Fighting Fistula

©Alixandra Fazzina/ Noor

Obstetric fistula is the most devastating of all childbirth injuries, although many may never have even heard of it. Constantly in pain, leaking urine or faeces, bearing a heavy burden of sadness in discovering their child stillborn, outcasts because of their offensive smell; ashamed, these young women live on the periphery of their former existence, without friends and without hope.

Although once common in western countries, the obstetric fistula is virtually unknown in the developed world today. During prolonged, obstructed labour, sometimes lasting several days, the pressure from the trapped foetus cuts off the blood supply to tissue between the mother's vagina and her bladder or rectum, causing that tissue to die away and creating a hole, or fistula.

Eradicated in western countries at the end of the 19th century when caesarean section became widely available, obstetric fistula continues to plague an estimated two million women worldwide, according to the United Nations Population Fund.

Reconstructive surgery can often heal these women, returning to them their dignity and their lives. However, with an estimated 100,000 new fistula cases each year and the international capacity to treat fistula remaining at only 6,500 per year, the suffering and isolation is life-long for an incalculable number of desperate women, who can’t access treatment.

The specialist surgery skills to treat fistulas must be learned in those countries where women and girls suffer from this debilitating and humiliating condition, primarily in Africa and Southeast Asia. A handful of international humanitarian groups and charities are working to eliminate obstetric fistula, among them Médecins Sans Frontières (Doctors Without Boarders), which has provided fistula repair in numerous countries including Liberia, Somalia, Sierra Leone, Central African Republic, Burundi, Nigeria, Ivory Coast, Chad and, more recently, the Democratic Republic of the Congo (DRC).

This year, due to the numbers of patients identified as needing this specialised reconstructive surgery in MSF’s ongoing programmes, it was agreed to run three camps in the DRC, the first of which was in May, another was held in August and an third is planned for September.

Helen O'Neill, a Dublin-born nurse, is MSF's Operational Advisor for the DRC, India and Sri Lanka, and is based in Holland. She explains to Scope that a month-long MSF camp last year in the village of Dubie in Katanga, DRC, during which 78 young women were surgically treated, identified many, many more fistula sufferers.

“We’ve generated some awareness about the fact that there’s a possibility to treat this condition, and hundreds of ladies have been identified. We don’t have the capacity to do that many, so we will do one camp now [May] and put on an extra in August but in another location. It means some people won’t get treated, but this problem is not going to go away. It’s a life long affliction unless it’s repaired, so maybe next year we will be able to offer them help,” Helen adds, all to aware that she and her team of surgical and nursing volunteers may never be able to keep pace with the numbers who need treatment.

“In 1997, I was in Sierra Leone and we identified a number of women with this problem and I was really lobbying hard, it was so difficult to get anything done. The nearest place that any of them could get repaired, at that time, was in Nigeria. And I think that there were only two surgeons in the world with the expertise to do this specialised surgery at that time, and they were in Nigeria and Ethiopia.

“So we started doing it ourselves in Sierra Leone. We did the first 100 ladies or so and that’s a small volume but it’s still a very small select group of people who have the expertise. It’s quite specialised, but once you learn it, you can repeat it.”

Since then, several MSF surgeons have mastered the techniques and train others through MSF. Dr Volker Herzog, an experienced MSF obstetric fistula specialist, has participated in numerous fistula camps over the years throughout Africa, including this latest programme in the Congo.

“MSF organised the first vesico-vaginal fistula (VVF) camp in Katanga, DRC, three years ago, in the town of Dubie. We operated on about 70 patients and, when we finished the session, the patients who were operated successfully wrote a letter and asked that we return to treat the women who had not yet been operated on. Since then MSF has organised a special VVF camp every year for the past two years. This year it is in Shamwana,” Volker tells Scope.

Helen remarks that this rural village is hard to find on a map. It lies northwest of Dubie. “It’s a very basic bush place, when we started working there we built a hospital and that’s where this fistula camp is, on the hospital grounds. We use the hospital lab facilities and the staff are the same but with two extra – the surgeon and one nurse.”

A Congolese surgeon was scrubbed in alongside Volker to assist and train in fistula repairs during the camp last May. The second camp in August helped to hone the local doctor’s skill in this specialised surgery so that, should MSF ever have to pull out of that region in the future, for whatever reason, there is someone there who knows how to do these repairs.

“We started by raising awareness of the condition among the population in the district via local radio and over 230 potential patients were identified. Of course it is not possible to operate on so many patients in one session so it was planned to start with 80 patients, and that is what we did,” Volker recounts, adding that it is an immense logistical task to install 80 beds, toilets, water supply and food for so many patients and their care takers, and this in addition to running a hospital with about 70 beds.

“MSF operates on about 15 patients a week and at the end we hope that we will have operated on about 70 patients. Not all of the 80 patients we examined had a fistula. Some of them have urethra incontinence so that they are treated with physiotherapy, and some have a urinary tract infection, which can produce symptoms similar to those of a fistula, but can be treated by antibiotics.

“In about 8 percent of operations, the first attempt is not completely successful and the patient requires a second operation. Sometimes the damage in the vagina is too extensive and the patient is inoperable. But usually the outcome is very successful with a cure rate of 90 percent,” the German surgeon notes.

The surgeons, indigenous and foreign, who train to perform reconstructive obstetric fistula repair, are not drawn to this specialised area because of monetary reward - $300 covers the cost of surgery, post-operative care and rehabilitation support - indeed, many offer their services for free. It is the complete transformation of personality in those women successfully treated that spurs these doctors on; the joy that they see in the eyes of patients on the day of discharge, these women are re-animated in the knowledge that their lives can begin again.

“I was confronted with the condition for the first time during the war in Mauritania/Liberia in 2003, where I operated on a woman with a perforated appendicitis and noticed the dreadful smell of urine.

“I was so concerned about the fate of this woman that I decided to learn to repair fistulas. So, I joined the most experienced fistula surgeon, Dr Kees Waaldijk, who has operated on 25,000 VVF patients. I trained with him on three occasions at his hospital in North Nigeria,” recalls Volker.

“The constant leaking of urine out of their bladder wets their clothes and due to the accompanying smell, many communities consider these women outcasts and often they are abandoned by their families and husbands. With a successful operation these women are not only healed of their condition they have had their dignity returned to them - they are no longer outcasts from society and can look forward to their new lives.

“The estimated number of VVF patients in Africa is about 2 million so it is obvious that we need more VVF camps like ours and more surgeons who can operate the obstetric fistulas. More importantly there needs to be more maternal services for pregnant women to prevent obstetric fistulas from occurring in the first place and to avoid unnecessary maternal deaths,” he stresses.

The UNPFA agrees that the key to ending fistula is to prevent it from happening in the first place. Skilled attendance at birth, including swift surgical intervention if obstructed labour occurs, can prevent a fistula.

©Alixandra Fazzina/ Noor

At present, many women in sub-Saharan Africa have little or no access to such services. Births are traditionally at home with untrained people, and even when health care is available nearby, social mores can take precedence over the health of the mother.

A large number of those who die from obstructed labour or who survive with fistulas are between the ages of 10 and 18 and are of small stature. They might have been made to marry and become pregnant quite young, and because their bodies have not fully developed, they cannot deliver the baby. These are the women and girls who are at risk of such complications, and huge numbers of them die.

Helen describes the overall health services not only in this DRC region where MSF operates, but also many other rural areas of Africa, as abysmal. “In theory, or maybe on paper, it doesn’t look too bad but in practice it isn’t good. There are a lot of people that don’t have any healthcare at all. They are extremely poor, yet they are expected to pay for healthcare. They can’t manage that so they will not bother to seek it out. There’s no point in taking a sick child to the hospital if it’s going to die because you can’t afford to pay for the hospital. It’s very sad,” she says.

“For women with an obstetric fistula - some of them may have been suffering with it for decades - this surgery changes their lives completely. Suddenly, they are allowed back into society; they do not smell anymore. They are young women and most of them would be able to have children again.

“I met three women together recently, and the difference before and after surgery is extraordinary. They were all aged between 18 and 30; they were cowed, quiet, miserable, afraid, ashamed – all of these things – when you met them at the beginning. And when you meet them post-surgery, they are laughing, smiling, “bonjour Monsieur le Docteur”, happy women. It’s quite extraordinary.”

The eradication of obstetric fistulas in Africa is decades away at least. But these doctors and nurses with MSF, and other humanitarian groups, are taking crucial first steps toward that goal.

The Campaign to End Fistula

©Alixandra Fazzina/ Noor

During most of the 20th century obstetric fistula was largely missing from the international global health agenda. This is reflected by the fact that obstetric fistula was not included as a topic at the landmark United Nations 1994 International Conference on Population and Development (ICPD).

However, since 2003 obstetric fistula has been gaining awareness amongst the general and medical public and has received critical attention from the United Nations Population Fund (UNFPA), which is spearheading the first-ever global campaign to "End Fistula". Its overall goal is to make the condition as rare in the developing world as it is elsewhere.

The Campaign, launched in 2003, has already brought fistula to the attention of a wide audience, including the general public, policy-makers, health officials and women with fistula. More than $25 million in funding has been mobilised from a variety of donors and activities are underway or being planned in more than 40 countries.

In each country, the Campaign proceeds in three phases:

• First, needs assessments are undertaken to determine the extent of the problem and the resources to treat fistula.
• Second, each country that completes a needs assessment receives financial support for planning, including raising awareness of the issue, developing appropriate national strategies and building capacity.
• Finally, a multi-year implementation phase begins, which includes interventions to prevent and treat fistula, such as improving obstetric care; training health providers; creating or expanding and equipping fistula treatment centres; and helping women reintegrate into their communities.

What can be done to help?

Skilled surgeons can repair obstetric fistula. A simple repair may take only 45 minutes to complete, but many cases are more complex and require several operations. After the operation, the woman will need a bladder catheter for a couple of weeks and will be taught pelvic floor exercises to strengthen their muscles.

Women who have had a fistula repaired are able to have a healthy child, if they receive appropriate antenatal care.

Training local midwives to help mothers give birth safely is vital. They can spot when a mother is in difficulty with the labour and arrange help before it is too late.

The Irish Surgeon and America's Wounded Warriors

The toll of US soldiers wounded in Iraq and Afghanistan now exceeds 41,000, and the trademark of these battles is the vet who lost a limb. Many of these wounded warriors are battling long-term to recover from instantaneous carnage. Eimear Vize speaks to an Irish surgeon in Manhattan, who is helping to save the limbs of America’s wounded war heroes.

US Army Captain Brian Jantzen was only days away from surgery to remove his lower right leg. Military doctors had told the young captain - whose legs, feet and anklebones were shattered when his vehicle was hit by an IED (improvised explosive device) while on patrol in Ramadi, Iraq - that amputation was necessary. Then a chance conversation led him to Dubliner Dr John Kennedy, a top Manhattan orthopaedic surgeon, for a second opinion. That was three years ago and Jantzen was the Irish doctor’s first referral from the Wounded Warriors Project, which aids severely injured service members. With the help of a groundbreaking bone regeneration technique, the young soldier kept his leg. And John has gone on to perform a growing number of limb-saving surgeries, free of charge, for gravely wounded veterans of the Iraq and Afghanistan wars.

An RCSI graduate, John Kennedy is an Associate Professor of Orthopaedics and the director of research in the Foot and Ankle Department at the Hospital for Special Surgery (HSS) in New York - ranked as the number one orthopaedic hospital in the United States. During an awards dinner in 2007, at which he was named one of the "Top 100 Irish Americans", John found himself sitting with Flip Mullen, another of the honourees. John was receiving the coveted award for his work in Santo Domingo where he performs 15 to 20 orthopaedic surgeries every year for those patients in the greatest need. Flip, a retired New York fire fighter, was being honoured for tireless work with the Wounded Warriors Project. The two men started talking and within minutes a relationship was formed that has since offered fresh hope to severely wounded soldiers, helping them to take back their lives.

“The work that Flip and his team were doing to help wounded veterans was simply inspiring and humbling. Flip has dedicated his life’s mission to helping the men and women who become severely injured in the fight to keep us all safe,” John tells Scope from his office in New York.

“All the branches of the armed service have an outstanding medical operation and they were doing exceptional work at the front line, in Germany, and ultimately in Walter Reed here in the US and other institutions. However, there are a certain number of soldiers who I thought might benefit from some of the procedures that we were doing at Hospital for Special Surgery, so when I was speaking with Flip that evening I suggested that we might be able to help.”

Soon after, Flip met 29-year-old Jantzen, who was on a Wounded Warrior trip to New York, in part to observe how the amputees cope to prepare him for his own imminent surgery. The two fell into conversation and Mullen questioned Jantzen about his wounds and the prognosis. “He said: ‘I know a doctor…’” Jantzen recalled in an interview later.

“Since that time, my work, in collaboration with my colleague Dr Austin Fragomen, has been small by comparison to the hundreds of volunteers from the NYPD, NYFD and ordinary folk who have given of their time, expertise and compassion to the Wounded Warriors,” John is quick to acknowledge.

“In return we all get something that is not quantifiable but is worth more than anything else that we work for in our daily lives. To make even the smallest bit of difference to these men and women returning from war, whether by a surgical procedure, or to have dinner and listen, or to simply acknowledge their sacrifice and the sacrifice of those that will not be returning, is something that instils a deep sense of gratitude on both sides.

“These are the best America has - the fittest, smartest, toughest people who went out to put themselves in harms way for the rest of us. When you see the destruction that war visits upon them, it underscores the sacrifices they have made.”

When invited to talk about some of these cases, John hesitates. “This is hard because most of these guys don’t want any publicity and don’t want to be written about. In general, their stories are all similar. It’s just a different time and a different place. All of them have been in the wrong place at the wrong time and so much of this is just bad luck.”

He recalls one of his patients, Capt Ryan Miller, a US Army Ranger who was on patrol when his Humvee hit an IED. The bomb killed his best friend. Surgeons in the Landstuhl Hospital at Ramstein Air Force Base in Germany removed a copper shell casing from his abdomen, which Ryan now wears around his wrist with the name and serial number of his buddy who died. 

“Capt Miller was a 4.0 grade point average student who was headed for Harvard when 9/11 happened. He joined West Point instead and went to serve his country. When that IED went off his country did everything it could to help him, and the men and women of the medical corps performed miracles so that Ryan would survive. At the end of his treatment, Ryan was left with a leg deformity from blast injury and shrapnel that left him with a drop foot, missing a part of his foot and a leg that was mal aligned and rotated.

“Ryan has been through four operations with us and is recovering from his fourth, and hopefully last, to address all these concerns. Ryan is typical of the men and women we treat. He is proud to have served but now wants to resume living his life. He has applied to Harvard business school and when he recovers fully plans to run a marathon.

“As a surgeon there is no better patient to have than one who is motivated to overcome their injuries no matter how severe and see the positives in life rather than the negatives.”

But John understands that in some of these extreme cases it is often not clear whether he truly can save a limb and, if so, at what cost? “There are times when amputation is the best way forward. There is no training in medical school to know when enough is enough. There are the hard cases where you have given 110 per cent to put it all back and as functional as possible, and then the patient says take it off doc, I cant deal with the pain.”

Ryan’s story is emblematic of many of today's wounded warriors. The ebbing death rate from battle wounds often translates to a rising tide of maimed survivors. The US armed forces have lost almost 4,400 soldiers in action in Iraq since 2003, and a further 1,000 fatalities have been recorded in Afghanistan since 2001, according to the latest data from the Iraq Coalition Casualty Count (www.icasualties.org). However, in Iraq alone, the ever-ascending tally of wounded soldiers has reached a staggering 31,616.

“I saw Jeff Guerin today. He was a 22-year-old army volunteer that was blown up by an IED outside of Baghdad three years ago. We have done several operations on Jeff and he came in today for a follow up with his Dad,” says John.

“Jeff’s face is scarred for life. He can see out of one eye only, the other is fixed permanently looking up and out, sightless. His skin is pock marked with purple and black shrapnel that is making its way slowly to the surface. Jeff is a Man United fan and wears their latest gear proudly and chats about how he loves how they beat Liverpool. His dad has devoted his life to helping Jeff get over his injuries, and sits proudly with a cap declaring "Go Army": A Proud dad.

“Jeff isn’t one bit sorry for himself. He has just got married and is getting on with his life as best as his injuries allow. Jeff has one major remaining orthopaedic issue - his talus bone lost its blood supply after the blast and his bone was dying in his ankle. Our treatment is typically to put these soldiers in a frame that distracts the joint and prevents the bone from collapsing while the bone revascularises. We perform tiny drill holes in the bone to allow marrow cells to populate the bone and start producing blood vessels and new bone. It’s a time intensive procedure but can be very worthwhile ultimately.”

John explains that distraction arthroplasty, or the use of a frame to spare the joint while the joint and surrounding bones heal, has been used previously only in very select cases. Having had the experience of using this technique in several of the wounded veterans, John and his colleague Dr Fragomen can now refine its application to the civilian population.

“These cases are all done at HSS,” he adds. “When I spoke to Tom Sculco, the Surgeon in Chief, about the wounded warriors, he was very supportive. The hospital donates the OR and staff for any surgery and post op care.”

Another of Kennedy’s Wounded Warrior patients is Sergeant John Borders. Both of his legs were crushed, his left arm sustained two open fractures, his ring finger was severed, he fractured a vertebra in his neck, had contusions to his lungs, a lacerated liver, shrapnel to his eyes, face and torso, and multiple burns in an explosion that happened while he was on patrol in Taji, Iraq in 2006.

Sgt Borders had undergone 50 operations, including the amputation of his left leg, and met with Kennedy and his team as a last ditch effort to save his remaining leg. They operated with great success in December 2007. “Dr Kennedy is a life saver,” Borders’ wife Mollie told Irish America recently.

It is to be expected that John’s interaction with these brave soldiers - all of them so young but dealing stoically with their enormous trauma and loss - has left an indelible impression on the Irish surgeon.

“War is a tragic waste of the best a nation has to offer,” he ponders quietly. “The men and women I have met through the wounded warrior program have left a profound effect on me, and my family. I am humbled and honoured to know them. During the summer of 2009 the Wounded Warriors had an award ceremony. I was very lucky to be invited and even luckier to get an award along with many other recipients. When I went up to receive the award, a young 19-year-old marine was looking at me. He had returned from Afghanistan two months earlier. He had no legs and no arms. He had a new prosthetic arm and was learning to try and use it. He looked at me and tried to clap. I will never forget that man or that moment.”

The Sports Doc

Dr John Kennedy credits his interest in orthopaedics to his involvement in sports. As an athlete, he said he “broke plenty of bones” competing at national and international levels in track, rugby, fencing, and water skiing, and became fascinated by how they healed. He graduated from RCSI in 1989 and, in the mid-nineties, immigrated to Boston to begin a fellowship in orthopaedic sports and orthopaedic joint reconstruction at Saint Elizabeth’s Medical Center.

During this time, John was also involved in the Children’s Hospital and the Andres Laboratory of the Harvard Medical School where he spent time investigating new composites in bone regeneration, which he later presented as a thesis for his master’s in surgery.

As part of his Fellowship year, the young Irishman was engaged as an assistant team physician to Boston College Football. Ever since, John has been actively involved in the treatment of both recreational athletes as well as elite athletes from the New York Giants, New York Metro Stars, Manhattan Rugby, the National Basketball Players Association, and the National Basketball Referees Association.

2001 found Dr Kennedy in New York City where he worked in the Memorial Sloan-Kettering Cancer Center before moving on to the Hospital for Special Surgery (HSS). He is currently the clinical director of the running clinic in the gait laboratory at HSS. Dr Kennedy's involvement in all aspects of lower limb sports injuries has led him to publish articles on running injuries, cycling injuries, ballet injuries, and ankle instability following sports injuries. He has published more than 100 peer-reviewed articles. Read more about Dr Kennedy on his personal websites, www.sportsmedicinenewyork.com; www.osteochondraldefects.com.

Extremity war injuries

“During World War II, the likelihood of surviving battlefield wounds was 69.7 per cent; by the end of the Vietnam War it had improved to 76.4 per cent; and survival of those wounded in the current Iraq War has increased to an astounding 90.4 per cent.”

US Department of Defence’s Directorate for Information Operations and Reports

The majority of trauma that currently occurs among both military and civilians in Iraq and Afghanistan involves the upper and lower extremities, and happens as a result of the detonation of explosive devices. That’s according to a paper summarising the findings from the Extremity War Injuries Symposium held in Washington, DC, published in the January 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

"Our military medical personnel in Iraq and Afghanistan are facing serious challenges on every level," noted key author, Dr Andrew Pollak, Professor and Head, Division of Orthopaedic Trauma, University of Maryland School of Medicine, Baltimore, MD. "But the most critical need right now is funding for more research, so medical personnel can offer the highest level of care," he added.

"Our goal is to provide our wounded warriors with the best care possible to improve their quality of life. Since orthopaedic injuries result in the largest source of disability cost for the government, investing to improve care should result in less expense for the taxpayers in the long run."

The symposium also revealed important information related to host nation care capabilities. A major portion of the care currently delivered by U.S. military medical personnel is offered to the local population. In Afghanistan, this includes many enemy combatants and insurgents as well as members of the regular Afghan military forces.

"The common theme we learned is that the inherent capacity of the Iraqis and Afghans to deliver this care themselves is extremely lacking—and even absent in some areas," said Dr Pollak. "The patient follow-up care also is not available in these countries."

RISE OF THE MACHINE

Hearing the words ‘master’, ‘slave’ and ‘robot’ in the same sentence conjure images of alien invasion but Professor Tony Costello is describing an invaluable addition to his surgical team. A mammoth robot with multiple surgical arms operates on his patients while he sits at a control consol several feet away; manipulating it’s every move. 

“When the surgeon moves his hand in a particular way, the robot mimics that: it’s what they call a master-slave robot - a scenario that reverses when I go home,” laughs the Australian surgeon, who spoke to Scope during a recent trip to Ireland where he was awarded an Honorary Fellowship of the RCSI.

A Professor of Urology in the Royal Melbourne Hospital and University of Melbourne, Tony is one of the leading prostate specialists in Australia. He pioneered the use of laser surgery in the 1980s as a viable alternative to traditional transurethral resection and in 2003 he became the first surgeon in the Southern Hemisphere to perform a Robotic Assisted laparoscopic Prostatectomy (RALP).

“I’m very proud to be awarded an honorary fellowship of the RCSI, partly because of my Irish heritage and partly because the RCSI is such a prestigious insitiution. It’s  very validating thing for me to be given such an honour, it’s a very big deal, I’m very excited about it,” he affirms.

Surgeons from around the world, including Ireland, travel to Melbourne to train with Tony and his team at the Richmond campus, Epworth Hospital, where more than 700 cases of robotic laparoscopic prostatectomy have been performed.

Designed by NASA and the US Department of Defence to facilitate remote-controlled surgery in space and on the battlefield, this groundbreaking surgical robot provides unprecedented laparoscopic vision and precise robotic instrument manipulation. Its makers call it the "da Vinci" and it has been cited as number one in Forbes Magazine's "Five Robots That Will Change Your Life".

“It takes surgery beyond the limits of the human hand. We now have a robotic programme responsible for outstanding results with regard to return of urinary continence and preservation of sexual potency. And a couple of our best surgeons have some to us from Ireland,” says Tony, who is very proud of his “100 per cent Irish” heritage. His dad hails from Mayo and his mum from Clare.

He explains that, with a high-tech device like the da Vinci Surgical System, patients can experience smaller incisions and quicker recovery times. Surgeons can sit rather than stand for lengthy surgeries and have their skills enhanced through the precision of the robot.

Robotic surgery also reflects a broader push to reduce the risk of infections and other complications, to shorten hospital stays and to get patients on their feet in days rather than weeks.

“It’s the logical next step; surgery is very technology driven. It has been a sea change in abdominal surgery and it is starting to break through into other disciplines - cardiovascular surgery and gynaecology cancer, head and neck cancer. We’ve now set up a programme for cancer robotics for gynaecology cancer and colon cancer with the da Vinci robot,” he adds.

Surgical robotics was little more than a medical curiosity until 1999, the year California-based Intuitive Surgical introduced the da Vinci Surgical System. Today, this revolutionary technology is being used in a wide variety of surgical procedures, including mitral valve repair, cardiac revascularisation, gastric bypass surgery, radical prostatectomy (da Vinci Prostatectomy), hysterectomy, myomectomy and sacrocolpopexy, cardiac tissue ablation, and epicardial pacemaker lead placement for biventricular resynchronisation.

More than 1,000 da Vinci robots have been installed in hospitals worldwide, including two in Ireland - Cork University Maternity Hospital and the Galway Clinic – with a third recently purchased by the Mater Private Hospital in Dublin.

“Surgeons who use the da Vinci just love it; once you start, it’s a very beguiling technology. You can see ten times better, you have a three dimensional view of the surgical field, and you can be far more dextrous.” Tony remarks, expounding that it achieves this by scaling down and filtering out any tremors of the surgeon’s hand and translating his or her actions into the seamless movements of the instruments.

The patented surgical instruments also have a wider range of motion than a human hand and wrist, making it easier for a surgeon to manoeuvre in tight areas. Furthermore, the surgical robot employs a variety of overrides and fail-safes that prevent harmful mishaps. For example, if the surgeon were to suddenly swing her arms outward while keeping her hands in the gripper stirrups, this movement would be disastrous for the patient. But the da Vinci doesn’t translate such erratic motions to the robot arms at the patient cart. It knows to keep the instruments within the fixed positions of the incisions.

“We first introduced the da Vinci robot to our hospital in Australia in 2003. The technology sort of came on in 2001 in the US in one centre, and in 2002 in two centres, we were about the sixth centre in the world.”

His RALP unit’s complication rate has been reduced from 12 per cent in its first 100 cases to around about 2 per cent in the last 300 cases. “And we have had no deaths related to our surgery,” Tony stresses. By comparison, open radical prostatectomy carries a complication rate of 10 per cent and there is one death in every 200 surgeries.

“It’s amazing to see how far we’ve come and how much we’ve achieved in those few years. We have performed about 710 robotic assisted prostatectomies at the hospital. Between myself and one of my colleagues, we do about 300 cases a year, and we have trained lots of surgeons from America, seven from Ireland, and from all over Europe.

“We give a very didactic and modular learning on robotics and then they go back and usually their hospitals, because they have someone who is fully trained, will then install a robotic programme, so it’s working pretty well. I’m really pround of our surgeons.

“Basically, the surgeons who are accepted onto our programme come for a year to train and they receive what we call a robotic fellowship. At first the fellows get to use the machine without a patient underneath it. They will perfom basic drills with it so they can get use to the technology, and then we get them to be what we call a bedside assistant, who changes the robotic instruments and introduces sutures when required. 

“They then transition to the consol and we divide the operation into a number of steps, the easier steps they do.  I sit beside them and assist if they need it, and then take over, so it’s very structured learning, it’s like teaching a pilot,” he offers. “In fact, using the da Vinci feels like flying a plane. It’s very similar to using your hands and feet to flying a plane, that’s what I would say.”

Tony’s fellows can usually take their first patient after six to eight months of training. The training programme he has developed at Epworth is light years ahead of his own training experience in 2003 at the University of California Irvine: “When I was being taught, the surgeon had only done 60 cases himself, so it was a very new technology and there were no textbooks to guide you through, it was really more of a ‘seat of the pants’ thing. We would watch the procedure being done and then we did cadavers. The first time I operated on a live patient with the da Vinci I felt privilaged but also pretty scared because I wasn’t sure this would work. Now it’s very teachable, it’s very structured and it’s much easier for the doctors to learn the surgery.

“I’ve trained seven Irish surgeons so far,” he continues. “There are a lot of intellectualy bright people here in Ireland. I always welcome them to come and work with us in Australia and make it better for us. I have another surgeon coming to work with me from Dublin called Stephen Conway, he’s starting in July and I’m sure he’ll get involved in the robotics when he comes back here after his training. Two of the Fellows have stayed with me and the others have returned to Ireland with a new skill that can offer so much more to many patients than traditional surgery.”

Two of his prodigies, consultant urologists Drs Paddy O’ Malley and David Bouchier Hayes, who were the first to return to Ireland following their fellowship training, performed the first robotic assisted prostatectomy in Ireland in November 2007 and soon after established the country’s first robotic surgery unit for the treatment of prostate cancer, based in the Galway Clinic. The unit’s €2.2 million Da Vinci system is the largest capital investment in the treatment of prostate cancer in the history of the state.

Now in its third year, the unit has yielded encouraging results comparable to international standards. “Between David and myself, we have done about 100 cases to date and I’d say our complication rate is about 5 per cent,” Paddy tells Scope.

“The machine was funded locally. We had a unique sitation where the entire cost was underwritten by a group of 20 local business men, on the basis of the business case we gave them that the robot would pay for it’s self over a number of years. They guaranteed that if there was a shortfall they would pay, and they have been released from that already because we have reached ort target for the first three year. It is currently being paid off at the projected target,” he says.

The major thrusts in surgery today are to develop more precise and minimally invasive procedures. Tony is convinced that it is through increasingly sophisticated technology that surgeons will find the best treatment for their patients.

“No doubt about it, I think our improvements in surgery are technology based, so I can’t see us going backwards. I think it’s going to be very rare that a patient will get an incision in their tummy or their chest, it’s going to be a thing of the past.

“With the proviso that this technology is expensive and it will take some time before the cost comes down, once that happens you’ll see the technology spread through all surgical departments, in the western world anyway,” he predicts.

Tony adds that patients are far from daunted by the conceivably intimidating apperance of this huge octopus-like robot. “They don’t mind at all in fact,” he points out. “I think most patients are attracted to high-tech, provided of course there is the caviat that it’s actually better for them. It is very enticing for patients to think that they have got the latest in technology that will make a better outcome. They love the da Vinci; patients really love it. It makes a big difference for them too. With only a tiny incision to deal with, the patient can get out of bed the afternoon after the surgery or in the morning after surgery, so you don’t get the DVTs or the pheumonias or the cardiovascular complications. And they don’t need any blood. Typically, when I did open surgery, probably about 80 per cent of patients would have to have a blood transfusion but now we never or very rarely have to give a blood transfusion.”

He also points out that a RALP procedure takes the same length of time as traditional surgery, perhaps even a little quicker under the right circumstances. “Once you have all the nurses and everybody is familiar with it, we can move very quickly. It takes us about an hour and forty minutes. It has actually developed a good team relationship; the nurses really took to it; they love the technology and they get to do a bit more as scrub nurses than normally. So it has been a great thing for the team and quite a moral booster for the hospital I think as well.”

As a pivotal member of his surgical team, does his mechanised surgical assistant have a name? “We wanted to give it one, we even had a competition but there were so many different versions we never came up with one. Robodoc was the closest we got,” laughs Tony.

Prostate cancer surgeons 'feel' with their eyes

Robotic surgical technology with its three-dimensional, high-definition view gives surgeons the sensation of touch, even as they operate from a remote console. A new study describes the phenomenon, called intersensory integration, and reports that surgical outcomes for prostate cancer surgery using minimally invasive robotic technology compare favouurably with traditional invasive surgery.

Led by physician-scientists at New York-Presbyterian Hospital/Weill Cornell Medical Center and appearing in the March 2010 issue of British Journal of Urology International, the study is the first to show that a lack of tactile feedback during robotic surgery does not adversely impact outcomes in patients with prostate cancer. It also identified various visual cues that surgeons can use to improve clinical outcomes.

"Anatomical details and visual cues available through robotic surgery not only allow experienced surgeons to compensate for a lack of tactile feedback, but actually give the illusion of that sensation," says Dr Ashutosh Tewari, the study's lead author; professor of urology, urologic oncology, and public health at Weill Cornell Medical College; and director of the Lefrak Center of Robotic Surgery and the Institute of Prostate Cancer at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

"For patients, this means the safety of knowing the benefits of a robotic approach, including a quicker recovery, don't compromise the surgery's primary mission of removing the cancer."

In recent years, robotic-assisted laparoscopic prostatectomy (RALP) has become a popular surgical method for treating prostate cancer because it is less invasive than traditional surgery. No studies have shown that RALP leads to worse outcomes, but doctors have wondered whether this was the case because surgeons often use their fingers to feel the prostate during traditional surgery to refine how much they cut to achieve the best outcome.

Cancer cells produce changes in tissue firmness that surgeons can sense. Because this tactile evaluation is not possible for surgeons using RALP, clinicians have wondered whether the robotic approach could lead surgeons to miss some cancer, and thus subject patients to a greater risk of cancer recurrence.

To find out, the investigators videotaped 1,340 RALPs. After every couple hundred procedures, they examined the pathology results of the prostate that was removed to determine the incidence of positive surgical margins, an indication that a surgeon might not have removed all of the cancer. In this study, the investigators focused on the posterolateral surgical margin (PLSM+), the area where the prostate is attached to the nerves.

"When you look at the entire specimen after surgery is done, you want to see cancer inside of the prostate but you don't want to see cancer touching the surface," Dr Tewari says. "After surgery we look at the specimen, and if there are no cancer cells touching the surface, we call that a negative margin. If cancer is touching the edge, then we say it has positive margins. This means there may be some cancer left in the patient."

The investigators then studied the videotapes to determine what refinements in the procedure resulted in negative margins. Using this new knowledge to refine the surgery, they conducted the next couple hundred RALPs, reviewed the videotapes, refined their techniques, conducted the next round of RALPs, reviewed, refined and so on.

The investigators found that robotic surgery did not compromise outcomes. The incidence of PLSM+ was 2.1 percent, which gradually declined to 1 percent in the last 100 patients. Positive PLSMs are found in 2.8 percent to 9 percent of patients undergoing traditional prostatectomy.

The researchers say that the enhanced vision allowed by the robotic approach brings about a "reverse Braille phenomenon" or the ability to "feel" when vision is enhanced. They have also identified a number of visual cues that clinicians can use to improve outcomes, including the colour of tissue, the location of veins as a landmark for the location of nerves, signs of inflammation, and appreciation of so-called compartments outside the prostate.

"As someone with 30 years of experience as a pathologist, I, too, have developed the ability described in this paper. I can look at a tissue sample and know if it is firm or soft and what to expect in its pathology - something that helps me to home in on the area with the abnormality," says Dr Maria M. Shevchuk, the study's senior author, associate professor of pathology at Weill Cornell Medical College, and a pathologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "It is only natural that this ability would also be present in experienced robotic surgeons."

The Sound of Surgery

When Australia’s top surgeons emerged after the mammoth 32-hour surgery to separate conjoined twins Trishna and Krishna late last year, they revealed that listening to music had helped the team get through the marathon procedure. The steady beeps of monitors, the sound of suction, the stirring strains of Beethoven’s 9^th Symphony - It seems, as elsewhere in modern life, surgery has acquired a soundtrack.

Surgeons are just as receptive to the calming benefits of music as anyone else, perhaps even more so, as several studies have demonstrated improved task performance among staff in the operating theatre when a CD or radio is playing in the background.

Ask most surgeons about their operating theatres, and they will describe them as havens from the stresses and pressures of a busy clinical practice. Most theatre personnel would gladly accommodate any means that might diminish the stress or enhance the smooth running of an operation. Techniques such as dimming the lights, decreasing human traffic, and playing a selection of tunes from the surgeon’s iPod are increasingly common in theatre. Music reduces stress. It lifts moods, making the operating room a more pleasant work environment.

But this is by no means a recent revelation. The beneficial effects of music during surgery have been lauded in medical journals going back 50 years. In fact, the magazine ‘Popular Mechanics’ wrote in a 1924 edition, “music has been found of value in surgical operations to ease patients during and after the administration of ether. Melodies are supplied by a phonograph or instrumental selections are rendered by an artist. Several demonstrations have been made at a Brooklyn, New York, hospital.”

A generation ago, music in operating rooms was rare, partially because the surgeons who ran them didn’t want it but also because it was impractical: radio reception was often poor and tinny. Boom boxes that first played cassettes and then compact discs were an improvement, and today’s MP3 players can hold thousands of songs, so now surgeons can carry their entire music library around in their pockets.

A growing body of research in recent years shows mild benefits for the patient going under the knife as well as for the surgeon holding it. A landmark study that observed the effects of music on 50 male surgeons (aged 31–61 years) who regularly used music in the operating room was published in the Journal of the American Medical Association (JAMA) in September 1994.

Skin conductance, systolic blood pressure, and pulse rate were measured during the performance of two mental arithmetic problems separated by a five-minute rest period. The researchers found that the beneficial autonomic effects of the music were due primarily to reduced cardiovascular reactivity, and that the beneficial behavioural effects were derived primarily from improved task performance.

Furthermore, investigators writing in the journal Surgery reported on an objective evaluation of the effect of noise on the performance of a complex laparoscopic task in 2004. They concluded that music did not interfere with or impede the performance of the surgeons in any way.

Scope contacted a number of Irish surgeons and asked whether they felt music had an important de-stressing role to play in the sterile environment of their operating theatres. And Scope can reveal that indeed the sound of music and the occasional hummed melody is a frequent companion to surgery, with most of the doctors surveyed agreeing that listening to music while they worked had a relaxing effect, helping to focus their attention.

But, naturally, there are rules and restrictions. As one surgeon pointed out, they work in an operating theatre, not a concert venue. The volume usually doesn’t go above background level, the music often doesn’t start until after the patient is asleep and surgery is in progress, and if a case is especially difficult or if problems rise during the procedure, the music is switched off.

Nevertheless, music has become a regular component to life in the operating theatre, as illustrated in two separate studies. In a survey of 200 Anaesthetists published in 1997 in the British journal Anaesthesia, 72 percent of respondents said music was played regularly in their operating rooms. Also, a 2008 study in the journal Injury found that almost two thirds of more than 170 doctors and nurses in three hospitals listened to music on a regular basis in the operating theatre. Classical music was the most requested (58 per cent), and about eight in ten of the participants claimed that music in the OR made them calmer and more efficient. The authors concurred, “Music has a positive effect on the staff working in the operating rooms”.

Mr Javaid Butt, a Consultant General/Breast Surgeon in St James's Hospital, Dublin, says that he ‘always’ listens to music during elective surgery. When Scope caught up with him, Abba was playing softly in the background as he left the theatre, having just finished a procedure.

“I like to listen to music in the background while I’m in surgery. We have a CD player in the theatre and the music selection is open to requests. The nurses bring a selection of music, usually classical but sometimes the latest chart hits, once it’s not too intrusive. And sometimes we listen to the radio, so it’s a mixture,” he explains.

Mr Butt’s personal favourite melodic accompaniment is classical music: “I find it helps with concentration when the procedure is complex.”

“Sometimes the type of music depends on the procedure, or which stage we’re at during the procedure. The music may get a little livelier when I’m closing, for example. Today it was Abba.”

He adds that he usually listens to music in theatre at a medium volume and he finds it does not interfere with his performance at all. However, if he is dealing with an emergency case, there is no music.

“When we are doing emergencies, we don’t listen to music. When it’s elective surgery, we start the music after the first skin incision, and the music usually stops by the time we finish stitching up. But if there are any complications during the procedure we tend to stop the music.”

Mr Sean Carroll, a Plastic, Cosmetic and Hand Surgery in Saint Vincent's University Hospital Dublin and the Beacon Clinic, also listens to a CD player while he works in Theatre. He says the volume is usually low – “nice background noise” – and his preferred selection of tracks vary from rock to classical, depending on the procedure and the mood of his surgical team. And who gets to select the play list for the time in theatre? “Democracy rules,” Mr Carroll quips.

“I believe music can have both beneficial and perhaps adverse affects when played during an operation. That is why I can switch it off whenever things were not going well,” he says.

However, there are some surgeons, including those who love music in other parts of their lives, who find it too distracting while they’re operating. Music can also prove intrusive while teaching, according to Prof Michael Kerin, Professor of Surgery at NUI Galway, who says he doesn’t usually listen to music when he has medical students and NCHDs with him in theatre.

“There is usually silence or discussion during elective lists and music in emergency theatre. It depends on what Anaesthetist likes,” he tells Scope. Prof Kerin, who is a Consultant in Breast, Endocrine & General Surgery in University College Hospital Galway, also remarks that the positive or negative effects of listening to music during theatre may be down to personal preference. He says it’s “like listening to music during study:  Some people like it and some don’t.”

His deference to the anaesthetist, who works alongside him in theatre, raises a valid issue concerning the addition of music to this work environment. Auditory input is important to anaesthetists for monitoring the patient and for communication between the anaesthetist, surgeon and nursing staff.  Some doctors think that music can be a distraction that could undermine communication and the crucial teamwork necessary to pull off a difficult operation.

More than a quarter of the 200 Anaesthetists surveyed for the 1997 study in Anaesthesia felt that music potentially “reduced their vigilance" and impaired communication with other theatre staff, whereas 11.5 percent of them felt music might distract them from alarms. Just over half of respondents felt that music was distracting when a problem was encountered during the anaesthetic.

However, a subsequent study by the same research group on 12 trainee anaesthetists using a computer-based psychomotor performance assessment failed to show any adverse effects of self-chosen music, silence, white noise or classical music on their performance in these tests (Anaesthesia 1998).

The same cannot be said for the effect of music on patients. A 2005 study by the Yale School of Medicine confirmed previous work showing that surgery patients listening to music require much less sedation. Previous studies left open the question of whether it was music that did the trick, or just the act of blocking out the sound of dropped surgical instruments and other operating room noise.

However, Prof Zeev Kain, a Yale professor in the Department of Anaesthesiology, writing in the journal Anesthesia & Analgesia, remarked: "Doctors and patients should both note that music can be used to supplement sedation in the operating room.” He arrived at this conclusion after testing 90 surgery patients at two facilities. Some wore headphones and listened to the music of their choice. Others heard white noise designed to drown out noises in the operating room. Others had no headphones. Prof Kain and his team reported that blocking sounds with white noise did not decrease sedative requirements, but music did.

His results confirmed a 1999 study in Pain, which found that music after abdominal surgery reduced patients' post-operative pain. And other studies have shown that music before and during surgery can reduce blood pressure and nervousness.

These beneficial effects are being witnessed first-hand by Mr Arthur Cummings, a consultant ophthalmic surgeon in the Beacon Hospital in Sandyford and the Wellington Eye Clinic in on the Beacon medical campus, Dublin.

“I feel music is beneficial for patient, surgeon and the rest of the staff in theatre. I find it calms everyone down including the patient. Almost all my surgery is under topical anaesthesia,” he explains.

Ninety percent of the time the music playing in his operating room is from the radio, the rest of the time a CD player provides some ambient tunes.

“During surgery we simply avoid anything too loud and anything that may startle the patient or anyone of the staff, such as music with loud drum solos or very high pitched singing. The music is quite soft so that it’s still very easy for the patient and I to communicate. We’re never ‘fighting to be heard’ against the music.”

Mr Cummings says that all of his staff in theatre gets to pick the music and put whatever they like on. “It’s mostly laid-back, easy listening type of music so there are not too many surprises at all in terms of song choices or CD choices,” he adds.

But the last word is always left with the patient. If they would prefer silence in the room, then the music is turned off.

Mr Butt in St James’s is convinced of the benefits of listening to relaxing music in the operating room. “Definitely, it has a very calming effect,” he asserts. “Obviously it all depends on the individual person but I feel very calm and relaxed and my concentration is in fact enhanced while listening to classical music in theatre. It brings with it a happy background factor and you tend to concentrate more during surgery,” he says, however he is aware that not all of his surgical colleagues share his fervour. “Many of my colleagues listen to music in theatre. They would have different music selections, whatever works for them and their team at the time, but some of my colleagues of course don’t listen to music at all while they work. That is their choice, this is how they work best, and in the end that is what is best for the patient.”

The overall feedback from Irish surgeons is that music can bring a welcome vibe to their operating theatre. It can help put them in the right frame of mind, relax the other members of the surgical team, and contribute to the feeling that the theatre is a refuge from their busy lives, a place where they can focus solely on the patient, the surgery and their skills. Musical tastes vary, from Sinatra to Debussy to Coldplay, but they are all united on one point: if at any stage the music interferes with the procedure at hand, the ‘off’ button is pressed.

Live from the OR

Combining music with surgery is what Dr Jorge Camara does best. As an internationally renowned ophthalmologist and classically trained pianist, Camara has infused what he says are clinically proven relaxing properties of classical music with medicine to produce a recently released album, Live from the Operating Room.

The CD was recorded in the operating theatre of then St Francis Medical Center in Honolulu (now Hawaii Medical Center East) when he played live classical piano music for 115 patients before operating on their eyes.

He believes it's the first study in which a surgeon performed on a piano in an operating room for patients before surgery.

The patients, aged 49 to 79 years old, were having surgery for the first time. Camara’s study reports average decreases of 21 per cent in their blood pressure, 8 per cent in heart rate and 21 per cent in breathing rate.

The music had "profound" physical benefits, lowered the patients' blood pressure and heart and respiratory rates before any sedation or pain medication, according to a paper in the Medscape Journal of Medicine (Medscape J Med. 2008;10(6):149).

“My co-researchers and I found that playing live classical music for patients significantly brought down their blood pressure, heart rate and breathing rate. We published the study to share the information with other physicians, and I decided to release the music from the study so that other people could benefit from the music without necessarily having to undergo surgery,” explains Dr Camara, who is Clinical Assistant Professor of Ophthalmology at the University of Hawaii’s John A Burns School of Medicine.

The album includes many recognisable pieces, including Chopin’s Nocturne In E Flat, Etude in E Major and Beethoven’s Moonlight Sonata. More information about Dr Camara, his work and music is available on his website: http://www.livefromtheor.com/themusic.html

Medical Myth Busters

You know you’ve struck a sensitive cord with the medical profession when you’re forced to take out a restraining order against an abusive and threatening doctor. Such is the price for debunking myths, half-truths and outright lies about our health.

When American paediatricians Aaron Carroll and Rachel Vreeman published their book ‘Don't Swallow Your Gum!’ last year, which tackles commonly held medical beliefs, laying out the science that proves or disproves them, they were somewhat prepared for the negative backlash that ensued. Apparently, their earlier British Medical Journal article in 2007, which set the record straight on the top ten medical myths, triggered a bombardment of criticism from doctors who simply refused to let go of their long-held beliefs.

"We were shocked at how many people had strong reactions to the beliefs we debunked in the BMJ studies. These myths may be things people have heard since childhood, like 'you lose most of your body heat through your head.' Some people have a hard time letting these beliefs go," offers Dr Rachel Vreeman, Assistant Professor of Paediatrics at the Indiana University School of Medicine (IUSM) in Indianapolis.

Dr Aaron Carroll, who is Associate Professor of Paediatrics at IUSM, told Scope: “People believe these things incredibly strongly. We were just hit hard. There were a lot of complaints. On the BMJ website, for the first paper, they allowed people to post comments and some of them were really very angry, you know, personally attacking us. We were not expecting that,” he laughs. “We had one gentleman here in the United States, who was so angry about our conclusions about the recommended eight glasses of water a day that he phoned repeatedly and was so abusive to our staff they had to get a police restraining order against him to get him to stop calling back!”

The fact is there is no scientific proof stating that you need to drink anywhere near eight glasses of water. One doctor who made this his research focus, Dr Heinz Valtin, searched through many electronic databases and also consulted nutritionists and colleagues who specialise in water balance in the body. In all of his research, and in all of the research Drs Carroll and Vreeman conducted to double check his work, no scientific evidence could be found to back up the daily requirement of eight glasses of water.

“The water in coffee is water, and the water in fruits and vegetables is water. The body doesn’t know the molecule difference, water is water and it’s all good. Actually people should be careful not to drink too much water,” Aaron cautions, referring to a recent and much publicised death of a young woman who participated in a water drinking contest hosted by her local radio station in the US. Too much water dilutes the normal level of sodium in the blood, causing hyponatremia, in which the brain cells can swell and die.

In their book, ‘Don't Swallow Your Gum! And Other Medical Myths Debunked”, Drs Carroll and Vreeman take on all those weird and worrisome things we think about our body and expose them for what they are. The authors blend authoritative research with a breezy sense of humour, providing the ultimate myth-busting collection of more than eighty enlightening, practical, and quirky facts about health and wellbeing.

Aaron, who is Director of the Center for Health Policy and Professionalism Research at IUSM, admits that he had assumed most doctors, armed with their medical training, might have been less inclined to entertain some of the commonly held myths about health.

“I don’t think you can generalise too much but doctors are just as guilty, we are all human beings and most of these myths are things you’ve heard from your parents back in the day so you just believe it’s true.

“And you’d be shocked at how much in medicine is ‘best guess’. As doctors, we are use to taking what we’ve been told or taught or using experience to decide how to actually practice medicine, and unfortunately some of the stuff we’ve been told is not correct. Doctors are often the most difficult to change minds because they are just so convinced that not only are they correct personally but professionally as well. It is very difficult to change their minds,’ he observes.

Aaron readily confesses that he was just as misguided in some of his long-held beliefs as the next person.

“The really fun part of writing this book was that we had believed so many of these myths - but upon reflection, we weren't sure whether they were true or not. As health services researchers, we couldn't resist the temptation to be myth busters.

“I’m a paediatrician and I can tell you that I spend hours talking about the myths that concern kids, such as teething doesn’t cause a fever – lots of paediatricians believe that – the truth is teething doesn’t cause a fever but I hear doctors say it does all the time. And I still hear people who really believe that sugar makes kids hyper and that is absolutely not true. In fact that was one myth I firmly and absolutely believed. It blows my mind to this day! I have three kids and I was convinced that giving them sugar made them hyper but it simply isn’t true.

“Another one is that Turkey makes you sleepy, I mean, I just believed that. Everybody knows it’s the tryptophan. The sleep-inducing effects of tryptophan in turkey are common currency in America, I just absolutely knew that was true, but then to find out that, first of all, Turkey isn’t high in tryptophan, and then that tryptophan needs to be taken on an empty stomach - the worst way to get it is a big meal - that was just mind blowing.

“But I can rattle off others too. I thought a dog’s mouth was cleaner than a human’s. I thought you needed eight glasses of water - I assumed that was proven science. There were just lots and lots of them. I absolutely believed as many of these as anyone else who’s reading them. Like eating at night, I totally believed that eating at night made you fat. Every weight loss programme in the United States says that, so I assumed it was true. If you eat and go straight to bed it turn right to fat but that is totally not true.

“My favourite two are probably sugar makes kids hyper and turkey makes you sleepy, those are probably the two that I believed the most strongly and they have the most unbelievable solid evidence showing that they’re just not true,”

Their book, which was published by Penguin in Europe in November 2009, is divided into six sections:

"Look at the size of his feet!" Myths about your body

"Do you want to catch pneumonia out there?" Myths about how we contract and treat diseases

"But I was on the pill!" Myths about sex and pregnancy

"He won't get into Harvard without Baby Einstein" Myths about babies and children

"Don't swallow your gum!" Myths about what we eat and drink

"Shots made my baby autistic" Myths that spark controversy and debate.

Already on its fourth reprint in the USA – an impressive result for a paperback – the concept for this quirky book of endlessly fascinating and occasionally disgusting facts (aren’t they the best?) actually began as a conference paper. Aaron and his then Fellow, Rachel, delivered a hugely popular talk exposing the top ten medical myths to a meeting of paediatricians in the US several years ago. Their paper was later published in the BMJ and ever since both doctors have been contacted by email, text and casual conversation about a myriad of health-related myths.

Ranging from the curious to the seriously bizarre, they began compiling a list of myths that would provide the bones of a book for which they would fill in the flesh through a fact-finding trawl of medical and scientific research.

Although co-authoring a book can be notoriously problematical, the two colleagues fell easily into pace not only with each other’s writing styles but also with proportioning the workload.

“It was pretty easy for us. Perhaps that’s because, in writing medical research, you’re a little more use to collaboration. Papers have multiple authors almost every single time and so you get use to one person taking the lead and another person doing serious editing.

“For this book, we would divide up chapters and divide up responsibilities. Sometimes I’d be responsible for doing the research and then hand it off to Rachel to write up that chapter, and sometimes we’d do the opposite. In fact, we got so use to working and writing together that we will have arguments to this day over who wrote which chapter so I guess that speaks well of the fact that our writing merges well. 

“We’re from the same division in the same department in the same hospital (Riley Hospital for Children). We’ve been colleagues and worked together for such a long that it wasn’t that big a deal. There wasn’t any competition between us either, we were both doing this for fun and it was exciting. Neither one of us expected it to go this far,” Aaron admits happily.

Their extensive research has secured a large fan-base, along with the inevitable detractors of course, and their work has been featured in The New York Times, USA Today, The Los Angeles Times, Scientific American, Newsweek, and many other publications. They have also appeared on Good Morning America, CBS Evening News, and ABC News NOW, as well as attracting a host of the international media.

When Aaron reveals that he and his myth-busting partner are now talking to their agent and editor about writing a sequel to their runaway success, it requires a true feat of will power not to blurt out some myths of my own.

Eventually, I relent – joining the many before me proffering their myths - and I suggest that they research whether ‘sea air’ is the appetite stimulating, sleep inducing constituent my mother has long claimed it to be.

Aaron graciously appears interested, almost fascinated. He has never heard that one, and will certainly look it up. If the scientific research is available on the miracles of ‘sea air’, he assures me it will make the cut for their next book. I tell him my mum would be delighted “But you realise,” I hasten to add. “You’re going to have to prove her right.”

How Bizarre!

During his daily clinic, paediatrician Aaron Carroll hears many myths from mothers concerning their baby’s health and wellbeing. “There are some that come into play that are just really strange,” he confides.

“Like there’s a group of mothers who believe that breast milk can be used for everything, including curing ear infections. They think if you put it into someone’s ear it’ll cure their ear infection. They also recommend breast milk in the eye for eye infections or pink eye. Some of their other suggestions for any spare breast milk you might have around the house include clearing up a stuffed-nose or easing a sore throat, removing make-up and healing mosquito bites. It’s crazy.

“I remember I met one set of parents who believed that if they blew tobacco smoke into a child’s ear it would prevent ear infections. Oh my God! Why would you ever want to blow tobacco smoke at a child’s face? But people believe crazy things all the time.”

In this book “Don’t Swallow Your Gum”, Aaron and his co-author Dr Rachel Vreeman select several other bizarre myths and the peculiar individuals who believe them.

In exposing the myth that you can beat a breathalyser test by, for example, sucking on cough drops, onions, peanuts and pennies; they recount the true story of one intoxicated man who even thought that a mouthful of his own faeces would stump the breathalyser. His blood alcohol level was found to be twice the legal limit.

“We think that most people would have to be more drunk than that to lean over, poo in their own hand and then stuff it in their mouth,” the writers remark.

The truth is hard to swallow

The next time you are at a party and considering a plunge into the dip bowl, perhaps you should take a look at the people around you. Would you kiss them or lick the insides of their mouths, ask the two medical scribes of “Don’t Swallow Your Gum”.

Apparently, one intrepid group of microbiologists, led by Dr Paul Dawson, studied whether or not bacteria were really transferred from mouth to chip to dip (the double-dipping scenario). Their findings revealed that on average three to six double dips transferred about 10,000 bacteria from the eater’s mouth to the dip.

And another group of food scientists and microbiologists decided to put the ‘five second’ rule to the test to find out what happens when this myth comes up against Salmonella typhimurium, a fairy common but nasty bacterium.

They found that bacteria were still alive after four weeks on a variety of floor surfaces, although the rate of transfer varied. The worst offender of the five-second rule was tile, from which over 99 percent of the bacteria cells transferred to the dropped food after just five seconds.

As for the book’s title myth of swallowing chewing gum, does it actually stay in your stomach for seven years? The reality is, even though gum is sticky, it is no match for your gut and like all indigestible foods will eventually be “pooed out by the power of peristalsis”.