technology future healthcare - aia washington...
TRANSCRIPT
Richard M. Satava, MD FACSProfessor of Surgery
University of Washington
and
Senior Science Advisor
US Army Medical Research and Materiel Command
Challenges in Designing
Technology Future Healthcare
and the
Orthopedic Surgery Simulation Summit
American Academy of Orthopedic Surgeons
Chicago, IL
4 November, 2011
Hospital of the Future
of
Richard M. Satava, MD FACS
Financial Support: None (… but still hoping)
Consulting: Karl Storz
ISIS Support Stryker
SimuLab
US Surgical
Investment InTouch Technologies, Inc
* There will be no discussion of products from these companies
Presenter Financial Disclosure Slide
“The Future is not what it used to be”
….Yogi Berra
Disruptive Visions
What does your patient want?
Super Her
Arrives in the office and expects:
Infinite amount of time
Instant diagnosis
Immediate treatment
Absolutely no pain
Leaves cured!
EXP
E
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T
A
T
I
O
N
S
Physician and Nurse as
Expectations are high . . .
. . . Challenges are great
What This Is NOT About
What This Is All About*
Replacing healthcare providers with robots
Dehumanizing patient care
Enhancing healthcare providers capabilities
Freeing time for more patient contact
* Lessons learned from the 58th Congress of the AORN, Philadelphia Pa, March 2011
New technologies that are emerging
from Information Age discoveries
are driving our basic approach
in all areas of healthcare education
. . . EXAMPLES
Fundamental Concept
“The Future is here …
. . . it’s the Information Age”
Current Visions
Why Robots?
The Touch Lab, MITMovie: Alien
S
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M
U
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The Industry Standard
CAD/CAM
Virtual Design
Virtual Prototyping
Virtual Testing & Evaluation
HolomerTotal body-scan
for total knowledge
Satava March, 2004Virtual Soldier Program
Information Representation of a PatientMedical equivalent of CAD/CAM
Multi-modal total body scan on
every trauma patient in 15 seconds
Why modeling & simulation,
imaging and robotics
• Healthcare is the only industry without a
computer representation of its “product”
•A robot is not a machine . . .
it is an information system with arms . . .
• A CT scanner is not an imaging system
it is an information system with eyes . . .
thus
• An operating room is an information system with . . .
Original courtesy of Joel Jensen, SRI International, Menlo Park, CA
Minimally Invasive& Open Surgery
Pre-operative planning
Surgical Rehearsal
Intra-operative navigation
Remote Surgery
Energy- directed surgery
Total Integration of Surgical Care
Simulation & TrainingPre-operative Warmup
Risk
Mgmt
Credential
Privileges
Patient
Safety
Central
Supply
Quality
Improve
Electronic
Record
Total Integration of Surgical Care
Information
From tissue and instruments
to
Information and energy*
* “The Information Age is about changing from objects and atoms to bits & bytes”
Nicholas Negroponte “Being Digital” - 1995
The Fundamental Change
Intelligent Instruments
Courtesy Blake Hannaford, PhD, BioRobotics Lab, University of Washington, Seattle 2009
Point-of-care Noninvasive Therapy
High Intensity Focused Ultrasoundfor
Non-invasive Acoustic hemostasis
HIFU
Courtesy Larry Crum, Univ Washington Applied Physics Lab
Mechanics to energy
Courtesy Larry Crum,
Univ Washington
Applied Physics Lab
2003
Insure safety of other cells and tissues
Painless
Sterilization without supplies
100% effective
30 sec, Continuous DBD, 8kHz
Power: 0.8 W/cm2
Plasma Medicine
a. Low temperature (room temperature)
b. Normal pressure (not a vacuum)
c. Low energy required to generate
d. Normal atmosphere – room air (not noble gasses – argon, etc)
e. Untethered (hand held, battery generated)
f. Tolerated by human tissue (eukaryotic cells)
g. Surface phenomenon (< 1 mm penetration)
h. Kills all known biologic agents
Free electron Di-electric Barrier Discharge (FE-DBD)
The Science
Plasma Medicine
Sterilization & decontamination
Cutting, coagulation & ablation
Surgical instrument & procedure
Wound healing & regeneration
Molecular activation & inhibition control
Cancer & disease control/cure
Clinically Relevant Applications
The LSTATLife Support for Trauma and Transport
Courtesy of Integrated Medical Systems, Signal Hill, CA
“ . . . with a fully functional ICU ”
• Defibrillator
• Ventilator
• Suction
• Monitoring
• Blood Chemistry
Analysis
• 3-Channel Fluid/Drug
Infusion
•Data Storage and
Transmission
• On-board Battery
• On-board Oxygen
• Accepts Off-Board
Power and Oxygen
Total Patient Awareness
Bring the hospital to the casualty, not the casualty to the hospital . . .
212th MASH Deployed with LSTAT - Combat Support Hospital
LSTAT Deployment to Kosovo - March 2000
Courtesy of Integrated Medical Systems, Signal Hill, CA
LSTAT- lite
Classic Education and Examination
What is the REVOLUTION in Surgical Education?
Training for New Technical Skills
Halstedian Model: See One, Do One, Teach One
The Revolution
is
. . . Now
Roughly 100 year cycles
(1908 – Flexner Report)
Inter-professional Education
Improved Patient Safety
through
Advanced Medical Education
ManikinVirtual Reality
It’s all about . . .
Technology
Current areas of simulation
VirtualVirtual Live Constructive
ManikinVR
CAI
Models, tissue, animals
MethodologyObjective StructuredAssessment of Technical Skills
Richard Reznick, Univ of Toronto - 1998
OSATS
• Objective Training of Technical Skills
Simulators (technology)
Curriculum (training method)
• Assessment of Cognitive and Technical Skills
Criterion-based tools
Objective metrics
Two Components of the Revolution
Using Modeling and Simulation
Synthetic Cadaver
From website of Syndaver Labs, Tampa, FL http://syndaver.com
Realistic synthetic tissues., organs etc
Vascular system which can pump ‘blood’
CR, MRI, US and fluoroscopy compatible
Anatomy and physiology teaching
Procedural training
Surgical rehearsalUses P
ropert
ies
Mannequin-based Simulator - Realistic physiologic response
Individual and Team Training
Human Patient Simulator 2005Courtesy METI, Inc Sarasota, FL 2006
First Mannequin VR Simulator – David Gaba 1984Courtesy MedSim, Inc - 1991
The Realization
The Dream
Ready - Stop & Time out
Set - Warm up & Check List
Go - OK to begin
Society of Laparoscopic Surgeons (SLS) – URL =
The Importance of Check-lists
Nurses Residents
OR
of
Pre-op ICUHand-off Hand-off
Real Pre-op Holding Area
Pre-operative Planning and Surgical Rehearsal
Courtesy Jacques Marescaux, IRCAD, Strasbourg, France, 2003.
Endovascular Simulators(Surgical Rehearsal)
Graphic
overlay
Patient specific image
Pre-operative Warm-up
Courtesy Marshall Smith, MD
Kanav Kahol, PhD
Portable Simulator rolled into the OR
25% errors 45% efficiency
25% time
Basic Skills
Simple Procedures
Team Training
Advanced Procedures
Continuity of Care
Comprehensive Curriculum
Task
Deconstruction
“Penelope” – robotic scrub nurse
Michael Treat MD, Columbia Univ, NYC. 2003
ROBOT SURGICAL TECHNOLOGIES, INC
Currently in Clinical Trials
Integrating Surgical Systems for AutonomyThe Operating Room (personnel) of the Future
100,000
Borrowing from the standard practices of other industries
Surgeon Assistant Scrub Nurse Circulating nurse
Demonstration of Phase 1
Operating Room with No People
SRI International, Menlo Park, CA January, 2007
SRI International, Menlo Park, CA January, 2007
Demonstration of Phase 1
Operating Room with No People
SATAVA 7 July, 1999
DARPA
Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003Predator 2003
28 Training & Simulation Journal August/September 2006
“Remote Pilots”
A last bastion of guts-and-glory aviation is falling, as
the U.S. Air Force prepares to unveil a new breed of
unmanned aircraft pilots. Known as “remote pilots”,
they’ll wear wings. They’ll fly aircraft. But chances are
many will never climb into a cockpit. .
Senior leaders have yet to approve the new
Undergraduate Remote Pilot Training (URT), but Air
Force officers familiar with the project expect approval
by the end of the year. Instead of sticking reluctant
manned aviators behind a console, the Air Force will
groom remote pilots from the start to fly what the
service now calls unmanned aerial systems
In Hospital OR Free- standing same day surgery In-Home surgery??
Eric LaPorta, Barcelona, Spain 2005
New Concepts for OR of the Future“The OR Without Lights”
Hybrid Operating RoomImage-guided Surgery
Triangle Biosystems,Inc
Neurosurgical Interventional SuiteReal-time multi-modality monitoring of imaging and physiologic data
Radiology or Surgery?
Non-invasive tumor ablation for solid organs (0.3mm accuracy)
Surgeon should be part of planning and implementation team
Surgeons may want to ‘adopt’ implementation
Accuray(Cyberknife)
Emergency Room Trauma Portal
+ TRAUMA PORTAL +
106% of severe trauma patients get CT scans Adrian Park, Univ MD Shock Trauma Service, 2009
Robotic Medical Assistant
SATAVA 7 July, 1999
DARPA
Nursing shortage crisis
Applicable at all levels
Hospitals
Clinics
Nursing Home
Assisted living
Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA
Humanoid Robot - navigation
Courtesy Boston Dynamics, Boston MA 2012
SATAVA 7 July, 1999
DARPA
The Information Age is NOT the Future
The Information Age is the Present ...
There is something else out there . . . .
Disruptive Visions
http://depts.washington.edu/biointel
“The Future is not what it used to be !”
- Yogi Berra
What is radically new?
Biomimetic Micro-robot
Courtesy Sandia National Labs
Capsule camera for gastrointestinal endoscopy
Courtesy Paul Swain, London, England
Courtesy D. Oleynkov, Univ Nebraska
Courtesy Danny Scott
Texas Southwestern
Dallas, TX
Core capsule
systems: optical
system, telemetry
and power
systems,
navigation etc.
Diagnostic
system: sensors
for enhanced
diagnosis
Therapeutic /
biopsy system:
devices for tissue
manipulation
Locomotion
system: actuators
for mobility.
Supported by the European Union as an Integrated Project
Information Society Technologies - Contract Number 033970
www.vector-project.comCourtesy Marc O. Schurr &
The VECTOR consortium - 2008
External magnetic guidance
Self-propelling Gastrointestinal EndoscopeCore functions
Locomotion Modular functions
Fluid environment
Vibratory locomotionWalking robot with legs
Internal Locomotion Actuators Currently Investigated
Source : A Menciassi et al., CRIM, Scuola Sant‘Anna, Pisa
Submarine
Source: M. Sfakiotakis et al., FORTH, Heraklion
Supported by the European Union as an Integrated Project
Information Society Technologies - Contract Number 033970
www.vector-project.com
Courtesy Marc O. Schurr &
The VECTOR consortium - 2008
Acrobat Document
Cold Spring Harbor Laboratory, Long Island, NY
Femtosecond Laser(1 x 10 –15 sec)
Time of Flight Spectroscopy
Cellular opto-poration
Los Alamos National Labs, Los Alamos NM
Surgical Console for Cellular Surgery
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Motion Commands
Surgical Console for Cellular Surgery
Courtesy: Rahul G. Thakar, Ph.D. 2007
Molecular Imaging
BioSurgery
Femtosecond Laser
Specific DNA targeting
Atomic Force Microscopy
Sonoporation of an ion channel
New Surgical Tools
Surgical Cockpit
Greg Kovacs. Stanford University, 1990
“BrainGate” John Donohue, Brown University, 2001
Richard Andersen, CalTech, 2003
Recorded activity for intended movement to a briefly flashed target.
TARGET MOVEMENT
Time
PLAN
Courtesy Richard Andersen, Cal Tech, Pasadena, CA
Brain Machine Interface – Controlling motion with thoughts
Miguel Nicholai, Duke University, 2002
Direct brain implant control of robot arm
Brain Machine Interface – Controlling motion with thoughts
Brain Machine Interface – Controlling motion with thoughts
Courtesy University of Hawaii 2008 Emotiv Technologies, 2009
a) Rheo Bionic knee Ossur, Reyknavik, Iceland
b) C-leg Otto Bock, Minneapolis, MN
Intelligent Prostheses Tissue Engineering
Liver Scaffolding Artificial Blood Vessel
J. Vacanti, MD MGH March, 2000
Artificial Ear
Replacing Human Body Parts
Organs which have been grown synthetically
3-D Printing (Stereo-lithography)
The Future of Surgery
3-D Printing (Stereo-lithography)
The Future of Everything?
Beyond Internet
Thingiverse
Internet of things
Replicator by MakerBot, Inc
Spider silk protein as biomaterial -BioSteel
Nexia Biotechnologies, Montreal Canada
Cross section of
synthetic fiber
Spinnerette of spiderOrb spider - web
Genetically Re-engineering the Body
ScienceDaily (July 27, 2010) — Researchers
have long envied spiders' ability to manufacture
silk that is light-weighted while as strong and
tough as steel or Kevlar. Indeed, finer than
human hair, five times stronger by weight than
steel, and three times tougher than the top quality
man-made fiber Kevlar, spider dragline silk is an
ideal material for numerous applications.
Professor Lee and his colleagues pieced
together the silk gene from chemically
synthesized oligonucleotides, and then inserted it
into the expression host, an industrially safe
bacteria Escherichia coli Moreover, many
other silk-like biomaterials such as elastin,
collagen, byssus, resilin, have similar features to
spider silk protein
Native-Like Spider Silk Produced in
Metabolically Engineered Bacteria
E.Coli engineered to produce silk
Prof Sang Yup Lee, Korea Advanced Institute of
Science and Technology (KAIST) in Daejeon, Korea
Floss DM, Sack M, Stadlmann J, Rademacher T, Scheller J, Stöger E, Fischer
R, Conrad U.. Biochemical and functional characterization of anti-HIV
antibody-ELP fusion proteins from transgenic plants.. Plant Biotechnol J.
2008 May;6(4):379-91.
Genetically Re-engineering Food & Drugs
Tobacco Plants Make HIV AntibodyFor the first time, a plant-produced antibody gets the
green light for clinical trials in the United Kingdom.
By Cristina Luiggi | July 21, 2011
Last month, a monoclonal antibody produced in the leaves
of tobacco plants entered phase I clinical trials in the United
Kingdom. The antibody, known as P2G12, recognizes an
HIV surface protein and is expected to help stop the
transmission of the virus, although it has never been tested
in humans.
This is the first plant-produced antibody to be cleared for
clinical trials by the Medicines and Healthcare Products
Agency Producing the antibody using tobacco plants grown
in a greenhouse in Germany is 10 to 100 times cheaper than
using conventional methods employing bacteria or
mammalian cells, Smart Planet reports
“Monoclonal antibodies can be made in plants to the
same quality as those made using existing conventional
production systems,” Professor Julian Ma from St George’s
University, London and joint coordinator of the project, told
“That is something many people did not believe could
be achieved.”
Posted on: 27 Jun 2011, 08:43 PM
Test tube-burger coming soon
London: Coming soon, the world's first test-tube
hamburger, say scientists. A team at Maastricht
University in the Netherlands claims that the first such
laboratory-made burger could be a year away. It will
have meat grown from stem cells, paving the way for
eating meat without animals being slaughtered.
The Scientists are currently developing the burger
which will be grown from 10,000 stem cells extracted
from cattle, which are then multiply more than a billion
times to produce muscle tissue similar to beef. The
product is called "in vitro" meat .
Prof Mark Post, who is leading the team, was quoted
as saying, "I don't see any way you could rely on old-
fashioned livestock in the coming decades. In vitro meat
will be the only choice left.” .
A colleague of Prof Post said, "When we are eating a
hamburger we don't think, 'I'm eating a dead cow'. And
when people are already far from what they eat, it's not
too hard to see them
Prof. Mark Post, Maastricht University Netherlands, 2011
Sep Oct Nov Dec Jan Feb Mar Apr May
bo
dy tem
pera
ture
(oC
)
-5
0
5
10
15
20
25
30
35
40
45arctic ground squirrel
Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02
Institute of Arctic Biology’s
Toolik Field Station,
Alaska's North Slope
Suspended Animation (Auto-anesthesia – FRAMR)
metabolic rate 0.5 0.01 (2%)
active hibernating
body temp. 37oC -2oC
gene ongoing transcription
function and translation suppressed
heart rate 300 3
resp. rate 150 <1 (breaths/min)
(beats/min)
(mlO2/g/h)
Confidential
Hypothesis
Design
Experiment
Results
Report
In Science and Discovery,
there is always Risk . . .
The Scientific Method
… make evidence-based decisions
The only thing more dangerous
than trying too hard and failing …
… is not trying hard enough
and succeeding ! Michelangelo 1503
Experience is the name everyone
gives to their mistakes - Oscar Wilde
Be careful of
unintended
consequences
• The rate of new discovery is accelerating exponentially
• The changes raise profound fundamental issues
• Moral and ethical solutions will take decades to resolve
Technologies Will Change the Future
Differing responses to scientific discovery by various sectors
TIME
Ra
te o
f C
ha
ng
e
Society
Business
Sector
Technology
Healthcare
Technology is Neutral - it is neither good or evil
It is up to us to breathe the moral and ethical life
into these technologies
And then apply them with empathy and compassion
for each and every patient
The Moral Dilemma
February 12, 2004
South Korean team demonstrates
cloning efficiency for humans similar to pigs, cattle | Thersa Tamkins
After outlandish claims, a few media circuses, and some near misses by legitimate researchers, a team of South Korean researchers reports the production of cloned human embryos. The findings, were released Wednesday (Science, DOI:10.1126 /science.1094515, February 12, 2004).Wook Suk Hwang and Shin Yong Moon of Seoul National University used somatic cell nuclear
transfer to produce 30 human blastocysts and a single embryonic stem cell line; SCNT-hES-1. Using 242 oocytes and cumulus cells from 16 unpaid donors, the group achieved a cloning efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%).
Human embryos
cloned
Chinese Cloning Control RequiredTuesday 16 April, 2002, 10:41 GMT 11:41 UK
Strict ethical guidelines are needed in China to
calm public fears about new cell technologies such
as cloning, the country's leading scientist said.
Professor Ching-Li Hu, the former deputy
director of the World Health Organization, was
speaking at the Seventh Human Genome Meeting
in Shanghai. His call follows recent reports that
Chinese scientists are making fast progress in
these research fields.
One group in the Central South University
in Changsa is said to be producing human
embryo clones, while another team from the Sun
Yat-sen University of Medical Sciences in
Guangzhou is reported to have fused human and
rabbit cells to make tissues for research.
Genetically “designed” child1997
Jeffery Steinberg, MD Fertility Institutes of Los Angeles
Five "designer babies"
created for stem cell
harvest
Five healthy babies have been born to provide stem
cells for siblings with serious non-heritable conditions.
This is the first time "savoir siblings" have
been created to treat children whose condition is not
genetic, says the medical team.The five babies were
born after a technique called preimplantation genetic
diagnosis (PGD) was used to test embryos for a tissue
type match to the ailing siblings, reports the team, led
by Anver Kuliev at the Reproductive Genetics Institute
in Chicago, US.The aim in these cases was to provide
stem cells for transplantation to children who are
suffering from leukaemia 'Unlawful and
unethical' However, the use of this technology to
provide a "designer baby" to treat an ill sibling is
highly controversial.A UK couple involved in this
1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
Preimplantation Genetic Screening
General Science: May 13, 2006
A British woman has become the first in the
country to conceive a "designer baby" selected
specifically to avoid an inherited cancer,
The woman, who was not identified, used
controversial genetic screening technology to ensure
she does not pass on to her child the condition
retinoblastoma, an hereditary form of eye cancer
from which she suffers.
Doctors tested embryos created by the woman
and her partner using in-vitro fertilisation (IVF)
methods for the cancer gene. Only unaffected
embryos were implanted in her womb, the
newspaper said.
It suggested the woman's pregnancy would
increase controversy over the procedure -- pre-
implantation genetic diagnosis (PGD) -- because
critics say it involves destroying otherwise healthy
embryos whose conditions are treatable.
Gregory Stock
Science Vol 315: 1723-25, Mar 2007
Emergence of Novel Color Vision in Mice Engineered
to Express Human Cone Photo-pigment
Changes in the genes encoding sensory recptor proteins are an essential step in
the evolution of new sensory capacities“new sensory capacities" . In primates, tri-
chromatic color vision evolved aftre changes in x chromosome linked photopigment genes.
Heterogous mouse females
human L pigments showed enhanced long-wavelength sensitivity and chromatic
discrimination. An inherent plasticity in the mammalian visual system thus permits emergence
whose retinas contained both mouse pigment andhuman L pigments
Extending Longevity
A strain of mice that have lived . . .
. . . more than three normal lifespans
Should humans live 200 years?
Life extension
Life extension consists of attempts to extend
human life beyond the natural lifespan. So far
none has been proven successful in humans.
Several aging mechanisms are known, and anti-
aging therapies aim to correct one or more of
these:
Dr. Leonard Hayflick discovered that mammalian
cells divide only a fixed number of times. This
"Hayflick limit" was later proven to be caused by
telomeres on the ends of chromosomes that
shorten with each cell-division. When the
telomeres are gone, the DNA can no longer be
copied, and cell division ceases. In 2001,
experimenters at Geron Corp. lengthened the
telomeres of senescent mammalian cells by
introducing telomerase to them. They then
became youthful cells. Sex and some stem cells
regenerate the telomeres by two mechanisms:
Telomerase, and ALT (alternative lengthening of
telomeres). At least one form of progeria (atypical
accelerated aging) is caused by premature
telomeric shortening. In 2001, research showed
that naturally occurring stem cells must
sometimes extend their telomeres, because some
stem cells in middle-aged humans had
anomalously long telomeres.
April 14, 2004
CAN I REPLACE MY
B O D Y ?
If I replace 95%
of my body . . .
. . . Am I still “human”?
Artificial organs
Smart Prostheses
Genetic engineering
Regeneration
Moral and Ethical Issues
Raised by Technological Success
will take DECADES of debate
Summary of Examples
Should we do research in areas we may not be able to control?
(eg, genetics, cloning, nanobots, intelligent machines?)
Will prolonging life result in more disease in the overall population
Can we change medicine from treatment to prevention of disease
In defeating diseases, will technology change a human into a combination
of man and machine - what does it mean to be “human”
How will we decide who gets the technology, especially in 3rd World
SATAVA 7 July, 1999
DARPA6
For the first time in history,
there walks upon this planet,
a species so powerful,
that it can control its own evolution,
at its own time of choosing …
… homo sapiens.
Who will be the next “created” species?
The Ultimate Ethical Question?
http://depts.washington.edu/biointel
Do Robots Dream ?