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
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.
5.
6. 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
8. 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
9. Current Visions
“The Future is here …
. . . it’s the Information Age”
10. Fundamental Concept
New technologies that are emerging
from Information Age discoveries
are driving our basic approach
in all areas of healthcare education
... EXAMPLES
12. SThe Industry Standard
I CAD/CAM
M
U Virtual Design
L
A
T Virtual Prototyping
I
O
N Virtual Testing & Evaluation
13. 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
14. 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
15. Virtual Autopsy . . .
. . . is a SIMULATED Autopsy
Wound Tract
Less than 2% of hospital deaths have autopsy
Statistics from autopsy drive national policies
16.
17.
18. 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 . . .
19. 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
20. 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
21. Therapy
Mechanics to energy
HIFU
High Intensity Focused Ultrasound
for
Non-invasive Acoustic hemostasis
Courtesy Larry Crum, Univ Washington Applied Physics
23. 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
24. Treatment of Topical Wounds:
Tissue Regeneration: Suppurated Burn Wound
Before treatment After 7 days of plasma
therapy
(5 sessions)
25. 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
26. LSTAT Deployment to Kosovo - March
212th MASH Deployed with2000 - Combat Support Hospital
LSTAT
LSTAT- lite
Courtesy of Integrated Medical Systems, Signal Hill, CA
27. Why now?
VTOL UAV technology is maturing rapidly enough to minimize risk.
28. Aeromedical evacuation
Nightingale UAV Goal
Identify
“optimum” VTOL
UAV design
Create a new
VTOL UAV
tailored to the
operational need
LSTAT
29. It’s all about . . .
Improved Patient Care
through
Virtual Reality
Manikin
dvanced Medical Education
32. Training for New Technical Skills
Halstedian Model: See One, Do One, Teach One
33. 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
34. 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
35. Standardized Curriculum
Suggested template
• Goals of the Simulation
• Anatomy
• Steps of the Procedures
• Errors
TEST
• Skills Training
• Outcomes
36. Technology
Current areas of simulation
Models, tissue, animals Manikin
VR
CAI
Virtual
Virtual Live Constructive
37. OSATS
Methodology
Objective StructuredAssessment of Technical Skills
Richard Reznick, Univ of Toronto - 1998
43. 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
49. 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
51. 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
52. The Future is MEMS
Biopsy forceps, 2 & 3 French (0.7 & 1 mm)
Courtesy MicroFab Inc, 2005
53. The Future is MEMS
Scissors (0.5 & 1 mm)
10 mm
Mechanical Scissors
Hydraulic Scissors Courtesy MicroFab Inc, 2005
55. New Concepts for OR of the Future
“The OR Without Lights”
Eric LaPorta, Barcelona, Spain 2005
56. ROBOT SURGICAL TECHNOLOGIES, INC
“Penelope” – robotic scrub nurse
Currently in Clinical Trials Michael Treat MD, Columbia Univ, NYC. 2003
57. 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
58.
59. Demonstration of Phase 1
Operating Room with no People
SRI International, Menlo Park, CA January, 2007
60. Demonstration of Phase 1
Operating Room with no People
SRI International, Menlo Park, CA January, 2007
63. “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
64.
65. The Information Age is NOT the Future
The Information Age is the Present ...
There is something else out there . . . .
SATAVA 7 July, 1999
DARPA
66. D isruptive V isions
“The Future is not what it used to be !”
- Yogi Berra
http://depts.washington.edu/biointel
70. 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
71. 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
72. 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
74. 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
75. Surgical Console for Cellular Surgery
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
76. Surgical Console for Cellular Surgery
Motion
Commands
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
83. “BrainGate” John Donohue, Brown University, 2001
Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990
84. 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
85.
86.
87. 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
89. 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.
90. Genetically Re-engineering the Body
Orb spider - web
Spinnerette of spider
Spider silk protein as biomaterial -BioSteel
Cross section of synthetic fiber
91. 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
93. Hypothesis The Scientific Method
… make evidence-based decisions
Design
Experiment
Results
Report
In Science and Discovery,
there is always Risk . . .
94. 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
95. 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
96. 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
97.
98. 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%).
99. 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
100. 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.
101. 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?
102. 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
103. 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?
104. 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.
