FUTURE
Impact
HEALTHCARE
and the
of
upon
Architecture
Richard M. Satava, MD FACS
Professor of Surgery
University of Washington
and
Senior Science Advisor
US Army Medical Research and Materiel Command
Future of Healthcare Design
AIA Seattle/AHP Healthcare Design Conference
Seattle, WA
February 14, 2008
Greetings
from
Monterey
California
Disruptive Visions
“The Future is not what it used to be”
….Yogi Berra
Current Visions
“The Future is here …
. . . it’s the Information Age”
Fundamental Concept
New technologies that are emerging
from Information Age discoveries
are driving our basic approach
in all areas of healthcare education
...
EXAMPLES
Why Robots?
Movie: Alien
The Touch Lab, MIT
Holomer
Total body-scan for total diagnosis
Virtual Soldier Program
Multi-modal total body scan on every trauma patient in 15 seconds
Satava
March, 2004
Virtual Autopsy . . .
. . . is a SIMULATED Autopsy
Wound Tract
Less than 2% of hospital deaths have autopsy
Statistics from autopsy drive national policies
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 . . .
Total Integration of Surgical Care
Minimally Invasive
& Open Surgery
Remote Surgery
Pre-operative planning
Surgical Rehearsal
Simulation & Training
Pre-operative Warmup
Intra-operative navigation
Courtesy of Joel Jensen,
SRI International, Menlo Park, CA
Surgical MEMS - Smart Surgical Tools
MEMS Sharps
Instrumented Scalpel
XACTIX
XACTIX
CONVENTIONAL
Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy
“TriCorder”
Mechanics to energy
Point-of-care noninvasive therapy
HIFU
High Intensity Focused Ultrasound
for
Non-invasive Acoustic hemostasis
Courtesy Larry Crum, Univ Washington Applied Physics Lab
Courtesy Larry Crum,
Univ Washington
Applied Physics Lab
2003
The Fundamental Changes
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
Bring the hospital to the casualty, not the casualty to the hospital . . .
“ . . . with a fully functional ICU ”
The LSTAT
Life Support for Trauma and Transport
Courtesy of Integrated Medical Systems, Signal Hill, CA
Total Patient Awareness
• 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
LSTAT Deployment to Kosovo - March 2000
212th MASH Deployed with LSTAT - Combat Support Hospital
Courtesy of Integrated Medical Systems, Signal Hill, CA
Aeromedical evacuation
Nightingale UAV Goal
 Identify
“optimum” VTOL
UAV design
 Create a new
VTOL UAV
tailored to the
operational need
LSTAT
Why now?
VTOL UAV technology is maturing rapidly enough to minimize risk.
LSTAT Lite
LSTAT – Back pack version
LSTAT for far-forward battlefield – less than 50 lbs
Emergency Room Trauma Portal
+ TRAUMA PORTAL +
Opportunities for LSTAT
• Pre-hospital transport, treatment &
continuity of care
• In-hospital transport
• Room Flexibility
• Surge Capability
• Disaster Response – local
• Disaster Response – national & transport
Trans Oral Intra-peritoneal Surgery
-
Future
Courtesy of N Reddy, Hyperbad India 20005
Early Luminal Malignancies - Robotic
Endoscopic Mucosal Resection - EMR
Courtesy of N Reddy, Hyperbad India 20005
Trans-gastric appendectomy
Courtesy of N Reddy, Hyperbad India 20005
So What ?
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
Classic Education and Examination
What is the REVOLUTION in surgical education?
Mannequin-based Simulator - Realistic physiologic response
Individual and Team Training
The Realization
The Dream
First Mannequin VR Simulator – David Gaba 1984
Human Patient Simulator 2005
Courtesy MedSim, Inc - 1991
Courtesy METI, Inc Sarasota, FL 2006
Simulation Incorporates Training
and Objective Assessment
Surgical
Simulators
Laparoscopic hysterectomy
Courtesy Michael vanLent, ICT, Los Angeles, CA
LapSim simulator tasks - abstract & texture mapped
Courtesy Andres Hytland, Sugical Science,
Gothenburg, Sweden, 2000
Laparoscopic Simulator with tactile feedback
Courtesy Murielle Launay, Xitact, Lausanne Switzerland
Dermatology Simulators
Pre-operative planning
• Strong collaborative environment
• UW Dermatology
– Daniel Berg
• Human Interface Technology
Laboratory (HIT lab)
– Suzanne Weghorst
– Peter Oppenheimer
Virtual Reality Suturing Simulator
Computer-based wound planning
Endovascular Simulators
(Surgical rehearsal)
Patient specific image
Graphic
overlay
Pacific Northwest Simulation Consortium
WWAMI: Washington, Wyoming, Alaska, Montana, Idaho
University of British Columbia, Vancouver, BC
Anchorage
Oregon University of Health Sciences, Portland, OR
Harborview
VA
ISIS
University
of
Washington
Vancouver
Spokane
Seattle
Billings
Children’s
Portland
Madigan
AMC
Boise
WWAMI Represents 27% of entire land mass of USA
Cheyenne
Another Concern
Over 500,000 operations performed …
…in foreign countries in 2007
Medical Tourism
Objective Assessment of Technical Skills
Objective Structured Assessment of Technical Skills – OSATS
Richard Reznick, Univ of Toronto
“Red Dragon”
“Blue Dragon”
passive recording device
Courtesy Blake Hannaford, PhD
University of Washington, Seattle
Novice
Objective Assessment
Intermediate
Expert
MEMS based tracking, RFID, etc
Hand motion tracking patterns
Ara Darzi, MD. Imperial College, London, 2000
New Concepts for OR of the Future
“The OR Without Lights”
Eric LaPorta, Barcelona, Spain 2005
ROBOT SURGICAL TECHNOLOGIES, INC
“Penelope” – robotic scrub nurse
Currently in Clinical Trials
Michael Treat MD, Columbia Univ, NYC. 2003
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
Demonstration of Phase 1
Operating Room with no People
SRI International, Menlo Park, CA
January, 2007
Demonstration of Phase 1
Operating Room with no People
SRI International, Menlo Park, CA
January, 2007
Fighter Pilots – until 2002
Predator 2003
Fighter Pilots – Beyond 2003
SATAVA 7 July, 1999
DARPA
“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
Robotic Medical Assistant
Nursing shortage crisis
Applicable at all levels
Hospitals
Clinics
Nursing Home
Assisted living
Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA
SATAVA 7 July, 1999
DARPA
Disruptive Visions
“The Future is not what it used to be”
….Yogi Berra
The Information Age is NOT the
Future
The Information Age is the
Present ...
There is something else out there
......
SATAVA 7 July, 1999
DARPA
¿And just what are these incredible new technologies?
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
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
Surgical console for cellular surgery
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Surgical console for cellular surgery
Motion
Commands
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Molecular Imaging
BioSurgery
Courtesy: Rahul G. Thakar, Ph.D. 2007
Simulataneous multifunctional –
6 different fluorophores in a cell
Monitoring
Roger Tsien, UC-San Diego, La Jolla, CA 2006
New Surgical Tools
Atomic Force Microscope Manipulator
Femtosecond Lasers
Fig. 2. Top: Fluorescent micrograph of the actin cytoskeleton of an engineered
striated muscle cell. Bottom: AFM-acquired topographical map. Wrinkles and
lines along the diagonals of the 30 micron square are actin stress fibers under the
lipid membrane surface.
Fig. 3. Schematic illustrating the technique for functionalizing AFM
tips to identify specific molecules on the cell surface during raster
scanning.
Fig. 4. Nanoincision by electroporation.
(A) The AFM cantilever is positioned above a region of interest in the cell.
(B) Electrical current is injected through the cantilever tip, causing the
formation of a nanometer scale pore in the membrane, thru which the AFM
tip can be dropped, or other instrumentation attached to the tip, prior to the
membrane resealing.
Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005
Surgical Cockpit
“BrainGate” John Donohue, Brown University, 2001
Richard Andersen, CalTech, 2003
Greg Kovacs. Stanford University, 1990
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
Sterilization without supplies
Leishmanaisis
Determine efficacy of inactivation of parasites
20-second treatm ent: near-com plete prom astigote inactivation
Promastigote concentraction (1/ml)
Insure safety of other cells and tissues
5.00E+08
4.00E+08
3.00E+08
2.00E+08
1.00E+08
0.00E+00
alive:
dead:
total:
Before treatment
3.48E+08
2.36E+07
3.72E+08
Plasma-treated
8.40E+06
3.80E+08
3.89E+08
Live/dead before and after treatment
Replacing human body parts
Intelligent Prostheses
Tissue Engineering
Artificial Ear
a) Rheo Bionic knee
Ossur,
Reyknavik, Iceland
b) C-leg
Otto Bock,
Minneapolis, MN
Liver Scaffolding
J. Vacanti, MD
Artificial Blood Vessel
MGH
March, 2000
Organs
Commercial Products
Neo-bladder – a commercial synthetic bladder
A surgeon takes a
small, full-thickness
biopsy from the
patient’s bladder.
urothelial and smooth
muscle cells that are
capable of regeneration
are isolated.
The isolated cells are
cultured separately until
there are a sufficient
quantity.
The cultured cells are
properly seeded onto a
biodegradable scaffold
shaped like a bladder.
The biodegradable
scaffold dissolves
and is eliminated
from the body,
leaving a functioning
bladder made only of
the patient’s own
newly regenerated
tissue.
The body uses the
neo-bladder construct
to regenerate and
integrate new tissue,
restoring the bladder’s
functionality.
The neo-bladder
construct is implanted
by the surgeon using
standard surgical
techniques.
Quality assurance that the
cells attach and grow
properly throughout the
scaffold. After about 8
weeks, the neo-bladder
construct is returned to the
surgeon for implantation.
Tegion,
Tengion
Courtesy of
East Norrington, PA 2007.
Genetically re-engineering the body
Orb spider - web
Spinnerette of spider
Spider silk protein as biomaterial -BioSteel
Cross section of synthetic fiber
Nexia Biotechnologies, Montreal Canada
Suspended Animation
( Auto-anesthesia - FRAMR )
Institute of Arctic Biology’s
Toolik Field Station,
Alaska's North Slope
heart rate
active
hibernating
300
3
(beats/min)
resp. rate
150
<1
(breaths/min)
body temp.
gene
function
metabolic rate
37oC
-2oC
ongoing
transcription
and translation suppressed
0.5
0.01 (2%)
(mlO2/g/h)
Brian M. Barnes,
Institute of Arctic Biology , University of Alaska Fairbanks 11/02
Be careful of
unintended
consequences
Experience is the name everyone
gives to their mistakes - Oscar Wilde
If you are not making mistakes
you are not working hard enough …
… and that’s a big mistake! Anonymous
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
Rate of Change
Technology
Business
Society
Healthcare
TIME
Differing responses to scientific discovery by various sectors
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
Human embryos
cloned
Chinese Cloning Control Required
Tuesday 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.
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-hES1. 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%).
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.
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,
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
Science Vol 315: 1723-25, Mar 2007
highly controversial.A UK couple involved in this
Gregory Stock
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.
Emergence of Novel Color Vision in Mice Engineered
Doctors tested embryos created by the woman and
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, triincrease controversy over the procedure -- prechromatic color vision evolved aftre changes in x chromosome linked photopigment genes.
implantation genetic diagnosis (PGD) -- because
Heterogous mouse females whose retinas contained both mouse pigment and
critics say it involves destroying otherwise healthy
human
humanLLpigments
pigments showed enhanced long-wavelength sensitivity and chromatic
embryos whose conditions are treatable.
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
Can conception, the most
intimate of human
experiences,
be automated?
26 July 2007
Womb-on-a-chip may boost IVF successes
Linda Geddes
Teruo Fujii of the University of Tokyo in Japan and his
colleagues are building a microfluidic chip to nurture the
first stages of pregnancy. They hope, eventually, to create a
fully automated artificial uterus in which egg and sperm
are fed in at one end and an early embryo comes out the
other, ready for implanting in a real mother. They say
using such a device could improve the success rate of IVF.
"While there have been many advances in the production
of in vitro embryos, these embryos are still sub-optimal
[compared] to their in vivo counterparts," says Matt
Wheeler of the University of Illinois in UrbanaChampaign who is also working on automated IVF
systems. One reason for this is that during IVF, eggs or
embryos are often moved or washed with culture fluid,
causing changes in temperature and pH, he says.
To tackle these problems, Fujii's team has created a "lab on
a chip" that is 2 millimetres across and 0.5 millimetres
high, in which up to 20 eggs can be fertilised and then
grown until they are ready for implantation. Endometrial
cells, which line real wombs, are also grown in the device,
so that the chemicals they produce can reach the embryos
help them grow. "We are providing embryos (cont. p28)
Embryo-on-a-chip
From the movie MATRIX RELOADED New Line Cinema
Extending Longevity
Life extension
A strain of mice that have lived . . .
. . . more than three normal lifespans
Should humans live 200 years?
April 14, 2004
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 antiaging 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.
CAN I REPLACE MY
BODY ?
Artificial organs
Smart Prostheses
Genetic engineering
Regeneration
If I replace 95%
of my body . . .
. . . Am I still “human”?
Should there be replacement
“parts” for astronauts?
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 with technology 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”
6
How will we decide who gets the technology,
especially in 3rd World
SATAVA 7 July, 1999
DARPA
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?
http://depts.washington.edu/biointel
Do Robots Dream ?