Lifelike simulations that make real-life surgery safer | Peter Weinstock

62,409 views ・ 2017-04-11

TED


Please double-click on the English subtitles below to play the video.

00:12
What if I told you there was a new technology
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that, when placed in the hands of doctors and nurses,
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improved outcomes for children and adults, patients of all ages;
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reduced pain and suffering,
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reduced time in the operating rooms,
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reduced anesthetic times,
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had the ultimate dose-response curve
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that the more you did it,
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the better it benefitted patients?
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Here's a kicker: it has no side effects,
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and it's available no matter where care is delivered.
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I can tell you as an ICU doctor at Boston Children's Hospital,
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this would be a game changer for me.
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That technology is lifelike rehearsal.
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This lifelike rehearsal is being delivered through medical simulation.
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I thought I would start with a case,
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just to really describe the challenge ahead,
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and why this technology is not just going to improve health care
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but why it's critical to health care.
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This is a child that's born, young girl.
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"Day of life zero," we call it,
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the first day of life, just born into the world.
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And just as she's being born,
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we notice very quickly that she is deteriorating.
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Her heart rate is going up, her blood pressure is going down,
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she's breathing very, very fast.
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And the reason for this is displayed in this chest X-ray.
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That's called a babygram,
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a full X-ray of a child's body, a little infant's body.
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As you look on the top side of this,
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that's where the heart and lungs are supposed to be.
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As you look at the bottom end, that's where the abdomen is,
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and that's where the intestines are supposed to be.
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And you can see how there's sort of that translucent area
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that made its way up into the right side of this child's chest.
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And those are the intestines -- in the wrong place.
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As a result, they're pushing on the lungs
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and making it very difficult for this poor baby to breathe.
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The fix for this problem
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is to take this child immediately to the operating room,
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bring those intestines back into the abdomen,
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let the lungs expand
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and allow this child to breathe again.
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But before she can go to the operating room,
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she must get whisked away to the ICU, where I work.
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I work with surgical teams.
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We gather around her,
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and we place this child on heart-lung bypass.
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We put her to sleep,
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we make a tiny little incision in the neck,
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we place catheters into the major vessels of the neck --
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and I can tell you that these vessels are about the size of a pen,
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the tip of a pen --
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and then we have blood drawn from the body,
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we bring it through a machine, it gets oxygenated,
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and it goes back into the body.
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We save her life,
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and get her safely to the operating room.
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Here's the problem:
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these disorders --
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what is known is congenital diaphragmatic hernia --
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this hole in the diaphragm that has allowed these intestines to sneak up --
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these disorders are rare.
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Even in the best hands in the world,
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there is still a challenge to get the volume --
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the natural volume of these patients --
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in order to get our expertise curve at 100 percent.
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They just don't present that often.
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So how do you make the rare common?
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Here's the other problem:
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in the health care system that I trained for over 20 years,
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what currently exists,
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the model of training is called the apprenticeship model.
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It's been around for centuries.
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It's based on this idea that you see a surgery maybe once,
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maybe several times,
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you then go do that surgery,
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and then ultimately you teach that surgery to the next generation.
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And implicit in this model --
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I don't need to tell you this --
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is that we practice on the very patients that we are delivering care to.
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That's a problem.
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I think there's a better approach.
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Medicine may very well be the last high-stakes industry
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that does not practice prior to game time.
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I want to describe to you a better approach through medical simulation.
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Well, the first thing we did is we went to other high-stakes industries
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that had been using this type of methodology for decades.
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This is nuclear power.
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Nuclear power runs scenarios on a regular basis
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in order to practice what they hope will never occur.
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And as we're all very familiar, the airline industry --
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we all get on planes now, comforted by the idea
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that pilots and crews have trained on simulators much like these,
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training on scenarios that we hope will never occur,
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but we know if they did,
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they would be prepared for the worst.
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In fact, the airline industry has gone as far as to create fuselages
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of simulation environments,
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because of the importance of the team coming together.
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This is an evacuation drill simulator.
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So again, if that ever were to happen, these rare, rare events,
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they're ready to act on the drop of a dime.
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I guess the most compelling for me in some ways is the sports industry --
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arguably high stakes.
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You think about a baseball team: baseball players practice.
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I think it's a beautiful example of progressive training.
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The first thing they do is go out to spring training.
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They go to a spring training camp,
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perhaps a simulator in baseball.
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They're not on the real field, but they're on a simulated field,
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and they're playing in the pregame season.
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Then they make their way to the field during the season games,
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and what's the first thing they do before they start the game?
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They go into the batting cage and do batting practice for hours,
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having different types of pitches being thrown at them,
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hitting ball after ball as they limber their muscles,
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getting ready for the game itself.
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And here's the most phenomenal part of this,
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and for all of you who watch any sport event,
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you will see this phenomenon happen.
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The batter gets into the batter's box,
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the pitcher gets ready to pitch.
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Right before the pitch is thrown,
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what does that batter do?
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The batter steps out of the box
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and takes a practice swing.
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He wouldn't do it any other way.
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I want to talk to you about how we're building practice swings like this
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in medicine.
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We are building batting cages for the patients that we care about
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at Boston Children's.
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I want to use this case that we recently built.
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It's the case of a four-year-old who had a progressively enlarging head,
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and as a result,
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had loss of developmental milestones, neurologic milestones,
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and the reason for this problem is here --
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it's called hydrocephalus.
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So, a quick study in neurosurgery.
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There's the brain,
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and you can see the cranium surrounding the brain.
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What surrounds the brain, between the brain and cranium,
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is something called cerebrospinal fluid or fluid,
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which acts as a shock absorber.
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In your heads right now,
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there is cerebrospinal fluid just bathing your brains
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and making its way around.
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It's produced in one area and flows through,
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and then is re-exchanged.
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And this beautiful flow pattern occurs for all of us.
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But unfortunately in some children,
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there's a blockage of this flow pattern,
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much like a traffic jam.
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As a result, the fluid accumulates,
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and the brain is pushed aside.
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It has difficulty growing.
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As a result, the child loses neurologic milestones.
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This is a devastating disease in children.
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The cure for this is surgery.
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The traditional surgery is to take a bit of the cranium off,
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a bit of the skull,
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drain this fluid out, stick a drain in place,
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and then eventually bring this drain internal to the body.
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Big operation.
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But some great news is that advances in neurosurgical care
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have allowed us to develop minimally invasive approaches
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to this surgery.
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Through a small pinhole, a camera can be inserted,
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led into the deep brain structure,
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and cause a little hole in a membrane that allows all that fluid to drain,
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much like it would in a sink.
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All of a sudden, the brain is no longer under pressure,
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can re-expand
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and we cure the child through a single-hole incision.
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But here's the problem:
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hydrocephalus is relatively rare.
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And there are no good training methods
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to get really good at getting this scope to the right place.
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But surgeons have been quite creative about this, even our own.
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And they've come up with training models.
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Here's the current training model.
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(Laughter)
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I kid you not.
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This is a red pepper, not made in Hollywood;
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it's real red pepper.
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And what surgeons do is they stick a scope into the pepper,
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and they do what is called a "seedectomy."
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(Laughter)
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They use this scope to remove seeds using a little tweezer.
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And that is a way to get under their belts
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the rudimentary components of doing this surgery.
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Then they head right into the apprenticeship model,
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seeing many of them as they present themselves,
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then doing it, and then teaching it --
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waiting for these patients to arrive.
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We can do a lot better.
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We are manufacturing reproductions of children
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in order for surgeons and surgical teams to rehearse
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in the most relevant possible ways.
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Let me show you this.
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Here's my team
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in what's called the SIM Engineering Division of the Simulator Program.
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This is an amazing team of individuals.
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They are mechanical engineers;
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you're seeing here, illustrators.
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They take primary data from CT scans and MRIs,
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translate it into digital information,
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animate it,
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put it together into the components of the child itself,
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surface-scan elements of the child that have been casted as needed,
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depending on the surgery itself,
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and then take this digital data and be able to output it
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on state-of-the-art, three-dimensional printing devices
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that allow us to print the components
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exactly to the micron detail of what the child's anatomy will look like.
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You can see here,
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the skull of this child being printed
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in the hours before we performed this surgery.
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But we could not do this work
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without our dear friends on the West Coast in Hollywood, California.
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These are individuals that are incredibly talented
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at being able to recreate reality.
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It was not a long leap for us.
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The more we got into this field,
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the more it became clear to us that we are doing cinematography.
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We're doing filmmaking,
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it's just that the actors are not actors.
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They're real doctors and nurses.
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So these are some photos of our dear friends at Fractured FX
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in Hollywood California,
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an Emmy-Award-winning special effects firm.
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This is Justin Raleigh and his group --
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this is not one of our patients --
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(Laughter)
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but kind of the exquisite work that these individuals do.
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We have now collaborated and fused our experience,
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bringing their group to Boston Children's Hospital,
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sending our group out to Hollywood, California
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and exchanging around this
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to be able to develop these type of simulators.
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What I'm about to show you is a reproduction of this child.
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You'll notice here that every hair on the child's head is reproduced.
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And in fact, this is also that reproduced child --
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and I apologize for any queasy stomachs,
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but that is a reproduction and simulation
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of the child they're about to operate on.
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Here's that membrane we had talked about,
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the inside of this child's brain.
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What you're going to be seeing here is, on one side, the actual patient,
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and on the other side, the simulator.
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As I mentioned, a scope, a little camera, needs to make its way down,
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and you're seeing that here.
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It needs to make a small hole in this membrane
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and allow this fluid to seep out.
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I won't do a quiz show to see who thinks which side is which,
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but on the right is the simulator.
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So surgeons can now produce training opportunities,
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do these surgeries as many times as they want,
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to their heart's content, until they feel comfortable.
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And then, and only then, bring the child into the operating room.
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But we don't stop here.
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We know that a key step to this is not just the skill itself,
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but combining that skill with a team who's going to deliver that care.
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Now we turn to Formula One.
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And here is an example of a technician putting on a tire
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and doing that time and time again on this car.
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But that is very quickly going to be incorporated
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within team-training experiences,
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now as a full team orchestrating the exchange of tires
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and getting this car back on the speedway.
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We've done that step in health care,
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so now what you're about to see is a simulated operation.
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We've taken the simulator I just described to you,
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we've brought it into the operating room at Boston Children's Hospital,
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and these individuals -- these native teams, operative teams --
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are doing the surgery before the surgery.
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Operate twice;
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cut once.
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Let me show that to you.
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(Video) Surgical team member 1: You want the head down or head up?
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STM 2: Can you lower it down to 10?
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STM 3: And then lower the whole table down a little bit?
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STM 4: Table coming down.
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STM 3: All right, this is behaving like a vessel.
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Could we have the scissors back, please?
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STM 5: I'm taking my gloves, 8 to 8 1/2, all right? I'll be right in.
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STM 6: Great! Thank you.
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Peter Weinstock: It's really amazing.
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The second step to this, which is critical,
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is we take these teams out immediately and debrief them.
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We use the same technologies
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that are used in Lean and Six Sigma in the military,
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and we bring them out and talk about what went right,
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but more importantly,
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we talk about what didn't go well,
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and how we're going to fix it.
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Then we bring them right back in and do it again.
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Deliberative batting practice in the moments when it matters most.
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Let's go back to this case now.
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Same child,
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but now let me describe how we care for this child
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at Boston Children's Hospital.
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This child was born at three o'clock in the morning.
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At two o'clock in the morning,
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we assembled the team,
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and took the reproduced anatomy
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that we would gain out of scans and images,
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and brought that team to the virtual bedside,
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to a simulated bedside --
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the same team that's going to operate on this child in the hours ahead --
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and we have them do the procedure.
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Let me show you a moment of this.
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This is not a real incision.
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And the baby has not yet been born.
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Imagine this.
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So now the conversations that I have with families
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in the intensive care unit at Boston Children's Hospital
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are totally different.
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Imagine this conversation:
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"Not only do we take care of this disorder frequently in our ICU,
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and not only have we done surgeries
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like the surgery we're going to do on your child,
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but we have done your child's surgery.
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And we did it two hours ago.
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And we did it 10 times.
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And now we're prepared to take them back to the operating room."
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So a new technology in health care:
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lifelike rehearsal.
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Practicing prior to game time.
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Thank you.
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(Applause)
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