Bits from a Trip – The Long Haul

This is the third post covering the Open Heart International kids’ heart surgery trip to Tanzania. You can find the first one here and the second one here

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The support for Tanzania is coming from all over, including Australia via Israel.

A heart operation is not just a work of hands or steel or thread that gathers together tissues to shape a new version of to and fro. We work also with light and sound and air.  We work in a sequence of small moments where each takes its place or all come together. Then at some time we leave the heart to take on the biggest share of all the work to come.

There is a point where the surgeon feels the operation is closer to the end than the beginning. In cases where the heart has been left still with a dose of potassium through the arteries there comes a moment where it is asked to wake. It is time to ask the heart if it is ready to do the work.

During part of that process we add breath to the lungs, holding them buoyant to try to bring multitudes of air bubbles back to somewhere we can remove them with a sucker. Then the surgeon asks for the flows through the bypass machine to fall and releases a clamp. The flows go back up and we wait as the heart gets the idea that it’s time to come back its calling.

In many operations we have an extra tool for looking at the heart. An ultrasound, casting particular wavelengths out to the back of the heart, listens for the returning echoes and constructs a picture of dots with all manner of resolutions and characteristics. The machine turns sound, distance and time into the light of a monitor screen where we can see the structure of the heart and what the chambers hold.

After the release, a wash of dancing pearls will tumble around those chambers. These are a few remnant bubbles of air. They are most often a note of a moment that will leave you with a bright speck of something beautiful on the screen. On some occasions this air becomes something else.

One of these pearls, a small bubble, may find its way out of the chamber and down an artery supplying the heart. Stuck within the narrowing vessel it blocks the normal flow of blood, maybe briefly. That can be enough to have the heart struggle and develop a rhythm that would be fatal in the absence of a heart-lung machine. One that needs quick action. Losing all coordination the muscle fibres mark their own time, twitching without any of the effect of a heart that pumps at a nudge from one conducting wave. Blood would not go anywhere.

On bypass this fibrillation is less critical but eventually it becomes harder to interrupt and get that heart back to work. At these times the sounds are a quick back and forth of plans and suggestions, requests made, drugs given and electricity added to the heart’s surface.

Twice on this trip in kids with hearts made into bags by disease, the air we see blocked the flow of blood and left the heart fibrillating. These were in hearts so large the strongest beat is felt low in the ribs and a hum makes its way to the fingers where you rest them. It took drugs, drains, wires, flow and electricity, jolt after jolt of current, to get the reset and time the heart needed.

They feel like long minutes when that first jolt doesn’t set things to right. Or the second. Or the third and fourth.

The operation is where the work might be concentrated but it’s the heart that has to do the rest of the running. The long haul later isn’t the first thing you think of when you contemplate an operation, but it’s the effort that asks much more.

We don’t count the charges. It is enough to know that the time after the air became enough. Those hearts got back to their reset point and took over.

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The local team taking the lead during this trip.

The Big Challenge

The Jakaya Kikwete Cardiac Institute has hosted us well. There must have been a lot of intense labour to set up the three floors. There are wards and clinics, operating theatres that join to the intensive care units and many of the machines and technology that you need to serve a people.

They have people creating a hospital that will serve kids in Tanzania well. They have moved across the country. The paediatric surgeon drives 90 minutes for his commute so he can offer his hands. Before he had the chance to do that he had to go to Israel to start his training in his very small subspecialty. He says that learning Hebrew is not that difficult really.

Their anaesthetist, Onesmo Mhewa, tells me Russian is quite difficult. It is Russia that he travelled to when he decided anaesthesia was his path and he had to find the best way he could to get it done. He now provides the anaesthesia and almost all of the medical drive for the intensive care unit.

These are just two people among many. They have cardiologists who are very clear-eyed about what they need. They have nurses who work every day at doing a bit more and claiming their vital role in that operating theatre or ward or intensive care unit with more confidence.

(They also offer frank life advice over fish heads. That advice provides the highlights you need to sustain a team when it’s late.  We promise them we wouldn’t want to be distracted by actually eating the fish heads while we learn from them.)

It must have taken a lot of intense work in the set-up phase to make things happen. The challenge now is the long, quiet effort. Setting up a hospital gives people bold ideas to latch onto. The buildings and walls can be admired. Machines can be used to wow visitors. Optimism can sustain things for a while.

What the clinicians trying to build this service will need is long-term support. That stage is a far more arduous request. This sort of care can chew up a lot of resources. The enthusiasm for providing ongoing funds is always under threat wherever you might work. At the moment for an outsider it looks like there are decisions made every day that are heavily constrained by the constant effort to find the resources for the mundane costs that all add up.

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Getting big this quickly requires continuous growth in funding.

That the team figure out a way to provide care is inspiring. They know that there are some things that separate really good services that don’t cost money. The way you encourage communication and work within a team. Identifying the heroes in each little part of the whole who will make everything in their section work better. This team has a very clear idea of how they can get there. Were their support to be dropped even a little though, the long effort will be that much harder.

I have little doubt that any of the teams from outside that have been coming to help whether from Australia, Saudi Arabia, Italy or Israel will all be very keen to see ongoing support for this group building something special on the edge of the Indian Ocean. It’s one of those aid trips you go on where you can see that you’ll be the smallest part of something that will take off.

A little bit more of the intense effort for now might be necessary but they’ve already made it clear they are ready for the rest of the work. We never even had that moment where we had to ask if they were ready.

 

Note:

I think it’s worth having a look at the Open Heart International post which mentions our colleague Onesmo. He is more than impressive.

If something about these trips makes you want to learn more, you could check out the OHI site. It provides comprehensive stuff on what they do and how people can help out either by volunteering or donating.

 

Bits from a Trip – The Masterclass

On the way to the hospital in Dar es Salaam there’s a sight that slightly jars. This is not to do with the minibus trip which starts at “I left the stove on and what if my house burns down?” pace and usually hits a point where the cars are so stuck you’d imagine they’d wedged themselves in a tar pit.

On the way there is a collection of shops, open for the bustling people in the small city that spreads out from the front gates of the hospital. This is before you get to the “Curare Pharmacy” which seems a bit curiously named if they actually know that curare is the root form of drugs that paralyse your muscles and would kill you if you were left to your own thwarted attempts to breathe.

These are shops, decorated in the preening advertisements of big American soft drink corporations, which are part of a cemetery. The old tombstones hold their air under shading low trees and swooning blades of grass, seeming to slowly crumble in that space. We never have the time to stop for an abstract reminiscence among those graves but we can see where they rub up against the stalls selling Coke and chips to eat first so you need something to wash them down. Like Coke.

The tombstones arrest all thoughts for a moment as the minibus picks up speed closer to the hospital, before clearing the security gates on the way to the Cardiac Institute and our waiting patients.

The other reason the first shop stands out is the name.

“The Rich Also Cry Shop”.

 

French Influences

The major operation we’ve been asked to help with this time around is for a particular condition called Tetralogy of Fallot. This naming dates back to a time when industrious people involved in medicine could claim signature diseases in a way that would stick.

Fallot was a French doctor who managed to put together a sequence of particular findings and have them named after him because he did that first little bit of detective work and put all four findings together. It’s possible he wasn’t the first to make the observation but he was the doctor who attached his name to the constellation.

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Notorious hipster, Fallot

To understand his four findings, maybe a refresher on heart anatomy would help. This is not to do with the poetic sort of heart anatomy that finds space for soaring highs and crushing, broken lows.

At some point while developing the heart develops into chambers. Some of these chambers are receiving areas and are called the atria. This is also not a real estate section. These atria receive blood. From the atria the blood passes through into the ventricles to hurry on to somewhere important.

When the blood returns at first it arrives at the right side of the heart, enters the right atrium, moves on to the right ventricle and from there jets out to the lungs to pass by the air sacs that provide space for the outside world. The layers between blood and air are so thin it’s as if a sheet of blood hangs suspended in the atmosphere, entering dark and spent and being painted bright red by an inrush of oxygen.

The blood, now embarrassed with its riches, returns to the heart but this time on the left side to be received in the left atrium. From there the next stop is the left ventricle, and then it flees onwards to the aorta.

So it’s fair to imagine whichever cartoon version of a heart catches the back of your mind and imagine a crucifix dividing it up into those four chambers.

 

The Four Stars of Fallot’s Constellation

The plumbing of the heart has many described variations. Sometimes the rooms are not walled off quite right and there is an additional doorway between two chambers where the blood shouldn’t be mixing. Any of the valves that act as doors between the chambers can be undersized, narrowed or have less swing in their function as a door. Whole blood vessels can be joined to the wrong ventricle.

In Tetralogy of Fallot there are four distinct findings. The right ventricle, usually a not particularly muscular muscle, has an overabundance of fibres. That’s the first part of the grouping. The area where the right ventricle leads up to the vessels to the lungs shows a degree of obstruction to the flow of blood, either below the valve or at the door or just about anywhere else. This is the second part. This makes the flow off to the lungs that much harder.

To go along with these two, the two ventricles have an opening between them, known as a ventricular septal defect. Part three. For many patients with such a hole in the heart, blood would mostly head back from the left ventricle to the right ventricle, circling back around the lungs.

For these patients though, the obstruction to those lungs means some of the blood feels it is easier to head to the left ventricle. This shunting of blood leaves it short of oxygen and the resultant mixing with the blood that did make it to the lungs that is in the left ventricle ready to head to the body drops the total amount of oxygen heading out to the body.

The last sign? The whole of the aorta, the big highway for blood to the body is shifted a little to the right, sitting a little over that hole in the heart.

 

Looks Blue and Squats

So these kids will sometimes be obvious because they have a hint of blue about them, thanks to that slightly underoxygenated blood. On top of that every now and then the overzealous muscle in the right ventricle can twitch right into spasm and when that happens the blood really struggles to reach the lungs. Less flow to the lungs means more of that oxygen-depleted “blue” blood getting out to the rest of the body and the patient actually turns blue.

At that point you might assume the patient does what comes naturally when you have something happening to your heart and lies down. Well the “doing what comes naturally” is definitely the case but they don’t lie down. They squat.

The reason they squat is pretty simple. When you squat you raise the pressure in the areas where the aorta is heading. That makes the pathway up to the lungs that little bit more interesting to that blood because just shifting across the hole in the heart becomes a little bit harder. Hopefully the blue loses some of its depth.

That “turns blue, squats and goes less blue” thing sounds perilous. It can be. At the same time, the blood flow around the body is generally continuous because at least the blood doesn’t slow down dangerously on the way to the lungs and stop reaching the left side of the heart at the rate you need to keep getting it out to the rest of you. That hole between the ventricles allows that blood to hurry on, even if it’s still a little blue.

 

So many blue kids …

The local team have been seeing lots of these kids turn up. Of the 88 operations they’d done in this spot, about one quarter have been for Tetralogy of Fallot, which is a really high number. You’d expect relatively straight forward holes in the heart to be presenting in overwhelming numbers. They’re not.

The locals have a theory about this. Kids with a relatively simple hole in the heart don’t present with obvious changes in colour or a history of squatting suddenly. They tend to look a bit malnourished, not grow quite as quickly and get lots of chest infections. There are plenty of other explanations for that. If they don’t get seen by the right person, they might just be put in a different category and die.

The right person might be a local doctor or health worker, but sometimes it takes the specially trained to pick these things up. Tanzania has about 45 million people with 4 or 5 million of those in Dar es Salaam. There are three paediatric heart specialists. They are all in Dar.

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The unnervingly anatomically accurate garden sign outside the institute.

So the current theory is that the kids with Tetralogy of Fallot survive to a point where their symptoms are obviously something heart-related, while the kids with a simple hole in the heart like a ventricular septal defect with no other associated heart issues don’t get a diagnosis.

 

That’s the Masterclass

Dr Sharau and team aim to develop their skills on the patients they are seeing now. They set up the plan for this trip – a masterclass in Tetralogy repair. Almost every day they’ve done another repair with a little support and guidance from our visiting team to try and make the repairs as good as possible. This is no small feat.

The surgeon needs to safely hook up the plumbing of the cardiopulmonary bypass system (sometimes popularly called the heart-lung machine) to keep blood circulating around the rest of the body during the operation. The team then needs to take the necessary steps to stop the heart and after opening a path to the outflow of that right ventricle they have to perform a number of steps to remodel that muscle and widen the outflow tract enough to make sure there is no ongoing obstruction.

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Dr Godwin Sharau, hard at that repair.

All while the heart is an entirely different state. After all, the heart won’t be empty, open and still once the operation is finished. If any level along the way isn’t right when you ask the heart to do its work again the obstruction will still remain but the defect between the ventricles will have been closed. That would mean there’s only a hard pathway up to the lungs with no chance for the blood to skip over to the left heart and keep things going.

The kid has a repair, but they have different issues.

For this trip things look to be going pretty well. Godwin and team seem happy with what they’ve achieved. The next challenge is to figure out how to make sure those patients who aren’t even reaching them get picked up with their much simpler holes in the heart. That will require work across a whole system.

Because there are kids out there who are never reaching the front gate of that hospital. They’re stuck somewhere else,maybe near some shops or struggling to get through the day, waiting to be found. It should never come to that.

 

Note: 

The first post from this trip is right here.

There are way more stories from this aid trip hitting the screens over at the Open Heart International blog too. I reckon it’s well worth a look. Of course, while you’re there, you could consider chipping in (*nudge, nudge).

Start Lines/Finish Lines

A trip to another country to work on open hearts starts with packing and checklists. It starts in a storeroom under a shed where they keep boxes and boxes of needles and tubes, blades that open chests and drapes to cover the skin. We check off spreadsheets and try to imagine exactly how many small plastic tubes we could want to place in veins and arteries and how many times we will need a second go.
Three months ago we wrote on lists and checked expiry dates and taped the boxes in two different directions. We stacked them on pallets and trusted that things we’d left before would still be found, somewhere in a storeroom.
 

Glamour starts here.

 
 The Real Start

A trip to open hearts starts earlier, now that I think about it. This trip started at least a year ago. Around the time of the last trip, where the seeds were sown to move the whole thing from Mwanza, curling around the shore of Lake Victoria, to Dar es Salaam where the water belongs to the Indian Ocean.

The local team had a plan that did not include machines that could not be convinced to work and time offered in theatres that would never materialise into actual time and space. So they moved and let anyone who was helping them know that they had turned the light on somewhere else.

The planning started a year back now and only looked like having a name change into an aborted mission twice along the way. Once even after the boxes were packed and on their way. Then Tuesday came and we were here and we found holes in hearts that could be patched and sewn so the blood pumping around the heart would follow better directions.

The Real Finish
Not every aid trip is the same. The Open Heart International trips are mostly not about serving lots of people right now. We volunteer to come and do a particular job which is to put ourselves out of work.

The aim isn’t to turn up and do lots and lots of cases. There’s probably a part of that which is about logistics and funding. It takes a bit of effort to get here from Australia and bring all the gear.

The bigger reason is that it doesn’t matter how often we drop by for a week of operating, we can’t meet the needs of Tanzania. You can set up trips where you aim to do 6 or 7 operations a day and leave 60 fixed kids but it takes a pretty big team and some resources to boot. The sort of resources you have when the guy in charge up Saudi Arabia way sends a team in his private jet with as many widgets and people as you need to do exactly that. That happens next week. That’s not a joke.

Ultimately even those efforts can’t serve Tanzania. A team that was here every day of the year that could look after patients every day, not just when a couple of weeks line up, is the real answer.

 That’s why our week is more about helping the local team working at Jakaya Kikwete Cardiac Institute. We’re not here to take their work. We need to be spending time supporting in areas they want to build their skills the most. This means less operations, but making those operations count for every member of the team here in Dar es Salaam.

 

Everyone here keeps commenting on how cold it is.

 
For this trip they’ve chosen the type of operations they want to focus on and they’re really working on the intensive care side. This isn’t to say they aren’t doing the other work. They do most of everything. So while we packed a surgeon (only recently, not in the boxes) the local surgeon, Dr Godwin Sharau, leads most of the cases with our guy, David Andrews, providing assistance and clever insights (and no, I won’t comment on whether complimenting a surgeon is a contractual arrangement).

Our nursing staff in theatres do their job in conjunction with the local nurses. Our perfusionist, the Red Leopard*, takes up most of the work of driving the wheels of steel (not interesting ones that would drop sick beats, just the ones that replace the work of the heart while the surgeons operate on it) but is also pretty much continuously chatting as he provides teaching for his local colleagues.

The anaesthetists? We just step in for bits when the local guys want us to keep things ticking over. Probably. We’re called upon mostly because the local anaesthetist who does most of this work is spending extra time in the ICU. It’s the ICU they want to focus on.

The goal? About two operations a day. We particularly want those operations to be the sort that mean the kids will end up getting on with school and a full life because all they needed was that pesky heart plumbing re-plumbed.
The bigger goal? Five years. That’s how long we want it to be before we’re out of a volunteer job. Our five year plan is to aspire to being tourists only. 

 

PS I feel like the name Red Leopard could do with an explainer. Our perfusionist, Brad, is a tall member of a tribe defined by their ginger colouring. Upon receiving a compliment from one of the local staff that she thought “his colour was good” he took it, as any proud redhead would, as a sign of admiration of his particular variant of freckled glory. The compliment was directed at his shirt. His very blue shirt.

 It did draw the rest of us to comment on the extreme usefulness of having an arrangement of red freckles perfect for breaking up his outline if he wanted to hide in the wild in these parts. A bit like a leopard with their spots. A bit like a red leopard if you will. We were just trying to be helpful, but he seems to have taken to it.

 

Chui mwekundu in his natural habitat

 
 That said, I think it’s probably better if he relies on his skill with the heart-lung machine than hiding in the long grass to earn his supper. 
For a broader take on this trip you could check out the Open Heart International website at www.ohi.org.au. They have a daily blog running and Brittany is starting to get stories from some of the kids and families. 
 
 

Talking Loud and Saying … Mostly the Wrong Thing

It doesn’t take that much to give people the wrong impression. You can drop a few pertinent facts that would otherwise give people the chance to form a full opinion.  You can make sure to compare almost-like with almost-like and say they’re the same. The way you select what you’ll mention frames everything that follows.

The way you frame it is the same in reverse though. When you want to discuss a topic with and leave the “right impression” the things you highlight, the studies you choose to quote, and the way you present them to the next person who doesn’t have the time to go through every reference will be a big part of the message they take with them.

The obvious spot where this come into a PhD is in the thesis. Perhaps particularly in the literature review where the stage for everything that follows is dressed and lit. There’s an awful lot of time in the PhD spent obsessing over what the evidence says, where the balance lies and how to present that fairly. It matters.

What Can You Say?

This all came to mind this last week. Around these parts there’s a show which likes to tout itself as our the apex of all things science show. It’s called “Catalyst” (I’m going to let you speculate on what particular reactions it might speed up). This last week they chose to talk about the risks to your health posed by everything that includes “Wi” and “Fi” in its tech specifications.

This is a pretty legitimate thing to talk about. It touches on lots of interesting stuff about how you assess and communicate risk. Except this is the frame they built to hang their pretty picture:” … “no evidence of established health risk,” is not the same as saying it’s safe. Sadly, guaranteeing safety is something not even our safety authority is willing to do.”

This is a fundamental misrepresentation of how evidence can be applied to assess risk and it sets an impossibly high bar. When I chat about anaesthetic risk with patients or families I can’t promise zero risk for the healthiest kid that turns up starving, waiting for their operation. I can only ever say that the risk of bad things happening is very, very low. I can’t say that nothing has ever been shown to happen under anaesthesia.

But that’s what they were after with this program. A complete and total guarantee of safety. Not just a heavy preponderance of multiple studies suggesting no measurable change in risk. Not just a lack of reproducibility of those few studies suggesting we should worry. Not just a lack of a biologically plausible mechanism but some sort of guarantee etched in a rare element more precious than humanity itself.

Which awful consumer hell version of critical thought have we reached where that’s the only acceptable option? Next time you walk through the city you’d better take precautions you won’t be seriously injured by a falling baby hermit crab. Sure there’s no plausible evidence that it’s a risk to worry about, but no one’s given you a guarantee, right?

Looking Sideways

What followed was a sequence of failures. The reporting was clearly heavily influenced by a single researcher. It opened by suggesting the heart has activity just like a pacemaker. They seemed to make the difference between ionising radiation, which can definitely alter DNA, and radio frequency, which doesn’t, a bit murky. There were claims the industry was pushing back, just like when people tried to stop smoking on planes.

The suggestion was made that the flatlining rate of brain cancer was just a result of the long latency of the disease, that would extend many decades from here. Just look at the delay after the atomic bombs we were reminded.

Except that the evidence on that front was misrepresented, not mentioning the steady rise in cases until a peak, and that some of the original research excluded all the cases of cancer from the first 13 years after those events. Not much latency.

They referred heavily to a particular study, the Interphone study, which suggested a possible link in one type of cancer in those who reported heavy use. They could have made more of the fact that this study relied on self-reported mobile use up to a decade earlier, including in those already diagnosed with a malignancy. They could have made more of the fact that the conclusion of the study reads “Overall, no increase in risk of glioma or meningioma was observed with use of mobile phones. There were suggestions of an increased risk of glioma at the highest exposure levels, but biases and error prevent a causal interpretation. The possible effects of long-term heavy use of mobile phones require further investigation.” It’s all about the frame you choose to hang.

When we got to the section of the program where the featured researcher, Dr Devra Davis, took us through the all important featured image of a child holding a mobile phone, then showed the terrifying colour bands, then realised it was a stock image available online with some added lurid bits and no real discussion of the quality of data, the whole thing was fairly cooked.

Capybara

Go ahead, put on a display. Don’t assume we’ll be impressed.

It was a fail. It was the sort of fail that would have had Fox Mulder slowly bleeding from an ear if he wasn’t busy having placebo-driven ‘magic mushroom’ trips to higher planes of consciousness so he could communicate in Arabic with brain injured coma patients (actual story line from the same week, no exaggeration).

Of course it’s also well established that the audience takes from any reportage the stuff they’re inclined to believe in the first place. Which means plenty of people would have been very persuaded by this coverage, rather than very persuaded by the holes.

The most distressing thing about all of this is that the biggest fail might not even be with that TV program. The biggest fail is possibly with the scientific groups who should be making themselves useful to people.

Tell Us About Risk

The International Agency for Research on Cancer are the ones who put out the information perceived as being all about risk that causes so much confusion. The really absurd bit is that everybody thinks it is about risk, but it’s not really about risk. It’s about how strong the evidence is.

This group is charged with looking at the evidence that any particular thing is related to cancer and break it up into any one of 5 groups: group 1 “carcinogenic to humans” meaning “we are pretty sure they have have the potential to cause cancer”. 2A gets “probably carcinogenic to humans” which in this case means “well there’s some evidence but we just can’t be sure”.

Group 3 is where you put all the substances that can’t be classified due to a lack of data and group 4 is for “probably not carcinogenic”. There’s one substance, caprolactam, in group 4.

So we come back to group 2B, which is for those things that are “possibly carcinogenic to humans”. This is somewhere between “there’s some evidence but we just don’t have enough to know where to put it” and “there’s not enough data to even guess”.

So it’s a dumping ground, a rubbish tip for over 250 things they’ve considered. Things like coffee. Or pickled vegetables. And that’s where WiFi comes in. About as dangerous as pickles.

To make it worse they’re not even mentioning the level of exposures that might be worth your time, or strength of associations in any of the groups. It’s really just about how much evidence is out there. Which means something with pretty much no evidence gets called a possible carcinogen. And everyone thinks quite reasonably that they’ve assessed risk, when they’ve really just assessed papers and words.

They just haven’t bothered to make an effort to communicate that properly.

Isn’t that an even bigger fail? Who are they trying to help or inform? What’s the point if the logic is inaccessible?

What’s the Conclusion?

The “flagship” science show failed every which way. The IARC fails to make things clear. Over and over after each deliberation, probably fuelled by “possibly carcinogenic” coffee. The show’s producers failed because of the way they framed everything they found. The other group failed because they don’t seem to bother even thinking about the frame.

In later responses, the ABC mentioned that a couple of experts who would have dismissed the links between cancer and WiFi were invited and declined to appear. They implied that they passed up an opportunity to have that alternative heard.

That might be true but the program ended up with a single voice presenting the view that more faithfully represents the consensus position. Not much effort there. It might just be that Catalyst, having previously had a program around statins and cardiovascular disease pulled offline for its lack of adequate representation of the evidence, has burned its credibility when reporting science. They’ve discouraged researchers from going on. A flagship, huh?

So what lessons do I take away when reflecting on how to present the evidence around a PhD? Perhaps the best advice comes from another science journalist.

Rose Eveleth writes and podcasts all over the joint. In this post at Last Word on Nothing, she describes a story that grabbed her interest on looting in archaeology. The author was very convincing on the subject. It seemed like time to pursue it.

Then she found someone else who flat out laughed at the idea. She disputed lots of the facts in a coherent fashion. She highlighted the complexity at looking in enough depth on the ground to actually represent the truth of the story. The story appealed, the evidence didn’t back it up. So the story got left behind.

Perhaps that’s the key. As it says in the final line of that post “always look for the person who will laugh at your story”.

If you can explore all the issues raised by that laughter and then communicate the research faithfully, that might be how you get there.

 

More Reading:

Here’s another one of the responses to the initial program.

The National Cancer Institute has an information page that seems pretty useful too.

Here’s a pretty useful thing on those IARC categories as well as a better way of showing the information, this time as it relates to meat.

That image was from the flickr Creative Commons area and is unaltered from the post by Heartlover1717.

Looking for Death in Little Cells

When we do the bit of kids’ anaesthesia that involves the drugs, we’re generally not trying to poison our patients. That was something you probably assumed. We use lots of medicines as part of anaesthesia that have their own side-effects and potential complications but they’re generally things we can make adjustments for and are only likely to cause issues for a small percentage in the first place. We can get on with the making people comfortable part of the job confident that we’re not causing big, long-term complications for simple cases.

Which is why there has been a lot of quiet sweating going on since one very particular possibility was raised: what if every time we gave anaesthesia, our drugs were causing little deaths in brain cells?

 

Talk to the Animals

A lot of this has come about from talking to animals. Well, not so much talking as giving them an anaesthetic trip and closely examining neurons at a later moment under some form of beady microscopic vision.

It turns out that when you expose very young animals to a lot of our anaesthetic and sedative agents (ones that can’t reliably produce full blown lack of awareness) cells from the central nervous system die. The initial suggestion was that something about the anaesthetic agent switched on or accelerated a thing that can happen in cells anyway – apoptosis (a process of cell death). Apoptosis is actually a normal bit of development. Except for when there’s too much and it’s triggered by other agents.

There’s more than just a microscopic version of this picture though. Rodents exposed seem to be not quite as good with learning and memory behaviours down the track. This is … not great.

Animals don’t always speak clearly though. Well, not without a bit of CGI or some very good peyote. Lots of flaws have been pointed out in that animal research. The first complaint was that the doses of anaesthetic agents used weren’t equivalent to what gets used in babies, or was even the equivalent of a huge overdose.

Sometimes the duration of anaesthesia equated to a brain development epoch of weeks and weeks in the life of a newborn. We don’t give anaesthesia continuously for weeks. It’s hard to get good coffee into the theatre late at night, you understand.

There were even concerns that the ages of the animal subjects didn’t match newborn humans because of the relative maturity of each. A newborn rodent might just equate with the sort of newborn human that’s about 4 months away from being newly born. All of these things make it hard to know what to make of the animal information.

The changes in the cells are real though and a worry. So what was the next step? Try to look at humans. Starting with humans that we sort of already know.

 

Allsorts

The next wodges of research that came out were mostly observational studies. This would be those sorts of studies where people known to be exposed to anaesthesia get followed up to see if they show signs of injury to those precious brain cells.

The findings? Well, mixed. Some studies have seemed to suggest there might be subsequent issues with neurodevelopment. Some have found no evidence of an issue. Those ones that might show an association also have a lot of fuzz about them, partly because they tend to show an association in those patients who have multiple anaesthetics.  The sorts of patients getting exposed often have other significant illnesses.

The studies often rely on pretty non-specific outcomes too. Things like grades at school or did they turn up for tests. What if the kid just didn’t get to school that day?  It’s hard to control for public transport scheduling in your observational study.

Those confounders have always got in the way. So wouldn’t it be good if we could try to get away from those splotchy bits of paint now messing up the redecoration job?

Three owls Tambako.jpg

Well two of them have got the idea.

Needles and Lumps

Just as well Australians came to the party with some observational work. Well, other people might be coming up with research too but a team led by Prof. Andrew Davidson at The Royal Children’s Hospital in Melbourne has done some excellent work to look at this.

Across a bunch of hospitals, small patients under 3 months pitching up to get hernias fixed up (yep, hernias aren’t just for old people wearing girdles) were randomized to one of two anaesthetic options – general anaesthesia with the smelly gases or an injection at the back while awake to make their lower half completely lacking in sensation so they couldn’t feel stuff. So that’s one group getting the knock out stuff, and one group avoiding it entirely.

That latter one is a legitimate technique for providing anaesthesia in this group so they weren’t coming up with anything revolutionary on that front. The advantage of choosing a procedure like this is that it’s mostly not associated with other health problems, you probably only need the one operation and you don’t need lots of other pain relievers or confounding medications. They’re also not long operations. Well, mostly.

They got a pretty good number of kids into it too (although that took 5 years and lots of participating centres). 722 kids randomized (with a few dropping out along the way naturally). The plan is to follow the kids out to 5 years to see if there’s a difference in cognitive function and this time around they’re reporting on the results on the 2 year screening.

 

The Report Card

So what about those findings? Equivalence. Sweet, boring equivalence. Which is what the study was set up to try and look for. That was across the combined cognitive score as well as the subgroup bits on motor scores, language scores and adaptive behaviour scores.

Phew. Wrap it up. Send that coffee I mentioned earlier. It’s all good.

Well, not quite. This study is a huge and impressive effort, but it’s not at all the end of the story. For starters, it doesn’t answer that key question about dose and exposure: get exposed to long anaesthetics (rather than the average 57 mins here) or lots of them and this isn’t your study. It’s still reassuring for the vast majority of young kids who only get the sleepy gas once though.

The other thing is that screening for cognitive stuff is probably best done when the kids are a little older. Like 5 years old. Which is why the investigators plan to do just that.

The other obvious question is whether there are particular types of developmental issue that are more common. Autistic spectrum disorders or cerebral palsy are the candidates probably of most interest. This study has no hope of really assessing that but didn’t spot a difference.

I can say that we’re not routinely inducing the death of all of the brain cells every day we pick up the mask and kick off kiddy karaoke time. Well, not with the drugs anyway. Can’t comment on the singing.

And like pretty much every other bit of research in this area, I can also say now that we have some better answers, we just need a few more.

 

Notes:

That owl image was posted to the Flickr Creative Commons area by Tambako the Jaguar and is unaltered.

As for the references, the original paper appeared in The Lancet and is here:

Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopment outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multi centre, randomised controlled trial. Lancet 2016;387:239-50. 

There’s quite a nice accompanying editorial too:

Warner DO, Flick RP. Anaesthetics, infants, and neurodevelopment: case closed? Lancet 2016;387:202-204.

I’ve also posted on one of the earlier observational studies here.

 

The Number

When I was 12 I hit the number 64, a milestone frozen short by an attempt at the run you could only contemplate in year 7 cricket emboldened by thirty chaotic throws from the opposition on prior attempts.

My standard warm up prior to a concert used to a require a minimum of 2112 practice strokes as single, interchanging notes. Right hand then left hand with my 5A sticks.

When I finished Uni I knew exactly how many exams I’d stretched my brain through, contorting memory and recitation to suit an old tutor’s conception of physiology or best evidence. I forgot the number within eight days.

There are days when I have known the exact pacing of a room in a hospital, not all of them wearing the informal blues of the operating theatre in a manner of their own formality.

We measure all sorts of spots in space and time with numbers that are often not much in the here and now. Which I guess is why I mention that this is post number 100 on this pretty random site.

Where it Began

This thing started out mostly to set up a place to talk about the PhD research. I started with bold aims to share everything I could about it and let people know the inner workings of the process.

Then by about post number two I figured out that if I tried to write about my research journey on every post I’d pretty much just be writing “week 84, still not that great at research”. Except I would have started writing that at week 7 and just built from there.

So I can’t claim there’s been much discipline about it. As far as a research blog goes it’s a rambling mess. I guess it’s a little like the way pets end up resembling their owners. Or the other way around.

There has been a little bit of stuff that says I’ve learned about research along the way though. It’s certainly made me think about ways to get better at the other elements of trying to be more academic. So hidden amongst those 99 posts I can find a whole host of things that are actually about the PhD or fitting it in or thinking small or grants or Italy or doing stuff that might not work or presentations or conferences (and trying to think about them before and after) or more on grants or feedback or even another thing on grants stuff).

So it worked. It did the job. I guess.

But what do you get?

The biggest benefit from blogging has been the things it forces me to do: it makes me write and it makes me look up and around. Writing regularly has put a whole set of new skills at the tips of my hand sausages. All of it very transferrable to writing in other contexts.

I also work very much in niche areas but trying to think about writing for people outside that little club with the unmarked doors and access to controlled substances has also been very useful. Then of course there’s the other audience and inspiration you find. The blog itself has led me to a range of researchers and other clever people who have informed my thinking, made me laugh, taught me how to do lots of stuff better and ended up inviting me to work.

That’s a pretty good return on ranting.

The Bonuses

Along the way there have been a few bonuses. I’ve had the chance to write about charities, rant on other sites like Croakey here and here, and test out non-existent stage skills while learning media stuff.

I would probably not have looked much into surgery in space or how to convey consciousness to non-anaesthetists or unboiling eggs if it weren’t for this blog. I wouldn’t have had a spot to put up thoughts on ketamine and global health, which ended up being the most popular thing ever on this site.

It’s given me a spot to talk about aid trips to Rwanda (starting here for a few posts) and Tanzania.

And of course I got to write something that feels like it mattered, both here and in its Guardian version. This really, really mattered. To me at least.

Stuart Richards

I’m still trying to figure out what this is too.

Where now?

Well, actually I don’t know. There’s still a PhD and still the project. I’m still learning stuff on that. I’m also now working on two other sites that are more medical though, The Collective (for the prehospital and retrieval work) and Songs or Stories (for kids’ anaesthesia). That stuff gives me a chance to try and chip in usefully in those niches. It does take a little time though.

I’d also like to try and get better at writing. That might mean trying a different kind of writing challenge. Who knows what that might be? I’m not sure where this site fits in.

Still. It’s an OK century. Particularly when you remember I’m still not much good at research.

 

Notes:

That image of the eagle probably wasn’t taken just before it ripped apart something meaty but was on flickr.com Creative Commons and is unchanged from Stuart Richards’ effort.

 

Unboiling Eggs and Making Medicine Local

A few truths. Winning a Nobel prize is pretty hard. You can’t clap with one hand.  You can’t unboil an egg.

Well winning a Nobel prize is probably pretty hard. The one hand thing though? Everyone knows you can clap with one hand. And of course eggs can be unboiled with a bit of vortex fluid action to do unfold some proteins. You all knew about vortex fluidic tech right?

(In a second I’m going to go to the next little heading, but I’m going to point right at the bit where you noticed I’m slightly misquoting  “you can’t unscramble an egg” to suit my purposes. Let’s just awkwardly nod in the direction of that little switch and move on in a spirit of togetherness.)

Egg

Now you don’t need to cry over spilt eggs. Wait, that’s wrong too.

Unfolding Your Way to the Ig Nobels

We can’t say if unboiling an egg will warrant a Nobel of course but it has already garnered an Ig Nobel. If you’re not familiar with the Ig Nobels they are bestowed yearly to celebrate some of the more improbable bits of research. They’re designed to celebrate research that makes you “laugh and then think”.

If you’ve got a minute you can work your way through a list of winners, all the way from the first recorded case of homosexual necrophilia in a particular kind of duck to the Italian team who demonstrated mathematically that organisations would become more efficient if they promote people at random (2008, Management Prize) or the group who published the seminal work on treating uncontrollable nosebleeds by packing the nose with strips of cured pork (2014).

Bacon. Is there anything it can’t do?

Now when the Vortex Fluidic Device (VFD) hit the news it was for that impressive and seemingly implausible ability to unboil an egg. It’s not that simple of course. When you boil an egg, you rearrange the proteins. They tangle differently.

The team involved here added something to a boiled egg they prepared earlier to liquefy the egg white. They then used the VFD to spin the fluid incredibly fast. As the liquid spreads out layers of different spin speed are created. The shearing forces between those films encourages folding and refolding of the proteins until they pretty much go back to what they once were.

It’s easy to see how it fulfils the brief of making you laugh. What about the making you think?

The Serious Bit

This technique isn’t mostly about food rejuvenation. Early in the piece the researchers mentioned that there would be applications for pharmaceuticals and biomedical areas. Drug development is mentioned. Cancer drugs in particular with exciting stuff already released on that.

Well the team has subsequently published something that isn’t so much about cancer. It’s about local anaesthetics. Y’know the things in the cocaine family that make you numb before the dentist does their bit.

Why go there so early? It’s not exactly cancer. Well I expect it wasn’t made a priority on the basis of world significance but there’s still a lot that can be gained.

Perhaps an example. Every couple of years a team of colleagues heads to a rural spot in India to fix up feet. Feet like this.

IMG_1129

Bilateral congenital talipes equinovarus. Also known as clubfeet.

Fixing up feet like that in that setting requires a fair bit of cutting. Wedges get taken out of bones. Or bones just get removed.

A key part of making kids comfortable for that is the use of local anaesthetics and not just the cream on the skin that’s become popular for making a tattoo easier. Local anaesthetic administered more centrally (either in the fluid around the spinal cord or in the space just outside the spinal cord, an epidural) makes the lower half of the body numb for a while.

When we do those trips we tend to take as much of the supply with us as we can. That’s because we can’t always rely on local stocks. Run out and the operating stops. On one occasion local strikes and roadblocks prevented all restocking in our little outpost. Replenishing our local anaesthetic supply relied on a guy and a motorbike finding his way through a tea plantation overnight. (For reasons I can’t quite understand, that adventure seems like the rider needs to have a scarf. Definitely a scarf.)

A glimpse of a future where some medicines might be locally produced with a device about as big as a suitcase is fairly exciting. No more supply chain to fret over. Drug production in real time where it’s needed.

That sort of technology is way more exciting for medicine everywhere than the latest surgical robot. It’s a bit like repurposing drones to deliver medical supplies to spots where there aren’t roads. Technology that promotes better access to healthcare will provide far more benefit to far more people than the newest generation machine that goes bing.

And if you can recycle a few eggs along the way, that’s just a bonus.

 

Notes:

There’s more on unboiling eggs here via Scientific American. Or you can watch this video version.

The image by Daniel Novta is unchanged and I found it on Flickr. It is under Creative Commons.