventureofhumanspaceflightovertheyears.

Burrows,WilliamE.ThisNewOcean:TheStoryoftheFirstSpaceAge.NewYork:RandomHouse,1999.Curtis,HowardD.OrbitalMechanicsforEngineeringStudents.London:Elsevier,2005.Seeespeciallypp.

257–73.Houtchens,BruceA.“Medical-CareSystemsforLong-DurationSpaceMissions.”ClinicalChemistry39,1

(January1,1993):13–21.NationalAeronauticsandSpaceAdministration.ReportoftheColumbiaAccidentInvestigationBoard.

Washington,DC:GovernmentPrintingOffice,August2003,www.nasa.gov/columbia/caib/html/start.htmlandhttp://history.nasa.gov/columbia/CAIB_reportindex.html.

ReportofthePresidentialCommissionontheSpaceShuttleChallengerAccident(RogersCommission).Washington,DC:June6,1986;repr.Collingdale,PA:DianePub.Co,1995;http://history.nasa.gov/rogersrep/genindex.htm.

Roth,EmanuelM.“Rapid(Explosive)DecompressionEmergenciesinPressure-SuitedSubjects,”NASAContractorReport1223.Washington,DC:NationalAeronauticsandSpaceAdministration,November1968.

Summers,RichardL.,etal.“EmergenciesinSpace.”AnnalsofEmergencyMedicine46,no.2(August2005):177–84.

Wolfe,Tom.TheRightStuff.London:JonathanCape,1979.

MARS

In1997weweredefinitelygoingtoMars.Atleastthat’sthewayitlookedtome.IrememberthatfirstvisittoHoustonveryfondly.Thehydroponicsandregenerativelife-support-systemexperimentswererunbyascientistbythenameofDougMing,whoremindedmealittleofBruceDern’scharacterinthefilmSilentRunning.

Astrophysicswasattractivetomebecauseitwasaboutboundary-conditionproblems:observingthebehaviorofsystemsattheextremes.Marsisinmanywaystheboundary-conditionmissionforthehumanbody.

IwastheluckyrecipientofaNESTA(NationalEndowmentforScience,TechnologyandtheArts)FellowshipandlateraBogueResearchFellowship,whichallowedmetocontinuemyworkwithNASA.ProfessorBillPaloskipatientlyfacilitatedmyreturnstoJohnsonSpaceCenterandhasservedasbothmentorandgoodfriendovertheyears.

HumanmissionstoMarscontinuetosoundlikethestuffofsciencefiction.ButwewillgotoMarsbeforethiscenturyisout.OfthatIamsure.Iftheendofthetwenty-firstcenturyisasdifferentfromitsbeginningastheendofthetwentiethprovedtobefromitsbeginning,we’llmanagethatandmuch,muchmore.

Braun,Wernhervon.TheMarsProject.Urbana:UniversityofIllinoisPress,1991.———.“CrossingtheLastFrontier.”Collier’s,March22,1952,pp.24–31.Carmeliet,Geert,GuyNys,andRogerBouillon.“MicrogravityReducestheDifferentiationofHuman

OsteoblasticMG-63Cells.”JournalofBoneandMineralResearch12,no.5(May1997):786–94.———,LaurenceVico,andRogerBouillon.“SpaceFlight:AChallengeforNormalBoneHomeostasis.”

CriticalReviewsinEukaryoticGeneExpression11,no.1–3(2001):131–44.Cassenti,BriceN.“TrajectoryOptionsforMannedMarsMissions.”JournalofSpacecraftandRockets42,

no.5(September–October2005):890–95.Crocco,GaetanoArturo.“One-YearExploration-TripEarth–Mars–Venus–Earth.”Paperpresentedatthe

SeventhCongressoftheInternationalAstronauticalFederation,Rome,Italy,1956,pp.227–52.D’Aunno,DominickS.,etal.“EffectofShort-andLong-DurationSpaceflightonQTcIntervalsinHealthy

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andEnvironmentalMedicine59,no.12(December1988):1185–89.Drake,BretG.,ed.“ReferenceMissionVersion3.0AddendumtotheHumanExplorationofMars:The

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Fitts,RobertH.,DannyR.Riley,andJeffreyJ.Widrick.“FunctionalandStructuralAdaptationsofSkeletalMuscletoMicrogravity.”JournalofExperimentalBiology204,no.18(September2001):3201–8.

Fogleman,Guy,LaurenLeveton,andJohnB.Charles.“TheBioastronauticsRoadmap:ARiskReductionStrategyforHumanExploration.”PaperpresentedatContinuingtheVoyageofDiscovery,theFirstSpaceExplorationConference,Orlando,FL,January30,2005,AmericanInstituteofAeronauticsandAstronauticsdocumentID:AIAA-2005-2526.

AstronauticsdocumentID:AIAA-2005-2526.Fritsch-Yelle,JaniceM.,etal.“AnEpisodeofVentricularTachycardiaDuringLong-Duration

Spaceflight.”AmericanJournalofCardiology81,no.11(June1998):1391–92.Graybiel,Ashton,BrantClark,andJ.J.Zarriello.“ObservationsonHumanSubjectsLivingina‘Slow

RotationRoom’forPeriodsofTwoDays.”ArchivesofNeurology3(1960):55–73.Harm,DeborahL.,andDonaldE.Parker.“PreflightAdaptationTrainingforSpatialOrientationandSpace

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Himmelskörper,1925).Washington,DC:NASATechnicalTranslationF-44,November1,1960.Holstein,GayR.,EwaKukielka,andGiorgioP.Martinelli.“AnatomicalObservationsoftheRatCerebellar

NodulusAfter24hrofSpaceflight.”JournalofGravitationalPhysiology6,no.1(July1999):47–50.Joosten,B.Kent.“PreliminaryAssessmentofArtificialGravityImpactstoDeep-SpaceVehicleDesign.”

Houston:NASAJohnsonSpaceCenter,2007,NASADocumentID:20070023306.Lackner,JamesR.“SpatialOrientationinWeightlessEnvironments.”Perception21(1992),no.6:803–12.LeBlanc,AdrianD.,etal.“AlendronateasanEffectiveCountermeasuretoDisuseInducedBoneLoss.”

JournalofMusculoskeletalandNeuronalInteractions2,no.4(June2002):335–43.———,etal.“BoneMineralandLeanTissueLossAfterLongDurationSpaceFlight.”Journalof

MusculoskeletalandNeuronalInteractions1,no.2(December2000):157–60.Macho,Ladislav,etal.“EffectsofExposuretoSpaceFlightonEndocrineRegulationsinExperimental

Animals.”EndocrineRegulations35,no.2(June2001):101–14.Oberth,Hermann.“DieRaketezudenPlanetenräume”[TheRockettoPlanetarySpace],inWegezur

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———.“ArtificialGravityasaMulti-SystemCountermeasuretoBedRestDeconditioning:PilotStudyOverview.”PaperpresentedattheTwenty-eighthAnnualInternationalGravitationalPhysiologyMeeting,April8–13,2007,SanAntonio,TX,NASATechnicalReportsServer,nodigitalversionavailable,abstractandorderinginformationathttp://nix.nasa.gov/search.jsp?R=20070016631&qs=N%3D4294950110%2B4294961628%2B4294930154.

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Reschke,MillardF.,etal.“SmoothPursuitDeficitsinSpaceFlightsofVariableLength.”JournalofGravitationalPhysiology9,no.1(July2002):133–36.

Shi,Shang-Jin,DonnaA.South,andJaniceV.Meck.“FludrocortisoneDoesNotPreventOrthostaticHypotensioninAstronautsAfterSpaceflight.”Aviation,Space,andEnvironmentalMedicine75,no.3(March2004):235–39.

Solder,J.K.“RoundTripMarsTrajectories:NewVariationsonClassicMissionProfiles.”AmericanInstituteofAeronauticsandAstronautics,August1990,documentID:90–3794.

Sonnenfeld,Gerald,andWilliamT.Shearer.“ImmuneFunctionDuringSpaceFlight.”Nutrition18,no.10(October2002):899–903.

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Turner,RussellT.“WhatDoWeKnowAbouttheEffectsofSpaceFlightonBone?”JournalofAppliedPhysiology89,no.2(August2000):870–47.

Vico,Laurence,etal.“EffectsofLong-TermMicrogravityExposureonCancellousandCorticalWeight-BearingBonesofCosmonauts.”Lancet355,no.9215(May2000):1607–11.

Walberg,Gerald.“HowShallWeGotoMars?”JournalofSpacecraftandRockets30,no.2(March–April1993):129–39.

Waters,WendyW.,MichaelG.Ziegler,andJaniceV.Meck.“PostspaceflightOrthostaticHypotensionOccursMostlyinWomenandIsPredictedbyLowVascularResistance.”JournalofAppliedPhysiology92,no.2(February2002):586–94.

Zubrin,Robert,DavidA.Baker,andOwenGwynne.“MarsDirect:ASimple,Robust,andCostEffectiveArchitecturefortheSpaceExplorationInitiative.”PaperpresentedatAmericanInstituteofAeronauticsandAstronautics29thAerospaceSciencesMeeting,Reno,NV,January7–10,1991,p.28,documentID:AIAAP.91-0328.

———,andDavidB.Weaver.“PracticalMethodsforNear-TermPilotedMarsMissions.”PaperpresentedatAIAA,SAE,ASME,andASEEJointPropulsionConferenceandExhibit,Monterey,CA,June28–30,1993,documentID:AIAAP.93-2089.

FINALFRONTIERS

IwillneverforgetJamesHudson;hewassofulloflifeevenduringwhatwastobehislastadmission.OvertheweeksthatIlookedafterhim,hetoldmethestoryofhisremarkablelifeininstallmentsandalwaysimploredmetocomebacksothathecouldtellmemore.IwouldliketothankhisdaughterValerieRussellforgivingmepermissiontorecountaspartofthisbooksomeofthestoriesthatIhadbeentold.

Mr.Hudsonhadalsocontributedtoatelevisiondocumentary—LloydGeorge’sWar—fortheBBCin1998,abouthisexperiencesduringtheFirstWorldWar.TheuneditedfootagefromthatprogramiskeptattheImperialWarMuseumarchives,anditisfromitthatthestoryofhisfumbledhandgrenadecomes.Additionally,theBritishDentalAssociationholdsanumberofrecordsandarticlesthatallowedmetotracehiscareermoreaccurately,fromapprenticetoqualifieddentistandfinallytohospitalsurgeon.

Asajuniordoctor,Ilearnedsomethingofthetradeofelder-caremedicineattheHammersmithHospitalfrommythenregistrarDr.GeoffCloud,whoisnowaconsultantinstrokemedicineatSt.George’sHospital.Whenitcametowritingthischapter,Ivisitedhimagaintoaskhisadvice.Inthatconversationandinfurtherreading,Igottheimpressionthatthefieldofgerontologyischangingrapidlyand,aselsewhereinmedicine,ourexpectationshavechangedbeyondanyrecognition.Ihadn’tpreviouslyappreciatedtheenormouscomplexityofthedebatesurroundingthesearchforageneraltheoryofaging.Iwasableonlytoscratchthesurfaceofthatherebutincludeallofthematerialforfurtherreading.

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Chamberlain,Geoffrey.“BritishMaternalMortalityinthe19thandEarly20thCenturies.”JournaloftheRoyalSocietyofMedicine99,no.11(November2006):559–63.

Christensen,Kaare,etal.“AgeingPopulations:TheChallengesAhead.”Lancet374,no.9696(October3,2009):1196–1208.

DiBiase,D.andD.Shelley,“DeathNotice”(JamesAlfredHudson).BritishDentalJournal191,no.5(September8,2001):282.

Gavrilov,LeonidA.,andNataliaS.Gavrilova.“TheQuestforaGeneralTheoryofAgingandLongevity.”ScienceofAgingKnowledgeEnvironmentno.28(July16,2003):1–10.

Gems,DavidH.,andYiladelaGuardia.“AlternativePerspectivesonAginginCaenorhabditiselegans:ReactiveOxygenSpeciesorHyperfunction?”Antioxidants&RedoxSignaling19,no.3(July20,2013):321–29.

Griffin,JohnP.“ChangingLifeExpectancyThroughoutHistory.”JournaloftheRoyalSocietyofMedicine101,no.12(December1,2008):577.

Hayflick,Leonard.“EntropyExplainsAging,GeneticDeterminismExplainsLongevity,andUndefinedTerminologyExplainsMisunderstandingBoth.”PublicLibraryofScienceGenetics3,no.12(December14,2007):e220.

Hudson,JamesAlfred.“TheDentalDepartmentatRedhillHospital,Edgware,asaCriterionfortheHospitalServicesoftheNationalHealthService.”BritishDentalJournal84(March1948):100–102.

———.“LongintheTooth:WitnessfortheProfession.”BritishDentalJournal171,no.5(September7,1991):138–40.

“HudsonReceivesFellowshipat102.”BritishDentalJournal(NewsandNotes)189,no.10(May27,2000):589.

Kirkwood,TomB.L.“LongevityinPerspective.”ReviewsofTheLongHistoryofOldAge,byPatThane,andTheLongTomorrow:HowEvolutionaryBiologyCanHelpUsPostponeAging,byMichaelR.Rose.Lancet367,no.9511(February25,2006):641–42.

———.“TheOriginsofHumanAgeing.”PhilosophicalTransactionsoftheRoyalSocietyofLondon,SeriesB,BiologicalSciences352,no.1363(1997):1765–72.

———.“WhereWillItAllEnd?”Lancet357,no.9256(February24,2001):576.———.TimeofOurLives:TheScienceofHumanAging.London:Phoenix,2000.Langdon,James.“Mr.JamesA.Hudson.”AnnalsoftheRoyalCollegeofSurgeonsofEngland83(2001

suppl.):26–27.LloydGeorge’sWar.BBCTimewatch,1998,uneditedinterviewsforprogram,heldbyImperialWar

Museum,London,catalogno.TV112X.Montagu,J.D.“LengthofLifeintheAncientWorld:AControlledStudy.”JournaloftheRoyalSocietyof

Medicine87,no.1(January1994):25–26.Shay,JerryW.,andWoodringE.Wright.“Hayflick,HisLimit,andCellularAgeing.”NatureReviews:

MolecularCellBiology1,no.1(October2000):72–76.Walsh,John.“TheLastSoldier.”Independent(London),November11,1999,p.1.

INDEX

Thepagenumbersinthisindexrefertotheprintedversionofthisbook.Tofindthecorrespondinglocationsinthetextofthisdigitalversion,pleaseusethe“search”functiononyoure-reader.Notethatnotalltermsmaybesearchable.Note:Pagenumbersinitalicsrefertoillustrations.

ABCpriority,99–100,105,109,110abdominalsurgery,74accelerometers,220,236,248acidity,160,166Adams,Douglas,TheHitchhiker’sGuidetotheGalaxy,190AdmiralDuncanpub,bombsite,115–16adrenaline,144AdvancedTraumaLifeSupport(ATLS)protocol,100,105,109,111,113age,chronologicalvs.physiological,250–51aging,241–52andbreathing,247anddisease,249,252andentropy,248–49,252lifeexpectancy,245,250andmuscles,246–48

air:fresh,241andlungs,154,157,169oceanof,168oxygenin,170,183–84pressurized,169

Airbus,215aircraftfuel,burningtemperatureof,42airliners,cruisingaltitudeof,183airlock,185airpressure,168–69,170–71airsafety,256airway,inABCpriority,99–100Aldrin,Buzz,212,254

Aldrin,Buzz,212,254algae,227altitude:Armstronglineat,184–86high,182medicalproblemsof,182–86

alveoli,77,157,169,184Amundsen,Roald,9,28,72,253–54anaerobicrespiration,166anesthesia,144,243andcardiacsurgery,87andintensive-caremedicine,129andpolio,130–35unconsciousnessof,128–29,134

aneurysm,23angiosomes,51Antarctica,9,12–14,15,27–28anteriorhorn,125antibiotics,85,87,88antiemeticmedications,221Apollospaceprogram,213,254Archimedesprinciple,154Aristotle,73Armstrong,HarryGeorge,185Armstrong,Neil,212,213,252–53,254Armstrongline,184–86arterialgasembolism,169–70arthritis,135ArtificialGravityPilotProject,233–36astronauts,190,221–24andabsenceofgravity,221,229–31disorientationof,223ontheMoon,253postflightorthostaticintolerance,223reacclimatizing,223–24andreentry,204–5andRTLSabort,193–94andSoyeon,197–203,205–8andweightlessness,210,214,216,221,232

Atlantis,186–90,208atmospheres,168autoaccidents:fatalinjuriesin,246first,244–45

axons,125

bacterialendocarditis,80–81,85Bågenholm,Anna,15–23,26,29,257Bailey,Charles,87,88,90–92,256balance,9barotrauma,170

barotrauma,170BattleofBritain,38–41,256BattleoftheBulge,82Billroth,ChristianAlbertTheodor,74biomolecules,248,249Bjørneboe,Mogens,129–30BlegdamHospital,Copenhagen,129,132–33blisters,37blood:airincontactwith,157bleedingtodeath,112–13andbypassmachine,20–21,26carbondioxidein,132,160,167circulationtotheheart,76–77hemoglobinin,141,184hemorrhaging,110,113lossof,83,112oxygenin,142,163andskin,49supplytotheface,51–52,60,61,62transfusions,83,87–88

bloodpressure,measuring,164–65bloodvessels,constrictingunderwater,164body,repairandregenerationof,249bombingincident,102–5,109–11,115Bonaparte,Napoléon,95bones:andaging,248andforceofgravity,218

Bower,Albert,132Bowers,Henry,27brain:andaging,248autopilotof,128damageto,53human,14neuronsin,124–26visualcortexin,210

brain-stemdeath,53–54breath-holddiving,163–65,167breathing,155–58inABCpriority,99actof,156–57,159–61andaging,247ataltitude,184indivingunderwater,170andexercise,174–75,176holdingyourbreath,155,160,163ashumandrive,161,167andlungs,156,161

BrighamandWomen’sHospital,Boston,55,61–64

BrighamandWomen’sHospital,Boston,55,61–64BritishAntarcticSurvey,28Brock,Russell,87bronchialtree,156–57Brudon,Pascale,137–38buoyancy,154–55andlungs,157negative,155,158

burns:andblisters,37deathsfrom,37,38disfigurementfrom,57electrical,57extentofaffectedarea,38,49inflammatoryresponseprovokedby,37–38painfrom,42andplasticsurgery,44–48andskin,seeskinandsurvival,38

bypasscircuits:andhypothermia,20–21,24andrisk,252–53andsurvival,257

Calment,Jeanne,250,251cancer,135,257CapeCanaveral,187,191–92carbondioxide:inblood,132,160,167expulsionfromlungs,132,133scrubbingout,226

cardiacarrest:ataltitude,185andbloodloss,83,112anddowntime,18inspace,194–95

cardiacsurgery,74,79,84,87–92,157cardiovascularsystem,andabsenceofgravity,222carotidartery,51cell,derivationofword,124–25CentersforDiseaseControl(CDC),138centralnervoussystem,126centrifuge,232,234Chain,ErnstBoris,85Challenger,186,190,205Chen,Johnny,136,138–39Cherry-Garrard,Apsley,27China,atypicalpneumoniain,136–40chronicillness,135Churchill,EdwardDelos,80circulation:inABCpriority,99,110

inABCpriority,99,110ataltitude,185remapping,50shuttingdownunderwater,166

ColdWar,254Collins,Michael,254Columbia,186,190,205consciousness,123,166consumption,135Copeland,David,116Copenhagen,poliovirusin,127,129–35,148,256coronavirus,147Craig,AlbertB.,163–64crash,andcardiacarrest,18CT(computerizedtomography)scans,60Cutler,ElliottCarr,80cytoplasm,124

D-Day,82DDT,27death:avoidanceof,14bleedingto,112–13fromhypothermia,11,12,14,26lifeafter,52newlydefined,53simplicityassynonymouswith,11

decompressionillness,176dermis,35Derosier,Jean-Paul,139Dezhbod,Esmail,23–25diaphragm,156disability,intraumapriority,100Discovery,27,186,251divereflex,167diving:ascendingslowlyafteradive,171breath-hold,163–65,167andbreathing,170freediving,163–64,166–67mammalianreflex,164narcoticeffects(“narcs”),170,171oxygenin,166atQalito,171–77scuba,152,167–68skindiving,162–63

divingtables,171Domagk,Gerhard,85downtime,andcardiacarrest,18drowning,158,166Dykes,Andrea,115–16

Dykes,Andrea,115–16Dykes,Julian,115

Eagle,253Earth:circumnavigationof,255gravitationalloadon,232orbitof,225orbiting,212–13watercovering,177–78

Edrich,Tom,59–60,62–63eldercare,241–44lifeexpectancy,245,250risk-benefitequationin,243,252–53

electricalburns,57electricalneutrality,10Elefteriades,John,24–25Ellis,LawrenceBrewster,86embolisms,169–70encephalitis,132Endeavour,186endocarditis,bacterial,80–81,85energy,10absenceof,12

Enterprise,180,195entropy,248–49,252epidermis,34–35burnsof,36

equipoise,9erectorspinae,217EuropeanSpaceAgency,215evolution,115,128,207,218exercise,andbreathing,174–75,176exploration,257exposure,intraumapriority,100eyeballs,219–20

face:bloodsupplyto,51–52,60,61,62donationof,54,62fulltransplantsof,52,54,55,58–64,257rolesof,57–58sculptingoffeatures,64,257

Falkenberg,Marie,15–16,17fight-or-flightresponse,175“First,donoharm”(primumnonnocere),78Fleming,Alexander,85flight,dynamicphasesof,205Florey,Howard,85fluinfections,146

fluinfections,146Fong,AhYoong,121,123fovea,219–20freediving,163–64,166–67freeflap,50,58FrenchHospital,Hanoi,137–38Gagarin,Yuri,208,211,254gasp,involuntary,161,166Geckeler,George,88genes,andaging,252geneticcode,56Gilbert,Mads,20Gillies,Harold,44,45glaciology,27Gleave,Tom,39–41,42–45,47Glenn,John,251globalwarming,evidenceof,28goldenhour,conceptof,96Golgiapparatus,124Gomersall,Charles,142–46gravity,216–18absenceof,221–22,229–31artificial,230–32,233–36one-G,231andorbit,190prescribing,232andspacetraining,216andspacetravel,221–22zero-G,214

GreyTurner,George,74–76,77–79,80,82,84GuineaPigClub,47–48,65gunshotwounds,68–71totheheart,74–76,77–78

Hakkapeople,121Harken,DwightE.,79–84,86–87,88–92,256Hawley,PaulR.,79,81healing:andimmunesystem,114newcellgrowthin,36–37

heart:andaging,247anatomicalcomplexityof,76bacterialendocarditisin,80–81beating,76bloodcirculationof,76–77bypassoperations,20–21,24,252–53,257cardiacarrest,112–13closed-heartsurgery,90,256contractionof,222gunshotwoundto,74–76,77–78

gunshotwoundto,74–76,77–78andhemorrhage,113intraoperativeresuscitationof,82–83andlackofgravity,222locationof,71–72missileslodgedin,74,75–76,77–78,82,84mitralvalvein,85–86moving,84repairof,85saferoutesthrough,83–84slowingunderwater,164,166

heart-lungbypassmachine,20–21,24,252andhypothermia,20–21,24andrisk,252–53andsurvival,257

hearttransplants,53,61helicoptercrashtraining,153–54HelicopterEmergencyMedicalService(HEMS),104helicopterevacuation,96,257HelicopterUnderwaterEscapeTraining(HUET),154,158–59hemoglobin,141,184hemorrhage,110,113HeroicAgeofexploration,28histology,33–34,50Hudson,James,250–52birthof,245intheGreatWar,239–40,245–46andmaxillofacialsurgery,246asoveracenturyold,244,245–48,250

hypercalcemia,221hyperventilation,158,183hypothermia:andBågenholm,17,18–23andcirculatoryarrest,24–25deathfrom,11,12,14,26andDezhbod,23–25overcoming,15andresuscitation,18–23andScott,9,12–14,26

Ibsen,Bjørn,130–34,135,143,256immunesystem:andaging,240attackingthebody’sowntissues,85–86fightingdisease,165andinfections,56,141inflammationin,143andmultiorganfailure,143suppressionof,56andtransplants,55–56andtrauma,114–15

andtrauma,114–15infantileparalysis,127;seealsopoliomyelitisinfection,protectionagainst,126inflammatoryresponse,37–38innerear,218–20,231,233,236,248innovation:andsurvival,111,114–15vs.experimentation,92

intensive-careunit:andanesthetics,129eighteen-year-oldpatientin,119–20,149–50improvementsin,143–44andpolioepidemic,130–31,135,148,256rolesof,120–21,135,146,147–48,256–57andSARS,148andsurvival,257andtrauma,115

InternationalSpaceStation(ISS),187,195,196,200–202ion-channelcontrol,42ions,10–11ironlungs,131,132–33,256

Janis,Jeff,57Japaneseamas,diving,162Joosten,Kent,231

KC-135weightlesstrainingaircraft,210Kennedy,JohnF.,254KennedySpaceCenter,187,191–92keratin,34kidneydialysis,144kidneytransplants,53,61KoreanWar,96KoSan,198,199

lacticacid,119Laika(doginspace),254Larrey,Dominique-Jean,95–97,111larynx,156Lassen,HenryCaiAlexander,129lenssystem,220life,edgeof,115lifeexpectancy,245,250life-supportsystems:inspace,186,191,193andtrauma,111,115fortriptoMars,229–31whentostop,120

Light,John,115–16LiMoonKi,121Lindfield,Henry,244–45

Lindfield,Henry,244–45lithiumhydroxide,226LiuJianlun,139–40livertransplants,61lungs:andaging,247airin,154,157,169andbreathing,156,161andbuoyancy,157carbondioxideexpelledfrom,132,133indiving,167inflating,184andruptureofalveoli,169TBin,241transplants,61waterin,158

Magellan,Ferdinand,255–56Malenchenko,Yuri,201,202–3,206Mamanucaislands,171Manish(resident),69–70markerproteins,56Mars,211–14gettingto,224–27,232,234gravityof,235lifesupportfortripto,229–31long-stayarchitecture,225,226orbitof,225resupplyfor,226short-stayarchitecture,225–26

MASHunits,96masks,high-filtration,118,144–45Mauritius,121–23polioepidemicon,122–23,127

maxillofacialsurgery,47,246McIndoe,Archibald,43,44–48,54,56,65,256medicine,frontiersof,72–73mercury,164–65microsurgery,49–50MiddlesexHospital,97–98,100–102Mifsud,Stéphane,166Mir,229mitochondria,124,156mitralvalve,85–87,88–90Moon:astronautson,253asdestination,212,213,232,236,255studiesof,253–54

Moore,Nick,116motorcortex,123,124–25mountaineers,182–83

mountaineers,182–83MountEverest,182–83,185,190MountVernonHospital,240–42,244MRI(magneticresonanceimaging),60musclecontraction,125muscles:aging,246–48wastingaway,218,221–22

Næsheim,Torvind,15–18,29NapoleonicWars,97,111narcoticeffects(“narcs”),indiving,170,171NASA,181–82,187,191,195–96Apollospaceprogram,213,215ArtificialGravityPilotProject,233–36author’sinternshipwith,181–82budgetcutsin,236Challenger,186,190,205Columbia,186,190,205Enterprise,180,195KennedySpaceCenter,187,191–92andMars,211–14andspaceshuttle,187,191trainingaircraft,210,215–17X-38,195–96

negativebuoyancy,155,158nervoussystem,cellsof,125–26neurons,124–26neutrality,10Nimrod,27nitrogen,170–71,175–76Nitsch,Herbert,166non-heart-beatingorgandonation,53–54noradrenaline,143nucleararmsrace,254

Oberth,Hermann,230,231orangeangels,215–17orbit,useofterm,190orbits,ofEarthandMars,225organelles,124organtransplants,52–53andimmunesystem,55–56matchingdonorandrecipient,56non-heart-beatingdonation,53–54orderofretrievalfor,61

OrpingtonGeneralHospital,England,42–43otoliths,218,219oxygen:absenceof,177

absenceof,177inair,170,183–84intheblood,142,163andbreathing,156,184indiving,166supplemental,182–83supplyof,165–66underpressure,170,184

ozonehole,28

Paget,Stephen,SurgeryoftheChest,73parabolicflight,216parafoil,196ParklandMemorialHospital,Dallas,57pearldivers,162Peiris,Malik,147penicillin,discoveryof,85photosynthesis,226–27plasticity,48–49plasticsurgery,44–48,58,257poliomyelitis,126andanesthesia,130–35infantileparalysisas,127andintensivecare,130–31,135,148,256andironlungs,131,132–33,256polioepidemicinCopenhagen,127,129–35,148,256polioepidemiconMauritius,122–23,127poliovirus,125,127vaccinationagainst,148,256

Polyakov,Valeri,229Pomahač,Bohdan,54–55,56,58–64Ponting,Herbert,photoby,8pregnancy,86pressure:air,168–69,170–71ataltitude,183atsealevel,170water,169woundof,170

pressurecookers,185pressurization,ofairlinecabin,183priority,ABC,99–100,105,109,110proteins:andburns,42matching,56

publichealth,147–48pulmonaryartery,76

Qalito,171–77quadriceps,218

QueenVictoriaHospital,England,30andMcIndoe,46Ward3in,43–48

radiationhazards,227,228radiology,87reconstructivesurgery,257redundancy,192respiration,anaerobic,166resuscitation:andhemorrhage,113intraoperative,82–83keyto,19andsurvival,257

retina,219–20returntolandingsite(RTLS),192–94rheumaticfever,86,89ribosomes,124ribs,156,158risk,92,252–53,254rocketscience,190–91,205RossIceShelf,9,12,27RoyalAirForce(RAF),38–41RussianProgressvehicle,226

SARS,139–48contagiousnessin,146decliningnumberofcases,146–47andGomersall,142–46howitworks,140–41andintensivecare,148andLiu,139–40andmasks,118,144–45SARS-CoV,147survival,148

sciencefiction,193–94Scott,RobertFalcon:deathof,14,15,26,253–54andhypothermia,9,12–14,26legacyof,27–29,72,207shipof,8,27

SCUBA(self-containedunderwaterbreathingapparatus),167–68scubadiving,152seasickness,220–21semicircularcanals,233Shackleton,Ernest,27shockcausedbyhemorrhage,83,84SiebeGormandivinggear,167Singstad,Ketil,17sinking,155

sinking,155skin,32–36agingcells,246andbloodsupplyvs.beauty,45–46,50,64bridgedtoface,30burned,32,36coldreceptorsin,161,164dermis,35epidermis,34–35asessentialorgan,37freeflapof,50,58grafted,56microsurgeryon,49–50newcellgrowth,36–37,126andplasticsurgery,44–48reconstructionof,46,50remappingthecirculationof,50sensoryarrayof,35–36strataof,34–35vaporbarrier,37vascularanatomyof,50–51,60waltzing,45–46,48–49,256

skindiving,162–63Smithy,Horace,87sodiumthiopental,134solarflares,227–29solidrocketboosters(SRBs),188SouthPole,9,27–29Soyuzspacevehicle,196onreentry,204–7TMA-12,200–202

space:andArmstrongline,184–86artificiallifesupportin,186,191,193AssuredCrewReturnVehicle,196deep-spacemaneuvers,225Enterprise,180,195explorationof,207frontierof,186–90Mars,seeMarsmedicalemergencyin,194–95,196mishapsin,207andNASAtraining,210,215–17andnucleararmsrace,254orbitalflight,207,212–13radiationhazardsin,227,228andreturntoEarth,205–7,208,223–24solarflares,227–29X-38,195–96

spacefall,224spaceflight:consequencesof,230

consequencesof,230useofterm,224

spaceshuttle,187,191–94,196,208spacevehicles,204–5Spanishflu,240spinalcolumn:anderectorspinae,217intraumacases,99–100

spleen,165Sputnik,254Starr,HaroldMorley,39Statti,GiorgiosHaggi,162–63,167stemcells,34,240stroke,125Styner,JamesK.,105–9,113suction,156supernova,238survivability,limitsof,5synapse,125syphilis,135

Taylor,Ian,50–51TerraNova,8,27testosterone,247thermalshield,205thermaltolerance,42thoracicaorta,aneurysmof,23thoracicsurgery,80,81,84thoracotomy,71Torquemada,Tomásde,234trachea,156tracheostomy,133–34transatlanticabort(TA),193transfusionmedicine,87–88transplantmedicine,52–54transplants:fullface,52,54,55,58–64,257andimmunesystem,55–56

trauma,243ABCpriorityin,99–100,105,109,110AdvancedTraumaLifeSupportprotocol,100,105,109,111,113andairplanecrash,105–9barotrauma,170body’sresponseto,113–14andbombingincident,102–5,109–11,115derivationofword,98–99andhemorrhage,110,113andimmunesystem,114–15andintensivecare,115protocolsin,104–5,108–9,111–12spinalcolumnin,99–100

spinalcolumnin,99–100TromsøUniversityHospital,Norway,19–23,29,257tuberculosis,241TudorEdwards,Arthur,79–80,81

unconsciousness,ofanesthesia,128–29,134underwaterexploration,177–78Urbani,Carlo,135–38,139,147U.S.Armyhospital,England,82

vaporbarrier,37venacava,76ventilators,128,135ironlungs,131,132–33,256andSARS,142–43

vestibularsystem,233Victoria,255–56VietnamWar,94,96viralpandemics,126,135,147–48,240viruses,126atypicalpneumoniainChina,136–40containingoutbreaksof,147coronavirus,147movefromanimalstohumans,140polio,125,127SARS,139–48

visualcortex,210vocalcords,247voluntarymovement,123vonBraun,Wernher,211–12vonKármánline,186VostokI,208

waltzingtheskin,45–46,48–49,256Ward,Claire,89–90,92water:boilingpointof,185coveringtheEarth,177–78densityof,168pressureof,169

Waterloo,Battleof,95weightlessness,210,214,216,221,232Wellington,ArthurWellesley,Dukeof,95Whipple,Allen,80whitebloodcells,55,114,165Whitson,Peggy,200,201,203Wiens,Dallas,56–65,257Wilson,Edward,27WorldHealthOrganization(WHO),136–38,139WorldWarI,73–76

WorldWarI,73–76inFrance,66gunshotwoundtotheheart,74–76Hudsonin,239–40,245–46X-raysin,75

WorldWarII:andacceptablerisk,92antibioticsin,85BattleofBritain,38–41,256bombercrewsin,184burnvictims,30cardiacsurgeryin,87D-Day,82helicopterevacuationsin,96mechanizationofcombatin,79skingraftsin,56

Wrightbrothers,6

X-38,195–96X-rays,75,228

YangTinYing,121YiSoyeon,197–203,208goingtoMoscow,198–99andreentry,202–3,205–7onspacestation,200–201

zero-G,214

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