Tuesday, September 8, 2009

Many are cold but few are frozen

Surgeon Rear Admiral Frank Golden OBE is a world authority on survival at sea and is credited with unravelling many of the mysteries surrounding immersion hypothermia. He talked to Eimear Vize about his acclaimed research and life in the Royal Navy
A born raconteur, Corkman Frank Golden vividly evokes one particular night spent at sea in near gale conditions. The waves were climbing to 13 feet and the sea’s incessant battering had caused the floor of his life raft to peel away, leaving him clinging to the inner-side of the raft tube, awaiting rescue. The story is even more remarkable when you realise that the Irish doctor didn’t have to be there. In fact, he volunteered for the entire experience.
Golden spent much of his career as a medical officer in the Royal Navy (RN) involved in cold-water survival research. He believed that the best and most accurate way to test the safety and endurance of a new life raft being proposed for Her Majesty’s sailing fleet was to spend a week inside, adrift on the open sea.
“Simulated conditions may be reproduced in a specialised laboratory ashore but all the variables likely to be encountered in a real life survival situation can only be satisfactorily replicated at sea. We were testing some new life rafts being introduced to the Royal Navy ships to determine the most appropriate type, in particular the thermal habitability qualities.
“In World War II, over two thirds of all Royal Navy fatalities escaped their sinking ships only to die subsequently in the survival phase from hypothermia. In wartime, modern search and rescue facilities may not be readably available so survivors may have to spend a considerable time afloat before rescue,” he explains.
The University College Cork graduate notes, with annoyance, that the thermal protection built into most modern life rafts is deficient for longer-term survival. However, these still meet existing, lax international standards.
Now retired, Frank recalls the life raft trials as hard, challenging but extremely satisfying. And, like many an old salt, he has a story to hand about a particularly hairy moment: “One night, in a Sea State Seven, the floor began to peel off the raft and we were quickly up to our armpits hanging on to the inner side of the raft tube while waiting to be rescued.”
Such assiduous methods were well rewarded, however. These real-life trials resulted in the thermal protective properties of the rafts being significantly modified and upgraded before they being fitted to the Royal Navy’s ships.
Indeed, Frank’s efforts over the decades has translated into a myriad of life-saving benefits for those who make their living or take their pleasure from the open sea. The high-ranking Naval Officer has come up with practical solutions to many of the critical factors leading to immersion-related deaths. His efforts have also significantly enhanced operational protocols for international air-sea rescues.
Dr Golden has received worldwide acclaim for his research and numerous awards, including an OBE for his work on sea survival; a Gilbert Blane Medal from the Royal College of Surgeons for his research in post-immersion death; and a Stewart Memorial Prize from the Royal Aeronautical Society for his work on the rescue of immersion victims.
Indeed, the name of Surgeon Rear Admiral Frank Golden is internationally synonymous with research into cold-water survival. He has quiet literally written the book on it with Survival at Sea being published in 2002, some nine years after he retired from his RN post.
Prior to hanging up his hat in 1993, the Munsterman spent 30 years in the Royal Navy, directing its survival medical research department whilst also acting as consultant advisor in applied physiology. He also advised government departments and interested bodies – including the UN International Maritime Organisation (IMO) – on matters pertaining to survival at sea.
He quips that it was his bank manager who acted as an inadvertent recruitment officer for the Royal Navy when the recently qualified medic was still struggling as a GP trainee.
“I was being paid a pittance and my bank manager said he’d like a chat with me, during which he pointed out that on looking at my monthly pay cheque and my essential outgoings, it was quite clear that I would be 80 before I could change the figures to black,” Frank laughs.
“He suggested – ever so politely – that I should go away and get a decent job! I decided then to do a short service job in the Navy to help reduce my overdraft.”
It seemed a sensible career choice by any standards until Frank readily confesses that he was petrified of the sea – a phobia that had been with him since childhood.
Born and raised in Cork city, like many children he enjoyed trips to the seaside and spent many happy family holidays fishing in Ballycotton. But the pernicious potential of the sea was brought home to him repeatedly as he weathered the trauma of the summer drownings of a number of friends and acquaintances.
“I was a very poor swimmer myself in my youth. I was tall and thin with negative buoyancy – I swam like a stone and thus became very phobic about water. I think that was what stimulated a latent interest in the nature and causes in immersion- related drowning deaths,” he muses.
Frank, who graduated from UCC in 1960 and travelled to the UK thereafter, recalls his life was ‘suddenly transformed’ when he donned the uniform of a Royal Navy Officer in 1963.
“It took me sometime to get over the transition from pauperism to the status of being a Naval Officer with an obvious solution to my monetary problems. The work was exciting and very stimulating. In addition to being paid a very good salary, over an 18 month period I cruised the world visiting locations that included the Mediterranean, Middle East, the Asian subcontinent, Africa, the Southern Atlantic (Tristan da Cunha, and South Georgia), Antarctica, and the east coast of South America.”
A subsequent posting to the Navy Air Station in Culdrose, Cornwall, offered a sample of air-sea rescue work. The young Irishman was soon hooked.
One of the major rescues he participated in involved the stricken oil super tanker, The Torrey Canyon, which went aground on the rocks between Lands end and the Scilly Isles on 18th March 1967.
I was flown out to The Torrey Canyon to provide immediate medical care to members of the salvage team who were injured following an explosion on board. The leader of the salvage team unfortunately died from extensive internal injuries before I could get him ashore. The remaining members of the salvage team all survived,” Frank recalls.
“It was that helicopter work which reawakened my interest in immersion deaths. It quickly became apparent that all the immersion/drowning casualties did not exactly conform to the information in the medical textbooks. A subsequent posting to the RN Air Medical School, which had a refrigerated pool, presented me with a opportunity to further my enquiries.”
Through personal experimental investigation Frank learned a great deal about ‘hypothermia’. Although the problem of hypothermia in sea survivors was well recognised by the end of World War II, there were still a great number of associated unanswered questions. These included the most basic one: Why did people die after just a few minutes of cold-water immersion?
“The popular belief was it was due to hypothermia but I knew from my experiments that even in ice-cold water, body temperature took some time to start dropping following immersion,” says Frank.
And the medical officer was troubled by many other questions. “Following cold water immersion, what was causing the muscular incapacitation, even in people who could swim, which prevented them swimming even five to ten meters to a safe refuge?
“Why did competent swimmers die after 20 or 30 minutes of swimming? Why did people who were wearing approved lifejackets drown?
“Why did about 20 per cent of those rescued alive – especially by helicopter – die during or shortly after rescue?” 
These puzzling phenomena were what drove Frank’s search for an understanding that he knew could be used to save countless lives at sea. In 1979 he undertook a PhD at the University of Leeds focusing on the physiological changes in immersion hypothermia with special reference to factors that could be responsible for death in the early re-warming phase. 
He explains that it was only after years of detailed studies at the Air Medical School and in open water situations that he was able to provide the heretofore-elusive answers (see panel right).
Another area of Dr Golden’s research involved studying the problems associated with escape from submerged vehicles, particularly helicopters. A key collaborator in this work was Frank’s PhD student at the time, Mick Tipton, now Professor of Human and Applied Science, University of Portsmouth.
Their pivotal research led to the development of an underwater escape device that provides the individual involved with sufficient air to facilitate escape, and it is now used extensively in the offshore oil industry.
Frank is rightly proud of his work. He has not just identified critical factors leading to immersion-related deaths, but used this new understanding to deliver practical solutions. One of many involves devising a simple method of lifting a victim in a horizontal attitude. Frank’s technique is now used worldwide by many helicopter sea rescues.
The information derived from the Irish pioneer’s many tests and experiments has also played a significant role in the design of much of the modern maritime lifesaving equipment, and he is frequently consulted by a variety of national and international organisations on matters related to survival at sea.
“My respect for the sea has increased enormously. I despair of many users who don’t follow the advice that is readily available, or who fail to learn the lessons from all those situations where lives have been repeatedly lost by inaction, carelessness, and the ‘it’ll never happen to me’ attitude. I could go on and on.
“The first and most important thing is to understand and respect the environment, and never think ‘it’ll never happen to me’. Identify potential disaster scenarios and rehearse the most immediate and essential actions required to prevent them worsening,” he advises.
Of course, the nature of some of Frank’s experimental work has precluded him for taking his own advice at times. A case in point was outlined at the outset of our interview when he recalled clinging helplessly to a disintegrating life raft with the sea surging around. But Frank is not one to go overboard without purpose. Asked if any of his perilous encounters were truly touch and go, he replies sagely: “Not really, although I’ve had several exciting ones.”
Essentials of Sea Survival
In 2002 Frank Golden co-authored the authoritative international handbook on survival at sea with his friend Prof Michael Tipton of the Department of Human and Applied Science at the University of Portsmouth.
Each year, 140,000 water-related deaths occur worldwide and Essentials of Sea Survival is a compelling, informative, and comprehensive guide that can help avoid disaster, even in worst-case scenarios.
Drawing on historical anecdotes as well as published scientific research, it examines the nature of the many threats confronting the survivor at sea and outlines, in lay terms, the methods that can be used to prevent or minimise the dangers.
Essentials of Sea Survival is a fascinating blend of historical anecdote, scientific fact, and practical application, including step-by-step explanations of how to safely abandon ship, board a life craft, dispense water and rations, divide duties, conserve energy and strength, and proceed with a successful rescue.
Scientists and academic readers are likely to find the technical research of interest, whilst the real-life scenarios will be striking for recreational water sport participants.
The sea survival mysteries unravelled by an Irish doctor
Surgeon Rear Admiral Frank Golden’s research has offered vital explanations for many of the mysteries that surrounded sea survival and hypothermia.
He discovered that difficulties experienced on initial cold-water immersion are associated with cardiac and respiratory reflexes resulting in tachycardia, intense peripheral vasoconstriction, hypertension and arrhythmias. These responses may result in an incapacitating cardiovascular accident or cardiac arrest in susceptible individuals.
“The respiratory response included an immediate, uncontrollable, substantial inspiratory gasp response, followed by hyperventilation during which breath-holding is impossible, frequently resulting in aspiration and drowning, especially in turbulent water,” the sea survival expert adds.
Frank also discovered that the swim failure, which often saw strong swimmers fail to make it five or ten metres to safety, is due to peripheral neuromuscular cooling before deep body temperature fell substantially (>2°C).
He established that longer term sea survival problems were associated with general hypothermia, leading to an inability to perform basic lifesaving actions, such as paddling to keep ones back to the oncoming waves, or providing additional support to keep one’s airway clear of the water in lifejackets. The lifejackets on many who lost their lives were “poorly fitted and without a crotch strap”.
Frank also realised that the puzzling collapse of many seas survivors on rescue was not – as Nazi experimenters in Dachau believed – due to the continued fall of deep body temperature, but was in fact related to the sudden removal of the hydrostatic support provided by the water pressure around the immersed body.
“In the absence of effective cardiovascular pressor receptors, due to cooling, the blood pressure collapses and cardiac arrest may ensue,” he adds.

Monday, September 7, 2009

Sick Games

From phones to fluedo, has the dreaded H1N1 morphed from flu into fun with a glut of Internet games and role-playing, dice throwing contests competing for popularity? Eimear Vize takes a closer look at this infectious activity and wonders, if laughter is the best medicine, is game playing the latest oinkment?
It’s all a bit of a laugh, isn’t it? This Swine Flu business: Just a little fun. What’s the pig deal? Since Swine Flu first started hogged headlines in April, the Internet has become infected by a pandemic of bad jokes (did you know swine flu is spread by capitalist pigs?) and a rash of online games battling swine flu is now spreading faster than the virus itself. In its first week, the most high profile of them, Swinefighter, amassed more than three million plays, helped by the viral clout of Twitter and Facebook. At the time of going to press, Swinefighter laid claim to destroying in excess of 20.5 million viruses!
As facetious as they are graphically wicked, most of these games are created for pure entertainment value, however, some have been hailed as the ‘latest weapon’ in the war against swine flu, and a couple are even useful and constructive tools.
The latest and most practical of these techno delights, introduced to the world in September by those innovative people at Apple, is a new iPhone application, created by researchers at Children's Hospital Boston in collaboration with the MIT Media Lab. It enables users to track and report outbreaks of swine flu on the ground in real-time.
The application, "Outbreaks Near Me," builds on the mission and proven capability of HealthMap, an online resource that collects, filters, maps and disseminates information about emerging infectious diseases, and provides a new, contextualised view of a user's specific location – pinpointing outbreaks that have been reported in the vicinity of the user and offering the opportunity to search for additional outbreak information by location or disease.
Additional functionality of Outbreaks Near Me is the ability to set alerts that will notify a user on their device or by e-mail when new outbreaks are reported in their proximity, or if a user enters a new area of activity.
And, yes, it works!  Tested by Scope’s zealous iPhone holders, not only did the versatile app list all media reports of current outbreaks and news of swine flu in Ireland, it also broke it down by county.
And if you spy an outbreak be the first to report it using the app’s unique outbreak reporting feature.  You will get credit as a disease detective and your find will be featured on HealthMap’s website (www.HealthMap.org)
"As people are equipped with more knowledge and awareness of infectious disease, the hope is that they will become more involved and proactive about public health," says HealthMap co-founder John Brownstein, PhD, assistant professor in the Children's Hospital Informatics Program (CHIP).
"This is grassroots, participatory epidemiology," chimes Clark Freifeld, HealthMap co-founder and a PhD student at the MIT Media Lab and research software developer at CHIP.
Outbreaks Near Me is available at no cost for download in the iTunes App Store. For more information on Outbreaks Near Me, visit: http://healthmap.org/iphone.php.
Remember when swine flu first struck? Governments responded with helplines, distribution points for anti-viral drugs and a promise of a vaccine by Christmas. But now health chiefs in the UK have unveiled a bizarre new tactic to combat the virus – a role-play game, using a set of dice.
The Flu Pandemic Game, which can be downloaded from the UK Department of Health’s website, is for three to 60 players, takes around 90 minutes and has chance cards much like Monopoly.
Initially devised by Camden Primary Care Trust in North London, the game 
is supposed to simulate ‘the effects of a flu pandemic on staffing in an imaginary group of small businesses’, and a version has also been developed for use in GP surgeries and hospitals.
The game has 15 rounds, each representing one working week. At the start of each round, players roll a set of four dice; with the number they roll indicating whether they will go down with swine flu. In the first round, it takes a roll of four sixes to be condemned to the virus. But as the rounds go on, the probability of each worker catching swine flu increases as the imaginary pandemic takes hold. By round six a player need only roll two sixes to come down with the virus.
And here’s the educational part: The surviving players are asked at the end of each round to discuss the impact that the pandemic has had on the various businesses involved.
Perhaps unsurprisingly, the game also comes with a Government health warning:
‘Some people may find it disturbing to play using details of their own organisation.
‘The game is a simulation and has no effect on subsequent events, but it can seem a little like fortune telling.’
Unlike in real life, however, the game does not actually allow players to die because, as officials claim, it would make it too ‘unwieldy’.
Critics have complained that it is a waste of time and that the resources should have been directed to the Government’s swine flu helpline. A Department of Health spokeswoman refused to be drawn on how much the game has cost the taxpayer.
Elsewhere in Europe, experts in the Netherlands have also revealed an unusual weapon in the fight against swine flu - a computer game designed by experts at the Erasmus Medical Centre in Rotterdam.
The clock is ticking, people are dying and a flu virus is sweeping the globe – that is the scenario of this new computer game, "The Great Flu", designed to make people think about how to respond to the swine flu pandemic. As the head of the fictitious "World Pandemic Control," players pick a flu strain, and then monitor that strain's spread around the world.
"The game is based on the need to increase public awareness to the threat posed by a pandemic and the measures in place to contain it," explains Dr Albert Osterhaus, one of the world’s leading virologists, based at the Erasmus Medical Centre, and one of the experts involved in creating the game.
"In no way is it intended to be a substitute for any advice given by the medical authorities," he quickly adds. "Its purpose is simply to create another avenue of information."
The game is played online and gives players the unenviable task of containing, as much as they can, the spread of an unknown flu virus. The more time passes, the more people become infected; more people die and more nations are hit.
The player has various tools to try and halt the pandemic. For instance, early warning systems can be established and citizens warned about the risks. Also available are facemasks and anti-viral drugs, as well as improved research centres and medical services.
The player is also given the option to close schools and airports, suspend businesses and quarantine infected members of the population.
Players face tough choices because starting funds are limited to stg£2 billion. Sweeping actions such as closing airports, beefing up research and isolating sick individuals does not come cheap. Strategy is key.
An introductory video for the game reminds players of the dreadful impact of past pandemics, such as the Spanish flu pandemic of 1918 which is estimated to have left 40 million dead. The game can only be played online at http://www.thegreatflu.com and it is free.
So are these online games all in bad taste, or do they fulfil a cathartic role? Are their creators conscious of the potential for offence, given that there have been deaths as a result of the swine flu outbreak?
Unlike many of the games out there, the very popular Swinefighter, is not about spreading the virus. It features a doctor wearing a surgical mask inoculating flying pigs with an oversized syringe, turning them from a sickly green to a healthy pink. The nimble medic can even step up the pace of the game by trading in his mammoth syringe for a retrofitted AK47! (http://www.swinefighter.com)
Sneeze - originally commissioned by the Wellcome Trust and Channel 4 as part of Routes, a series on genetics - illustrates how viruses spread. The game awards points for infecting as many people as possible with a single sneeze. (http://www.routesgame.com/games/?challengeId=2)
Players of Pandemic 2, a darker take on viral epidemics, aim to engineer a virus that wipes out humanity. A number of gaming fans described Pandemic 2 as “gruesome but gratifying”. Though some question whether games are an appropriate medium for examining topics such as disease, others argue that playing out worst-case scenarios is one way we make sense of things. (http://www.addictinggames.com/pandemic2.html)
A more educational game, Killer Flu, has had an upswing in interest since the swine flu story broke. Commissioned by the UK Clinical Virology Network, it casts the player as a virus attempting to infect as many people as possible. The website claims: “Here is a game that allows you to learn more about how the influenza virus is transmitted and how it changes every year - which explains why you can get more than one dose of the flu over your lifetime and why vaccines need changing every year.”
Mr Ian Bogost, the co-founder of Persuasive Games, which designed Killer Flu, remarked: "Games have a unique power that other media don't. They allow you to understand how systems work. Epidemiology may actually be better explained in game form than by a pamphlet or documentary."
So far, the games inspired by swine flu are neither particularly shocking nor satirical. But if the current swine flu pandemic escalates over the coming months, as is expected, and schools are closed, there are going to be a lot of children and teenagers sitting at home with little by way of entertainment. With luck these swine flu battling online games could breed a new generation of health and Government officials who understand and know exactly how to combat such virulent diseases.
And pigs might fly.
Some other infectious activity:
Swine Flu: Hamdemic
End the threat of pandemic by throwing pigs out of Mexico with a slingshot. You’d feel sorry for the pig though, as they are hacked by axe-wielding, yellow bio suited maniacs, catapulted onto cacti or roasted on a spit.
Swine flu: Pandemic Panic
Save the infected Mexicans by dropping them into quarantine before it’s too late!
Aporkalypse Now!
It's Armagammon! Grab your trusty weapon (shotgun or frying pan) and make bacon with the red-eyed zombie pigs!