Since the Birmingham Medical Research Expeditionary Society (BMRES) was founded in 1976, more than a hundred members have taken part in 15 research expeditions to the Greater Ranges as well as countless trips to mountains closer to home. Founding member, Professor Jo Bradwell, has recently published "Gasping Thin Air", a book that fondly describes the history of BMRES, describing not only the people and the places visited, but also the extraordinary research that has been undertaken over the years. If the text wasn't enough, the book is beautifully illustrated with line drawings and photographs throughout, making it a real feast for the eye. For anyone interested in mountain medicine this book will prove hard to resist! We took the opportunity to catch up with Jo during lockdown to talk to him about "Gasping Thin Air"...
Many congratulations on producing such a wonderful book. Can I start by asking what your hopes were for BMRES when it was founded back in 1976? Did you ever imagine that on it's 45th anniversary you'd be looking back on 15 expeditions to the Greater Ranges?
None of us thought beyond the first expedition. We imagined it was a single chance of a lifetime. We needed a month off service when holidays were no more than two weeks and we had massive workloads. However, its scientific success sufficiently impressed our bosses and colleagues for them to accept that we had not ‘only been on holiday’. The trip was, of course, very enjoyable but its scientific success allowed us to obtain grants for subsequent research.
In September 1977, 17 members of the newly formed BMRES left for Nepal with the aim of completing the challenging trek from Pokhara to the Thorong La (5416m). Later, Jo would write, "somewhat to our surprise, we discovered that acute mountain sickness was a very real disease with several expedition members becoming ill..."
From reading the book I got a strong sense that it was important to conduct scientific research on these expeditions. Did you feel, as Sir Walter Scott once wrote, "to enjoy leisure, it is absolutely necessary it should be preceded by occupation"?
The research allowed us, as friends and colleagues, to go on the expeditions. Colleagues, bosses and wives accepted that research was a good reason to visit the mountains. A mere holiday would not have been allowed. Yes, it was an escape from preoccupying jobs, but we also enjoyed the research, its scientific impact and the focussed intellectual challenges of working on interesting projects in wonderful environments.
The founding of BMRES coincided with the publication of Peter Hackett's landmark study on Acute Mountain Sickness (AMS). Were you aware of this study at the time? Did this direct your early research?
Peter Hackett’s paper on AMS and acetazolamide (Diamox) was not the reason for BMRES starting but it was a great focus for our studies. His work had flaws that we could address with more scientific rigour which directly led to some of our most exciting studies. There were other publications in the field and Hackett’s paper was not the first on Diamox, but undoubtedly his Lancet paper was very important.
Dr Peter Hackett was one of the first to study the impact of acetazolamide upon the incidence of AMS in trekkers visiting the Himalayas. A dose of 250mg BD for 4 days was found to reduce the incidence of AMS from 69% to 24% (P<0.01) in those trekking to Pheriche (4243m). Nevertheless, he concluded that a, "leisurely ascent, climbing high but sleeping low, is the safest method of walking up a high mountain trail"
Organising an expedition is never easy, especially when there is research to conduct. You write at one point of, "last minute problems which dogged us from time-to-time". What would you say were the greatest challenges that you and your team overcame in order to get the science done?
All of us had full-time jobs, many as busy clinicians, so little thought went into expedition research until near departure date. Then we really focused on what we needed to do. This led to new thoughts and ideas which were crammed into the last few weeks. Hence, extra last minute projects and logistical problems.
In January 2016, BMRES researchers embarked upon an ambitious series of experiments at the Whymper Refuge (5043m) on Chimborazo (6263m). Essential to much of their work was a state-of-the-art horizontal exercise bike. However an electrical fault nearly led to disaster until, "Cas came to the rescue. He realised that, whilst the wiring looms in the device were properly connected, the electronics were locked, perhaps because of a power surge from the generator. The central processor would need resetting. Remarkably he had brought a USB electronic toolbox ... Cas downloaded a program from his toolbox and reprogrammed it. It was resoldered and worked perfectly. Truly remarkable..."
Over the years a number of BMRES studies have looked at the impact of acetazolamide upon high altitude acclimatisation and performance. Early work showed a number of benefits - improvement in cerebral blood flow, a reduction in muscle loss and a lowering in the incidence of AMS. However more recent BMRES studies reveal a reduction in physical performance, especially in those who may be slow to excrete the drug. Does acetazolamide still have a role to play at high altitude?
Acetazolamide is a very important prophylactic and treatment for AMS. However, its mechanism of action relies on slowing down CO2 removal from the tissues (carbonic anhydrase inhibition). Its retention in the breathing centres leads to increased ventilation rates despite respiratory alkalosis from over-breathing at altitude. However, CO2 retention in exercising muscles decreases their pH and reduces maximum exercise ability. This is inconsequential in the normally prescribed doses. Individuals merely walk more slowly but it does reduce maximum exercise. However, without acetazolamide, users might develop AMS and walk even more slowly!
You write very fondly about the members of your expedition and the responsibility you felt towards them. At one point stating, "The research and experiments may be the bricks of the BMRES structure, but the high mountains with their skiing and climbing were the fire escapes from high pressure jobs in hospitals". But on several occasions members were unsuccessful or in some cases, sick. Did you find this stressful? How did you cope?
BMRES comprises a group of individuals who take their own responsibilities. They won’t be told what to do! They are all “consenting adults”. As regards health risks, there are always a dozen or more highly experienced doctors on the expeditions. Compared with most, who rarely have experienced doctors, ours are medically very safe. It is upsetting to see others suffering in the cause of science, but I only once felt there was serious danger and that was when we were trapped in a snow storm on Kanchenjunga.
In October 1999, BMRES headed back to Nepal and trekked to a series of remote settlements close to the world's third highest mountain - Kanchenjunga (8586m). Heavy snows and a high incidence of AMS led eventually to the science being abandoned. A treacherous descent followed through a maze of footpaths and deep snow. The very real risk of avalanche was never far away...
Is there one expedition that stands out for you? Or perhaps just a moment or two that has stayed with you?
The first expedition stands out, as does the first expedition for everyone. The beauty of the huge mountains, the excitement of being there with close friends for the first time and the surprise of seeing AMS with all its manifestations. I still remember every evening camp site from all the expeditions and that comprises a year or more in the mountains! That cannot be said of any week, month or perhaps even a year in a lifetime of medical practice!
You start the description of the expedition to Sikkim in October 2019 with the words, "The changing of the guard. The youngsters are taking over. Only John Delamere and I remained of the 17 keen young doctors that took to the Himalaya in 1977...". What hopes do you have for the future of the BMRES?
The next trip is to Annapurna in October 2021 and we already have well-planned research projects!
Following research in the Margherita Hut in 1989, Tim Harvey wrote,
"There are so many grey days, months and years that slip by without leaving any mark on the memory, but these brief moments of adventure, peril, beauty, terror, exhilaration, achievement, trust, fellowship and friendship are etched on the soul forever"
Thanks Jo for speaking to us.
“Gasping Thin Air” is highly recommended and is available from your local bookseller!
The Birmingham Medical Research Expeditionary Society (BMRES) and the British Mountain Medicine Society (BMMS) have joined forces to organise the 2021 Altitude Research Conference. The face-to-face event will take place in Birmingham on the 11th September. Speakers will include Jo Bradwell, Peter Bartsch and Chris Imray. There will also be presentations from members of the UK's leading research groups as well as ample opportunity for researchers, young and old, to present posters and short talks about their work.
Further details can be found here.
A series of extracts from the book will be published on the blog in the coming weeks. Part 2 can be found here.
If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.