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Quarto evento dell'11/06/09 - Richard Satava

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Quarto evento dell'11/06/09 - Richard Satava

  1. 1. The Evolution of Hospitals The Next 50 Years Richard M. Satava, MD FACS Professor of Surgery University of Washington and Senior Science Advisor US Army Medical Research and Materiel Command The Future of Healthcare – A.B. Medica Milano, Italy 11 June, 2009
  2. 2. reetings from Monterey Californi
  3. 3. Presenter Financial Disclosure Slide 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
  4. 4. E X P What does your patient want? Arrives in the office and expects: E Infinite amount of time C Instant diagnosis T Immediate treatment Absolutely no pain A Leaves cured! T I Physician as O N Super S
  5. 5. Disruptive Visions “The Future is not what it used to be” ….Yogi Berra
  6. 6. The Change-makers The Technologies Robots (large and small) Imaging Systems Photonics Nano-(molecular-) systems Genetics Tissue Engineering The Intangibles Information (PHR – all bets are off – no hospitals?) Integration Interoperability Energy Education
  7. 7. Current Visions “The Future is here … . . . it’s the Information Age”
  8. 8. Fundamental Concept New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education ... EXAMPLES
  9. 9. Why Robots? Movie: Alien The Touch Lab, MIT
  10. 10. SThe Industry Standard I CAD/CAM M U Virtual Design L A T Virtual Prototyping I O N Virtual Testing & Evaluation
  11. 11. 2 t’s Time to Transition How we view the EMR - the Interface 0 Atari 1977 Mac 1984 1 5 Healthcare has yet to realize the potential of high performance computing & simulation By 2015 a laptop will compute at 1 TeraHz - today’s supercomputer Courtesy A. Tsiaras Anatomic Travelogue
  12. 12. Information Representation of a Patient Medical equivalent of CAD/CAM Holomer Total body-scan for total knowledge Multi-modal total body scan on Virtual Soldier Program every trauma patient in 15 seconds Satava March, 2004
  13. 13. Virtual Autopsy . . . . . . is a SIMULATED Autopsy Wound Tract Less than 2% of hospital deaths have autopsy Statistics from autopsy drive national policies
  14. 14. 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 . . .
  15. 15. Total Integration of Surgical Care Minimally Invasive Remote Surgery & Open Surgery Pre-operative planning Simulation & Training Surgical Rehearsal Pre-operative Warmup Intra-operative navigation Courtesy of Joel Jensen, SRI International, Menlo Park, CA
  16. 16. The Fundamental Change 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
  17. 17. Therapy Mechanics to energy HIFU High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis Courtesy Larry Crum, Univ Washington Applied Physics
  18. 18. Courtesy Larry Crum, Univ Washington Applied Physics Lab 2003
  19. 19. Sterilization without supplies Painless 10 % e c 0 ffe tive 3 s c C ntinuo DBD, 8 0 e, o us kHz Insure safety of other cells and tissues Power: 0.8 W/cm2
  20. 20. Treatment of Topical Wounds: Tissue Regeneration: Suppurated Burn Wound Before treatment After 7 days of plasma therapy (5 sessions)
  21. 21. Bring the hospital to the casualty, not the casualty to the hospital . . . “ . . . with a fully functional ICU ” The LSTAT Total Patient Awareness Life Support for Trauma and Transport • Defibrillator • Ventilator • Suction • Monitoring • Blood Chemistry Analysis • 3-Channel Fluid/Drug Infusion •Data Storage and Transmission • On-board Battery • On-board Oxygen Courtesy of Integrated Medical Systems, Signal Hill, CA • Accepts Off-Board
  22. 22. LSTAT Deployment to Kosovo - March 212th MASH Deployed with2000 - Combat Support Hospital LSTAT LSTAT- lite Courtesy of Integrated Medical Systems, Signal Hill, CA
  23. 23. Why now? VTOL UAV technology is maturing rapidly enough to minimize risk.
  24. 24. Aeromedical evacuation Nightingale UAV Goal  Identify “optimum” VTOL UAV design  Create a new VTOL UAV tailored to the operational need LSTAT
  25. 25. It’s all about . . . Improved Patient Care through Virtual Reality Manikin dvanced Medical Education
  26. 26. MEDICAL EDUCATION The Revolution is . . . Now Roughly 100 year cycles
  27. 27. Classic Education and Examination What is the REVOLUTION in Medical Education?
  28. 28. Training for New Technical Skills Halstedian Model: See One, Do One, Teach One
  29. 29. The New Mandates Effective 1 July 2008 All residency programs must have RRC* a skills training (simulation) center 1 July 2009 All surgical residents must pass FLS** ABS in order to apply for board certificate
  30. 30. Two Components of the Revolution Using Modeling and Simulation • Objective Training of Technical Skills Simulators (technology) Curriculum (training method) • Assessment of Cognitive and Technical Skills Criterion-based tools Objective metrics
  31. 31. Standardized Curriculum Suggested template • Goals of the Simulation • Anatomy • Steps of the Procedures • Errors TEST • Skills Training • Outcomes
  32. 32. Technology Current areas of simulation Models, tissue, animals Manikin VR CAI Virtual Virtual Live Constructive
  33. 33. OSATS Methodology Objective StructuredAssessment of Technical Skills Richard Reznick, Univ of Toronto - 1998
  34. 34. Pre-operative Warm-up
  35. 35. Surgical Rehearsal Courtesy Jacques Marescaux, IRCAD, Strasbourg France
  36. 36. Nurses Residents
  37. 37. of ER Hand-off OR Hand-off ICU
  38. 38. Comprehensive Curriculum Basic Skills Simple Procedures Advanced Procedures Team Training Task Deconstruction Continuity of Care
  39. 39. Disruptive Technology in Surgery N.O.T.E.S. N atural O rifice T ransluminal E ndoscopic S urgery Trans-Gastric Surgery New surgery for great new opportunities We need: New “tools” for the new procedures New simulators for education and training
  40. 40. Trans Oral Intra-peritoneal Surgery - Future Courtesy of N Reddy, Hyperbad India 20005
  41. 41. Endo-luminal Malignancies Robotic Endoscopic Mucosal Resection - EMR Courtesy of N Reddy, Hyperbad India 20005
  42. 42. First Transgastric Appendectomy – N.O.T.E.S. Courtesy of N Reddy, Hyberdad India 2005
  43. 43. What next?
  44. 44. NOTES - for Bariatric Surgery
  45. 45. Multifunctional Set-ups A NUBISCOPE 2009 Grasper and hook Suturing set up ANUBIS Ancient Egyptian Godness „Magic surgery“ of mumification „Opening of the mouth“ ceremony Grasper and Laser tool additional suction tool Courtesy Karl Storz Endoscopy, Tutlingen, Germany 2009
  46. 46. N.O.T.E.S. COBRA DEVICE Courtesy of Olympus Endoscopy - 2007
  47. 47. Future EndoscopicWorkstation? Conventional colonoscopy Tele-endoscopy. Controlling micro-robot (which has been inserted into the rectum) from endoscope workstation [ Courtesy R Satava, GI Clinics North America, 1983] Endo-vascular work station – by Hansen Medical, Inc URL http://hansenmedical.com Feb, 2007
  48. 48. The Future is MEMS Biopsy forceps, 2 & 3 French (0.7 & 1 mm) Courtesy MicroFab Inc, 2005
  49. 49. The Future is MEMS Scissors (0.5 & 1 mm) 10 mm Mechanical Scissors Hydraulic Scissors Courtesy MicroFab Inc, 2005
  50. 50. Laparoscopic Sewing Machine Courtesy of Karl Storz, Tutlingen, German 2008
  51. 51. New Concepts for OR of the Future “The OR Without Lights” Eric LaPorta, Barcelona, Spain 2005
  52. 52. ROBOT SURGICAL TECHNOLOGIES, INC “Penelope” – robotic scrub nurse Currently in Clinical Trials Michael Treat MD, Columbia Univ, NYC. 2003
  53. 53. Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future 100,000 Surgeon Assistant Scrub Nurse Circulating nurse Borrowing from the standard practices of other industries
  54. 54. Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007
  55. 55. Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007
  56. 56. Predator 2003 Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003 SATAVA 7 July, 1999 DARPA
  57. 57. “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 28 Training & Simulation Journal August/September 2006
  58. 58. The Information Age is NOT the Future The Information Age is the Present ... There is something else out there . . . . SATAVA 7 July, 1999 DARPA
  59. 59. D isruptive V isions “The Future is not what it used to be !” - Yogi Berra http://depts.washington.edu/biointel
  60. 60. What is radically new?
  61. 61. University of Wisconson, 1999
  62. 62. Biomimetic Micro-robot Courtesy Sandia National Labs Courtesy Danny Scott Texas Southwestern Dallas, TX Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England Courtesy D. Oleynkov, Univ Nebraska
  63. 63. lf-propelling Gastrointestinal Endoscop Core functions Locomotion Modular functions External magnetic guidance Core capsule systems: optical system, telemetry and power systems, navigation etc. Diagnostic system: sensors Fluid environment 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 Courtesy Marc O. Schurr & www.vector-project.com The VECTOR consortium - 2008
  64. 64. Internal Locomotion Actuators Currently Investigated Walking robot with legs Submarine Vibratory locomotion Source (both): A Menciassi et al., CRIM, Scuola Sant‘Anna, Pisa Source: M. Sfakiotakis et al., FORTH, Heraklion Supported by the European Union as an Integrated Project Information Society Technologies - Contract Number 033970 Courtesy Marc O. Schurr & www.vector-project.com The VECTOR consortium - 2008
  65. 65. Acrobat Document
  66. 66. Femtosecond Laser (1 x 10 –15 sec) Los Alamos National Labs, Los Alamos NM Time of Flight Spectroscopy Cold Spring Harbor Laboratory, Long Island, NY Cellular opto-poration
  67. 67. Surgical Console for Cellular Surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
  68. 68. Surgical Console for Cellular Surgery Motion Commands Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
  69. 69. Molecular Imaging BioSurgery Courtesy: Rahul G. Thakar, Ph.D. 2007
  70. 70. Simulataneous multifunctional – Monitoring 6 different fluorophores in a cell Roger Tsien, UC-San Diego, La Jolla, CA 2006
  71. 71. Atomic Force Microscopy AFM AFM of DU 145 cells after sonoporation of an ion channel Sonoporation IMSaT Dundee
  72. 72. Surgical Cockpit
  73. 73. Simulated Tele-operation Chrysalis directed by Julien Leclercq. October 2007
  74. 74. “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990
  75. 75. Brain Machine Interface – Controlling motion with thoughts Recorded activity for intended movement to a briefly flashed target. TARGET PLAN MOVEMENT Time Courtesy Richard Andersen, Cal Tech, Pasadena, CA Direct brain implant control of robot arm Miguel Nicholai, Duke University, 2002
  76. 76. Replacing Human Body Parts Intelligent Prostheses Tissue Engineering Artificial Ear a) Rheo Bionic knee b) C-leg Liver Scaffolding Artificial Blood Vessel Ossur, Otto Bock, Reyknavik, Iceland Minneapolis, MN J. Vacanti, MD MGH March, 2000
  77. 77. Organs which have been grown synthetically
  78. 78. Commercial Products Neo-bladder – a commercial synthetic bladder A surgeon takes a urothelial and smooth The isolated cells are The cultured cells are small, full-thickness muscle cells that are cultured separately until properly seeded onto a biopsy from the capable of regeneration there are a sufficient biodegradable scaffold patient’s bladder. are isolated. quantity. shaped like a bladder. The biodegradable scaffold dissolves The body uses the The neo-bladder Quality assurance that the and is eliminated construct is implanted cells attach and grow neo-bladder construct from the body, to regenerate and by the surgeon using properly throughout the leaving a functioning integrate new tissue, standard surgical scaffold. After about 8 bladder made only of restoring the bladder’s techniques. weeks, the neo-bladder the patient’s own construct is returned to the functionality. newly regenerated surgeon for implantation. tissue. Courtesy of Tegion, Tengion East Norrington, PA 2007.
  79. 79. Genetically Re-engineering the Body Orb spider - web Spinnerette of spider Spider silk protein as biomaterial -BioSteel Cross section of synthetic fiber
  80. 80. Suspended Animation (Auto-anesthesia – FRAMR) Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope active hibernating heart rate 300 3 (beats/min) resp. rate 150 <1 (breaths/min) body temp. 37oC -2oC gene ongoing transcription function and translation suppressed metabolic rate 0.5 0.01 (2%) (mlO2/g/h) Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02
  81. 81. nti al n fi de Co
  82. 82. Hypothesis The Scientific Method … make evidence-based decisions Design Experiment Results Report In Science and Discovery, there is always Risk . . .
  83. 83. Be careful of unintended consequences Experience is the name everyone gives to their mistakes - Oscar Wilde The only thing more dangerous than trying too hard and failing … … is not trying hard enough and succeeding ! Michelangelo 1503
  84. 84. Technologies Will Change the Future • The rate of new discovery is accelerating exponentially • The changes raise profound fundamental issues • Moral and ethical solutions will take decades to resolve Sector Technology Rate of Change Business Society Healthcare TIME Differing responses to scientific discovery by various sectors
  85. 85. The Moral Dilemma 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
  86. 86. Human embryos cloned February 12, 2004 Chinese Cloning Control Required South Korean team demonstrates Tuesday 16 April, 2002, 10:41 GMT 11:41 UK cloning efficiency for humans similar Strict ethical guidelines are needed in China to to pigs, cattle | Thersa Tamkins calm public fears about new cell technologies such as cloning, the country's leading scientist said. After outlandish claims, a few media circuses, Professor Ching-Li Hu, the former deputy and some near misses by legitimate researchers, a team of South Korean director of the World Health Organization, was researchers reports the production of speaking at the Seventh Human Genome Meeting cloned human embryos. The findings, were in Shanghai. His call follows recent reports that released Wednesday (Science, Chinese scientists are making fast progress in DOI:10.1126 /science.1094515, February 12, these research fields. 2004).Wook Suk Hwang and Shin Yong One group in the Central South University Moon of Seoul National University used in Changsa is said to be producing human somatic cell nuclear transfer to produce 30 human blastocysts and a single embryonic embryo clones, while another team from the Sun stem cell line; SCNT-hES-1. Using 242 Yat-sen University of Medical Sciences in oocytes and cumulus cells from 16 unpaid Guangzhou is reported to have fused human and donors, the group achieved a cloning rabbit cells to make tissues for research. efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%).
  87. 87. Jeffery Steinberg, MD Fertility Institutes of Los Angeles Genetically “designed” child 1997 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, Preimplantation Genetic Screening says the medical team.The five babies were born after a General Science: May 13, 2006 technique called preimplantation genetic diagnosis (PGD) was used to test embryos for a tissue type match A British woman has become the first in the to the ailing siblings, reports the team, led by Anver country to conceive a "designer baby" selected Kuliev at the Reproductive Genetics Institute in specifically to avoid an inherited cancer, Chicago, US.The aim in these cases was to provide stem cells for transplantation to children who are The woman, who was not identified, used Gregory Stock suffering from leukaemia 'Unlawful and controversial genetic screening technology to ensure unethical' However, the use of this technology to she does not pass on to her child the condition provide a "designer baby" to treat an ill sibling is retinoblastoma, an hereditary form of eye cancer Science Vol 315: 1723-25, Mar 2007 highly controversial.A UK couple involved in this from which she suffers. Doctors tested embryos created by the woman and Emergence of Novel Color Vision in Mice Engineered her partner using in-vitro fertilisation (IVF) methods to Express Human Cone Photo-pigment for the cancer gene. Only unaffected embryos were implanted in her womb, the newspaper said. Changes in the genes encoding sensory recptor proteins are an essential step in It suggested the woman's pregnancy would the evolution of new sensory capacities“new sensory capacities" . In primates, tri- increase controversy over the procedure -- pre- implantation genetic diagnosis (PGD) -- because chromatic color vision evolved aftre changes in x chromosome linked photopigment genes. Heterogous mouse females critics say it involves destroying otherwise healthy whose retinas contained both mouse pigment embryos whose conditions are treatable. human L pigments showed enhanced long-wavelength sensitivity and chromatic human L pigments and discrimination. An inherent plasticity in the mammalian visual system thus permits emergence 1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
  88. 88. Extending Longevity April 14, 2004 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 A strain of mice that have lived . . . 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 . . . more than three normal lifespans 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 Should humans live 200 years? extend their telomeres, because some stem cells in middle-aged humans had anomalously long telomeres.
  89. 89. CAN I REPLACE MY Artificial organs BODY ? Smart Prostheses Genetic engineering Regeneration If I replace 95% of my body . . . . . . Am I still “human”? Should there be replacement “parts” for astronauts?
  90. 90. 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 6 DARPA
  91. 91. The Ultimate Ethical Question? 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?
  92. 92. SMIT2009 MIRA2010 January 27-30, 2010 San Diego, CA - Manchester Grand Hyatt C A LL F O R A B S TR A C TS D E A D L IN E : Au g u s t 14 , 2 0 0 9 Program Chair: Santiago Horgan, MD Minimally Invas ive Ro bo tic As s o c iatio n (MIRA) MISSION To raise the level of robotic surgery care in the world. As a multidisciplinary association, MIRA invites not only surgeons, but also internists, radiologist, engineers and computer scientists, interested in robotics, telerobotics, telepresence, teleconferencing and telementoring, to join the association and take part in the 2010 Sinaia, Romania, 7-9 October 2009 International Congress.
  93. 93. Do Robots Dream ? http://depts.washington.edu/biointel
  94. 94. The Fundamental Chang The Visual Medical Record Well, maybe not all people understand the importance of visualization