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 Impact upon Architecture Future of Healthcare Design AIA Seattle/AHP Healthcare Design Conference Seattle, WA February 14, 2008 and the

Greetings from Monterey California

“The Future is not what it used to be” ….Yogi Berra Disruptive Visions

“The Future is here …... it’s the Information Age” Current Visions

New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education... EXAMPLES Fundamental Concept

Why Robots? The Touch Lab, MIT Movie: Alien

Holomer Total body-scan for total diagnosis Satava March, 2004 Virtual Soldier Program Multi-modal total body scan on every trauma patient in 15 seconds

Virtual Autopsy... Wound Tract Less than 2% of hospital deaths have autopsy Statistics from autopsy drive national policies... is a SIMULATED Autopsy

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 Courtesy of Joel Jensen, SRI International, Menlo Park, CA Minimally Invasive & Open Surgery Pre-operative planning Surgical Rehearsal Intra-operative navigation Remote Surgery Simulation & Training Pre-operative Warmup

Surgical MEMS - Smart Surgical Tools Instrumented Scalpel XACTIX CONVENTIONAL MEMS Sharps Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy

“TriCorder” Point-of-care noninvasive therapy High Intensity Focused Ultrasound for 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

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” The Fundamental Changes

The LSTAT Life 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

Nightingale UAV Goal  Identify “optimum” VTOL UAV design  Create a new VTOL UAV tailored to the operational need LSTAT Aeromedical evacuation

Why now? VTOL UAV technology is maturing rapidly enough to minimize risk.

LSTAT Lite LSTAT for far-forward battlefield – less than 50 lbs LSTAT – Back pack version

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 ?

Tele-endoscopy. Controlling micro-robot (which has been inserted into the rectum) from endoscope workstation Conventional colonoscopy Future EndoscopicWorkstation? [ Courtesy R Satava, GI Clinics North America, 1983] Endo-vascular work station – by Hansen Medical, Inc URL Feb, 2007http://hansenmedical.com

Classic Education and Examination What is the REVOLUTION in surgical education?

Mannequin-based Simulator - Realistic physiologic response Individual and Team Training Human Patient Simulator 2005 Courtesy METI, Inc Sarasota, FL 2006 First Mannequin VR Simulator – David Gaba 1984 Courtesy MedSim, Inc The Realization The Dream

Laparoscopic Simulator with tactile feedback Courtesy Murielle Launay, Xitact, Lausanne Switzerland Laparoscopic hysterectomy Courtesy Michael vanLent, ICT, Los Angeles, CA LapSim simulator tasks - abstract & texture mapped Courtesy Andres Hytland, Sugical Science, Gothenburg, Sweden, 2000 Surgical Simulators Simulation Incorporates Training and Objective Assessment

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) Graphic overlay Patient specific image

Pacific Northwest Simulation Consortium WWAMI: Washington, Wyoming, Alaska, Montana, Idaho University of British Columbia, Vancouver, BC Oregon University of Health Sciences, Portland, OR VA Madigan AMC Harborview Children’s Cheyenne Billings Boise Spokane Anchorage ISIS University Washington Seattle of WWAMI Represents 27% of entire land mass of USA Vancouver Portland

Over 500,000 operations performed … …in foreign countries in 2007 Medical Tourism Another Concern Opportunity

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

Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000 Novice Intermediate Expert Objective Assessment MEMS based tracking, RFID, etc

Eric LaPorta, Barcelona, Spain 2005 New Concepts for OR of the Future “The OR Without Lights”

“Penelope” – robotic scrub nurse Michael Treat MD, Columbia Univ, NYC ROBOT SURGICAL TECHNOLOGIES, INC Currently in Clinical Trials

Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future Surgeon Assistant Scrub Nurse Circulating nurse 100,000 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

SATAVA 7 July, 1999 DARPA Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003 Predator 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

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

“The Future is not what it used to be” ….Yogi Berra Disruptive Visions

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 Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England Courtesy D. Oleynkov, Univ Nebraska Courtesy Danny Scott Texas Southwestern Dallas, TX

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

Surgical console for cellular surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005 Motion Commands

Courtesy: Rahul G. Thakar, Ph.D Molecular Imaging BioSurgery

Simulataneous multifunctional – 6 different fluorophores in a cell Roger Tsien, UC-San Diego, La Jolla, CA 2006 Monitoring

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. New Surgical Tools Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005 Atomic Force Microscope Manipulator Femtosecond Lasers

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. TARGETMOVEMENT 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

Sterilization without supplies Live/dead before and after treatment Determine efficacy of inactivation of parasites Insure safety of other cells and tissues Leishmanaisis

a)Rheo Bionic knee Ossur, Reyknavik, Iceland b) C-leg Otto Bock, Minneapolis, MN Intelligent Prostheses Tissue Engineering Liver ScaffoldingArtificial Blood Vessel J. Vacanti, MD MGH March, 2000 Artificial Ear Replacing human body parts

O rgans

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. 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. The neo-bladder construct is implanted by the surgeon using standard surgical techniques. The body uses the neo-bladder construct to regenerate and integrate new tissue, restoring the bladder’s functionality. The biodegradable scaffold dissolves and is eliminated from the body, leaving a functioning bladder made only of the patient’s own newly regenerated tissue. A surgeon takes a small, full-thickness biopsy from the patient’s bladder. Courtesy of Tengion East Norrington, PA Neo-bladder – a commercial synthetic bladder Tegion, C ommercial Products

Spider silk protein as biomaterial -BioSteel Nexia Biotechnologies, Montreal Canada Cross section of synthetic fiber Spinnerette of spider Orb spider - web Genetically re-engineering the body

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 (2%) active hibernating body temp. 37 o C -2 o C gene ongoing transcription function and translation suppressed heart rate resp. rate 150 <1 (breaths/min) (beats/min) (mlO 2 /g/h) Alternative

Confidential

If you are not making mistakes you are not working hard enough … … and that’s a big mistake! Anonymous Experience is the name everyone gives to their mistakes - Oscar Wilde B e 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 Rate of Change 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: /science , 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 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.

Genetically “designed” child 1997 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.technology Gregory Stock Science Vol 315: , 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 and human L pigments

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 Urbana- Champaign 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.working 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) Can conception, the most intimate of human experiences, be automated? From the movie MATRIX RELOADED New Line Cinema Embryo-on-a-chip

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 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” How will we decide who gets the technology, especially in 3rd World SATAVA 7 July, 1999 DARPA 6

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?

Do Robots Dream ?