Extreme Medicine (25 page)

There's a lot of work to be done before that can happen. We are unsure of the prescription, of how hard and how fast you would need to spin crew members to protect them from the ravages of weightlessness. Neither do we know how much protection the lesser gravity of Mars will provide, if any.

It is unclear what such a system might do to the inner ear. Early results from NASA's Artificial Gravity Pilot Project suggested that the heart and muscles might be usefully protected in this way. It would be surprising if bone didn't benefit too. But the inner ear and its organs of accelerometry are a different story. This strange rotational input might, over time, lead to maladaptive changes that might worsen their function. On the other hand, it might prove highly protective. Sadly, it doesn't seem that we'll find out the answers anytime soon.

In 2009, just as the artificial-gravity project was ready to enter a more comprehensive phase of investigation, a series of budget cuts tore through NASA. The strategy that would have seen the short-arm centrifuge investigated thoroughly on the ground and then made ready for flight aboard the space station was canned. It isn't the last we've seen of this; as one of the investigators quipped, “Artificial gravity is an idea that comes around and around. . . .”

About the same time, a new vision was set, one that prioritized a return to the Moon over a first human mission to Mars. And once again the Red Planet receded into the future.

I
n 1917, Private Hudson cut an unimpressive figure on the Western Front. He was small but wiry in build and by his own account, five feet four inches tall. Overloaded with his full complement of equipment, he struggled to clamber in and out of the trenches, even when the German guns weren't trained on him and his pals.

On his first day on the front lines of the Great War, he had a nearly lethal mishap with a hand grenade. Standing in the safety of his own trenches, he and a small team of men were practicing hurling the devices far enough away to avoid shrapnel injuries.

The seventeen-year-old pulled out the pin and hurled the small metal pineapple as hard as he could. But it strayed off course, colliding with the top of the parapet wall and rebounding. It fell at his feet with the fuse inside burning down, counting off the seconds before it reached the explosive. There was a moment of panic before he and the rest of the bombing party scattered into the zigzag maze of the trenches, safely out of the way of the blast.

Stumbling across the shell holes of the Western Front and fumbling the occasional explosive device, the young James Hudson was nevertheless at the peak of his biological fitness.

Physiologically he would never be better than he was in that war. Damage suffered by his body through disease, accident, or the wear and tear of everyday living was addressed promptly and definitively.

The stem cells of his body were capable of stunning feats of regeneration; his immune system was robust; his body boasted huge physiological reserves. He could run faster, fight harder, and survive longer in the face of adversity than at just about any other time in his life. But he was already in his second decade of life and about to enter his third. And the process of aging would soon begin to gain traction.

The changes were at first imperceptible to the young private; they would have been measurable only in the laboratory by the most discriminating tests. Later that would change.

But Private James Hudson was a born survivor in every sense. He went over the top in the terrible battles of Mons, Arras, and later Ypres, staying alive against incredible odds. He also escaped the sweeping pandemic of Spanish flu that followed the Great War—a disease that claimed the lives of up to a hundred million worldwide.

Throughout his life, he continued to defy every expectation, living in three different centuries, watching a world transform beyond all recognition. And in the final years of his life, after more than a century of adventures and near misses, he finally found himself admitted to Mount Vernon Hospital, under the care of a medical team whose ranks I had just joined as a junior doctor.

—

W
HEN
M
OUNT
V
ERNON
H
OSPITAL
was built, in the middle of the nineteenth century, it was tuberculosis that stood as the great unmet challenge. It was a disease well described but poorly understood. Physicians could do little more than observe the consumptive horror of the infection as it took hold in lungs and spread to hearts, bones, muscles, and brains.

Mount Vernon specialized in its treatment. Built on the top of a hill, boasting wards with open balconies, it represented the cutting edge in Victorian tuberculosis therapy: essentially little more than a plan to expose patients to large volumes of fresh air.

Over its life, the hospital was repurposed more than once to meet the changing health-care needs of the population, as science and technology continued to redefine the fight against death and disease. It received the casualties of both world wars, becoming a full-fledged general hospital with an accident-and-emergency unit during the Second World War. Eventually, with the rationalization of health care in London and its surrounds, it lost its A&E department and became a “cold site” for the rehabilitation of elderly patients and the treatment of cancer. By the time I arrived, the hospital was over a century old, and it seemed fitting that in its twilight years, part of its raison d'être had become the care of the elderly.

Arriving fresh from nearly three years of acute medicine, with nights spent answering crash calls and pounding down corridors, it looked to me at first like the medical equivalent of limbo. A maze of small roads ran from the nineteenth-century buildings at the core to more modern units at the periphery. These aside, the site didn't look as though it had changed much in the last hundred years.

The elderly-care rehabilitation unit was housed in a two-story prefabricated building, one that had been built at some time as a temporary measure but had since acquired a more permanent role. It was a place that received patients transferred from bigger general hospitals with more urgent pressures on their beds. The job of this essential—but essentially forgotten—corner of the National Health Service was to restore its patients to something of their former glory in the hope of getting them home once more.

The nights were quiet, and the job offered a break from the cut and thrust of intensive care and A&E, a chance, I thought, to focus on making preparations for my dreaded postgraduate exams.

In the evenings when I was on call, I would tour the wards just before midnight, scribbling the odd prescription, checking on one or two patients whom we were worried about before turning in. There was a side room on a disused ward with a hospital bed and plastic-covered pillows where you could put your head down with the reasonable expectation that you'd get some sleep.

The practice of elderly care at first felt very alien. As a former physics student, I was always looking for a way to reduce the problems I faced on the wards to something simpler, for systems that would collapse neatly into a few lines of equation and a physiological principle. But here medicine was far less algorithmic. There were, you rapidly came to realize, no quick fixes or easy answers to the medical problems that accompanied advanced age.

Part of what I had liked about astrophysics was the abstraction and the simplicity of the systems under study, systems so invariant in property that you could ask questions of bewildering complexity and have a reasonable expectation of getting decent answers.

In medicine it was the other way around. The human body appeared so unfathomable that we could only ever hope to answer the very simplest questions about the people whom we treated. We did stuff largely because it worked. While statistical methods often told us that our therapies were doing some good, we weren't always able to explain why.

The field of anesthesia, with its emphasis on the integrated physiology of the human body and its attempts to explain acute changes at the level of first principle, was about as close to the reductionist approach of physics as I was ever going to get. And in the practice of trauma too, one was usually dealing with insults to physiologies otherwise uncomplicated by disease: a single, albeit massive, perturbation in an otherwise stable system. To some extent, all of this had felt vaguely familiar.

But when it came to the care of the elderly, the challenge became extreme. Here the underlying physiology of aged patients appeared to have been eroded, leaving them with less in the way of reserves, forever teetering on the brink of instability. Superimposed upon this were layers of chronic illnesses and side effects caused by dozens of drugs—many of which had undesirable interactions.

On top of all of this were considerations about the proper shape of an individual's life: the state of their home, the strength of their circle of family and friends. For the elderly, the true benefit of every intervention had to be understood and weighed carefully against the considerable risks it presented. The physiology of these individuals was fragile and unforgiving.

Having ever known only acute medicine with all its urgency, the rehabilitation of the elderly was like learning the rules again from scratch. The biology of the younger patients I had gotten used to looking after was less nuanced and certainly far more robust.

As heroic as the trauma calls had appeared, they were in comparison like a goal-line scramble in a game of football: urgent and played out in seconds but always with the possibility that you might recover from your mistakes right up until the last instant.

Being a doctor specializing in the care of the elderly was much more like playing chess. A single poorly considered decision could prove catastrophic. Things happened slowly and in small moves. Sometimes the advance of a pawn was all that was needed. Sometimes retreat was acceptable—even necessary.

There are many stereotypes concerning old age, but I quickly learned that people grow more, rather than less, different from one another as time passes.

The rehab unit was built on two levels with perhaps thirty inpatient beds upstairs, divided between a ward to the south for the women and one to the north for the men. In the third bed from the door on the men's side was Mr. Hudson, who had by this point reached the remarkable age of 103 in 2001. Now frail and afflicted with pneumonia, he was nevertheless sharp in mind and spirit. But the fact of his survival was perhaps less surprising to him than it was to us, his caregivers. For if there was one trick that James Hudson had learned in over a century of living, it was how to beat the odds.

—

W
HILE THE TWENTIETH CENTURY
brought lifesaving innovations, it also gave rise to an array of increasingly violent ways to destroy ourselves and each other.

On February 12, 1898, a gentleman by the name of Henry Lindfield became the first recorded fatality from an automobile accident when he lost control of his two-seater and smashed into a tree outside of Purley. He had been driving downhill at the heady rate of 17 miles per hour.

Almost exactly a month later, James Hudson was born in a mews house in London close to Paddington Station. Although the house was within spitting distance of St. Mary's Hospital, he was delivered at home, to a coachman and his wife, at a time when more than one in every ten newborn infants died at or shortly after birth.

He arrived in the world at the end of the nineteenth century, before highways or anything that resembled modern medicine, before the Wright brothers or Einstein's great theories, at a time when Everest stood unclimbed, hearts were considered inoperable, and the maps of the world still boasted a vast uncharted continent of snow and ice to the south.

In the year of his birth, London was a city of cobbled streets and horse-drawn carriages. There was no ambulance service, welfare state, or National Health Service. Health care was something that only those of means could afford. Everybody else depended upon simple charity.

In a time before vaccination and antibiotic therapy, infectious disease was the leading cause of death. As the twentieth century approached, a child could, on average, expect little more than forty-five years of life. Around two out of every ten children born in that time were dead before the age of five. Nearly a third did not survive beyond twenty-five years. But that was not to be James's fate.

Young Master Hudson left school at the age of fourteen. A bright and determined boy, he took up an apprenticeship in a dentist's office in Tonbridge, hoping that he might one day gain entry to a medical school.

The Great War intervened—and Hudson bore witness to the terrifying efficiency with which mechanized society could destroy lives. But none of this broke either him or his stride. A year after World War I ended, he enrolled at Guy's Hospital as a student of dentistry, and by 1928 he had his own dental practice.

Working within a hospital as a dental surgeon, Hudson began to notice an increase in the number of facial injuries and fractured jaws as a result of automobile accidents. He noted too that with his dental training and knowledge of the relevant anatomy, he was better equipped to deal with such patients than most general surgeons were.

He and several of his colleagues campaigned for the establishment of a new specialty—one that embraced dentistry and surgery in a single field, one specifically for injuries and operable diseases of the head and neck. This became the field of maxillofacial surgery. The boy who had started life in an apartment above a block of stables at the end of the nineteenth century became a consultant surgeon and one of the founders of a new surgical specialty.

—

A
LIFETIME LATER—AND NEARLY SIXTY YEARS
since the birth of the National Health Service—I work my way around the ward from patient to patient, pushing the trolley of notes as I go. From the end of the bed, James Hudson appears frail. Tucked up in a chair with a blanket on his lap, he is thin and bespectacled, with white hair. The sagging of his features represents the disappearance of elastin, a protein that gives skin its youthful appearance. The lines of skin cells that have marched forward over so many decades continue to do so, only these days they are slightly less well made.

The fibers of his muscles too have changed, shrinking back, losing much of their youthful bulk. Their “cut,” the lines of definition that demarcate each muscle group clearly, has faded, thanks to a decrease in his levels of testosterone. And so too has the testosterone. The same apparent weariness of his body's production line that is responsible for the changes in his skin has affected every system.

His spoken words are clear but noticeably less forceful than those of his younger visitors. The muscles that shape his voice, like those of his skeleton, have become weaker with time. The vocal cords cannot be held so consistently in position. They waver now in the same way that the muscles of his arm might if he were to lift a heavy weight. And the lungful of air that he expels in order to make those sounds is also smaller. Now that the recoil of his lungs is less powerful—like his skin, their elasticity too has been eroded—breathing out is more of an effort. The capacity of his lungs themselves has shrunk.

The evidence of Mr. Hudson's great age goes beyond that which I can see and hear from the end of the bed. His biochemistry is deranged. His kidneys are less impressive: less capable of filtering the volumes of blood that course through them, more vulnerable to insult. The toxins and drugs that they are supposed to remove are cleared more slowly these days.