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

翻译人员: Yan Gao 校对人员: Lipeng Chen

What if I told you there was a new technology

如果我告诉你有一种新技术，

that, when placed in the hands of doctors and nurses,

一旦医生和护士掌握了它，

improved outcomes for children and adults, patients of all ages;

就能改善儿童和成人， 所有年龄段患者的治疗效果，

reduced pain and suffering,

能减少疼痛和折磨，

reduced time in the operating rooms,

缩短手术时间，

reduced anesthetic times,

缩短麻醉时间，

had the ultimate dose-response curve

拥有最终极的剂量-效果曲线，

that the more you did it,

你用的越多

the better it benefitted patients?

就对患者越有益，你信不信？

Here's a kicker: it has no side effects,

关键是：它没有副作用，

and it's available no matter where care is delivered.

并且可以在任何治疗中使用。

I can tell you as an ICU doctor at Boston Children's Hospital,

我是波士顿儿童医院的 加护病房医生，

this would be a game changer for me.

这对我而言是划时代的技术。

That technology is lifelike rehearsal.

这项技术叫做生命模拟演练。

This lifelike rehearsal is being delivered through medical simulation.

这种生命模拟演练 是通过医疗模拟实现的。

I thought I would start with a case,

我会通过一个病例来开始讲述，

just to really describe the challenge ahead,

真实描述一下面临的挑战，

and why this technology is not just going to improve health care

以及为什么这项技术 不仅会改进医疗，

but why it's critical to health care.

而且对医疗至关重要。

This is a child that's born, young girl.

这是一个刚出生的小女孩。

"Day of life zero," we call it,

我们称为“生命首日”，

the first day of life, just born into the world.

她刚刚来到这个世界， 经历生命的第一天。

And just as she's being born,

刚一出生，

we notice very quickly that she is deteriorating.

我们就发现她的状况在迅速恶化。

Her heart rate is going up, her blood pressure is going down,

心率不断上升，血压不断下降，

she's breathing very, very fast.

呼吸非常急促。

病因就显示在这张X光片上。

And the reason for this is displayed in this chest X-ray.

That's called a babygram,

我们叫它婴儿透视，

a full X-ray of a child's body, a little infant's body.

是婴儿全身的X光片。

As you look on the top side of this,

这张图靠上的部分，

that's where the heart and lungs are supposed to be.

是心脏和肺所处的位置。

As you look at the bottom end, that's where the abdomen is,

靠下的部分是腹部，

and that's where the intestines are supposed to be.

是肠子所处的位置。

你们能看到这里有些半透明的区域，

And you can see how there's sort of that translucent area

向上移动到了孩子的右胸腔内。

that made its way up into the right side of this child's chest.

And those are the intestines -- in the wrong place.

那些是错位的肠子。

As a result, they're pushing on the lungs

结果就是它们压迫肺部，

and making it very difficult for this poor baby to breathe.

使这个可怜的孩子难以呼吸。

解决办法就是

The fix for this problem

is to take this child immediately to the operating room,

马上送她进手术室，

bring those intestines back into the abdomen,

把肠子移回腹部，

let the lungs expand

让肺扩张，

and allow this child to breathe again.

让孩子恢复呼吸。

But before she can go to the operating room,

但她进手术室之前，

she must get whisked away to the ICU, where I work.

必须先来重症监护室 ——我工作的地方。

I work with surgical teams.

我与手术团队合作，

We gather around her,

进行会诊，

and we place this child on heart-lung bypass.

我们采用心肺体外循环的方法。

We put her to sleep,

我们将孩子麻醉，

we make a tiny little incision in the neck,

在她脖子上开个小小的切口，

we place catheters into the major vessels of the neck --

把导管放入脖子的主血管内，

and I can tell you that these vessels are about the size of a pen,

这些血管的尺寸也就钢笔——

the tip of a pen --

钢笔尖那么粗，

and then we have blood drawn from the body,

我们把血液抽出来，

we bring it through a machine, it gets oxygenated,

导入一个机器，充氧，

and it goes back into the body.

再导回体内。

We save her life,

我们保住了她的性命，

and get her safely to the operating room.

把她安全送到了手术室。

Here's the problem:

问题在于：

these disorders --

这种疾病，

what is known is congenital diaphragmatic hernia --

我们称之为“先天性横膈疝气”——

this hole in the diaphragm that has allowed these intestines to sneak up --

也就是隔膜上有一个洞， 使得肠子能向上移位——

these disorders are rare.

这种疾病很罕见。

Even in the best hands in the world,

即使是世上最优秀医生，

there is still a challenge to get the volume --

临床经验也不足，

the natural volume of these patients --

因为患者的数量太少，

in order to get our expertise curve at 100 percent.

使得我们的技能曲线 很难达到百分之百。

They just don't present that often.

因为这种病例就是很难遇到。

So how do you make the rare common?

你怎样才能让罕见变得常见呢？

Here's the other problem:

还有一个问题：

in the health care system that I trained for over 20 years,

我在医疗系统中 接受训练超过20年，

what currently exists,

现有的训练模式叫做学徒模式，

the model of training is called the apprenticeship model.

It's been around for centuries.

它已经存在几百年了。

It's based on this idea that you see a surgery maybe once,

它的基本概念是，你观摩手术，

maybe several times,

也许一次，也许多次，

you then go do that surgery,

然后你亲自去做那个手术，

and then ultimately you teach that surgery to the next generation.

最后你再把这个手术传给下一代。

其实说白了，

And implicit in this model --

I don't need to tell you this --

相信大家也能想得到，

is that we practice on the very patients that we are delivering care to.

我们是在用患者进行练习。

That's a problem.

这是个大问题。

I think there's a better approach.

我认为有更好的方法。

Medicine may very well be the last high-stakes industry

医疗很可能是实操之前不进行训练的

that does not practice prior to game time.

最后一个高风险行业了。

I want to describe to you a better approach through medical simulation.

这个更好的方法就是医疗模拟。

Well, the first thing we did is we went to other high-stakes industries

我们首先去参观了 其他高风险行业，

that had been using this type of methodology for decades.

它们用这种方法已经几十年了。

This is nuclear power.

这是核电厂。

Nuclear power runs scenarios on a regular basis

核电厂会定期举行演习，

in order to practice what they hope will never occur.

为他们希望永不发生的事情做好准备

And as we're all very familiar, the airline industry --

以及我们都很熟悉的航空业——

we all get on planes now, comforted by the idea

现在大家坐飞机都很放松，

that pilots and crews have trained on simulators much like these,

是因为我们知道，飞行员和机组人员 在模拟器上进行了训练

training on scenarios that we hope will never occur,

为应对我们希望永不发生的情况，

but we know if they did,

而且我们知道，一旦发生，

they would be prepared for the worst.

他们也有能力应对。

In fact, the airline industry has gone as far as to create fuselages

事实上，航空业已经发展到

直接造一个机身进行模拟，

of simulation environments,

because of the importance of the team coming together.

这样可以使整个团队一同训练。

This is an evacuation drill simulator.

这是疏散训练模拟器。

So again, if that ever were to happen, these rare, rare events,

那么再次说明 一旦发生这种非常罕见的事故

they're ready to act on the drop of a dime.

他们能够瞬间作出反应

I guess the most compelling for me in some ways is the sports industry --

我想最吸引我的是体育行业了——

arguably high stakes.

有争议的高风险

You think about a baseball team: baseball players practice.

你想想棒球队：棒球手训练。

I think it's a beautiful example of progressive training.

我认为那是渐进训练的完美示例。

The first thing they do is go out to spring training.

首先他们要做的是春季训练。

They go to a spring training camp,

他们去春季训练营，

perhaps a simulator in baseball.

也许用棒球模拟器。

They're not on the real field, but they're on a simulated field,

他们不在真实赛场， 但在模拟赛场上，

and they're playing in the pregame season.

他们在赛前季节打球。

Then they make their way to the field during the season games,

然后在赛季比赛中进入赛场。

and what's the first thing they do before they start the game?

开始比赛前他们做什么？

They go into the batting cage and do batting practice for hours,

是去击球练习区做数小时的击打练习，

having different types of pitches being thrown at them,

球以各种投掷方式投向他们，

hitting ball after ball as they limber their muscles,

一次接一次地击球，练习肌肉，

getting ready for the game itself.

为真正的比赛做准备。

And here's the most phenomenal part of this,

这是最令人震惊的部分，

所有观看任何体育比赛的人，

and for all of you who watch any sport event,

you will see this phenomenon happen.

都会看到这种现象。

The batter gets into the batter's box,

击球手进入击球位，

the pitcher gets ready to pitch.

投球手准备投掷。

Right before the pitch is thrown,

就在马上投球之前，

what does that batter do?

击球手做了什么？

The batter steps out of the box

击球手退出击球位，

and takes a practice swing.

练习一次挥臂动作。

He wouldn't do it any other way.

他一定会这样做。

I want to talk to you about how we're building practice swings like this

我想告诉你的是，

我们在医疗行业是 如何像他们这样做击球练习的。

in medicine.

We are building batting cages for the patients that we care about

我们在波士顿儿童医院，

为我们的患者做一个击球练习区。

at Boston Children's.

I want to use this case that we recently built.

我想利用一下， 这个最近做好的病例。

It's the case of a four-year-old who had a progressively enlarging head,

这是四岁儿童头部逐渐扩大的病例，

and as a result,

作为结果，

had loss of developmental milestones, neurologic milestones,

这种病症会导致发育缺失，重要的神经功能缺失，

and the reason for this problem is here --

这个问题的原因在这里——

it's called hydrocephalus.

它叫做脑积水。

So, a quick study in neurosurgery.

那么，简短解释下脑外科知识。

There's the brain,

这是脑部。

and you can see the cranium surrounding the brain.

你能看到包围大脑的颅骨。

What surrounds the brain, between the brain and cranium,

在大脑和颅骨之间，围绕大脑的

is something called cerebrospinal fluid or fluid,

是脑脊液，

which acts as a shock absorber.

它的作用是减震。

In your heads right now,

现在你的头部里面，

there is cerebrospinal fluid just bathing your brains

有脑脊液正在浸泡着你的脑部，

and making its way around.

并围绕着脑部。

It's produced in one area and flows through,

它在一个区域产生，流动，

and then is re-exchanged.

然后再循环。

And this beautiful flow pattern occurs for all of us.

我们每个人都有这种美丽的流动通道。

But unfortunately in some children,

但不幸的是，有些孩子，

there's a blockage of this flow pattern,

这种流通通道受到阻碍，

much like a traffic jam.

就像堵车。

As a result, the fluid accumulates,

结果是，脑脊液积聚，

and the brain is pushed aside.

脑部被推到一边。

It has difficulty growing.

难以生长。

As a result, the child loses neurologic milestones.

结果，孩子失去神经系统的重要功能。

This is a devastating disease in children.

这是对于儿童的毁灭性疾病。

The cure for this is surgery.

它的治疗方法是手术。

The traditional surgery is to take a bit of the cranium off,

传统手术是取下一点颅骨，

a bit of the skull,

头骨的一小部分，

drain this fluid out, stick a drain in place,

排出液体，在适当位置安装排放管，

and then eventually bring this drain internal to the body.

然后最终把这排放管引到身体内部。

Big operation.

大手术。

But some great news is that advances in neurosurgical care

但好消息是，神经外科医疗的进步

have allowed us to develop minimally invasive approaches

让我们为这手术开发出

to this surgery.

微创方法。

Through a small pinhole, a camera can be inserted,

通过小针孔，可插入相机，

led into the deep brain structure,

引导相机进入深层脑结构，

and cause a little hole in a membrane that allows all that fluid to drain,

并在膜上开个小孔，让液体排出，

much like it would in a sink.

就像在水槽里排水一样。

All of a sudden, the brain is no longer under pressure,

转眼间，脑部不再受压，

can re-expand

能再扩大，

and we cure the child through a single-hole incision.

我们通过单孔切口治好了这孩子。

But here's the problem:

但问题是：

hydrocephalus is relatively rare.

脑积水比较少见。

And there are no good training methods

并且没有好的训练方法

to get really good at getting this scope to the right place.

能让我们在把镜头 放入正确位置时相当熟练。

But surgeons have been quite creative about this, even our own.

但外科医生对此特别有创造力， 甚至我们自己的医生也是。

And they've come up with training models.

他们发明了训练模型。

Here's the current training model.

这是目前的训练模型。

(Laughter)

（笑声）

I kid you not.

我可没开玩笑。

This is a red pepper, not made in Hollywood;

这是红辣椒，不是好莱坞做的；

it's real red pepper.

是真正的红辣椒。

And what surgeons do is they stick a scope into the pepper,

外科医生把镜头伸到辣椒里面，

and they do what is called a "seedectomy."

他们把这叫做“辣椒籽切除术”。

(Laughter)

（笑声）

They use this scope to remove seeds using a little tweezer.

他们利用这个镜头， 用小镊子摘除辣椒籽。

And that is a way to get under their belts

那是一种方式，能够学会

the rudimentary components of doing this surgery.

做这个手术的基本操作。

Then they head right into the apprenticeship model,

然后，他们直接进入学徒模式，

seeing many of them as they present themselves,

现场观摩很多手术，

then doing it, and then teaching it --

然后亲自做，然后传授——

waiting for these patients to arrive.

等待着新患者的到来。

We can do a lot better.

我们可以做得更好。

We are manufacturing reproductions of children

我们现在生产儿童的复制品

in order for surgeons and surgical teams to rehearse

用于给外科医生和手术团队

用最接近的方式演练。

in the most relevant possible ways.

Let me show you this.

我来展示一下这个。

Here's my team

这是我的团队，

in what's called the SIM Engineering Division of the Simulator Program.

它是模拟器项目的SIM工程部。

This is an amazing team of individuals.

这是多人组成的一个神奇团队。

They are mechanical engineers;

他们是机械工程师；

you're seeing here, illustrators.

这里看到的是演示器。

They take primary data from CT scans and MRIs,

他们拿到CT扫描和MRI的原始数据，

translate it into digital information,

翻译成数字信息，

animate it,

使其动态化，

put it together into the components of the child itself,

整合成儿童自己的身体器官，

surface-scan elements of the child that have been casted as needed,

根据手术本身，

depending on the surgery itself,

已经按需要投射儿童的体表扫描元素，

and then take this digital data and be able to output it

然后将这个数字数据输出到

on state-of-the-art, three-dimensional printing devices

最新技术的三维打印设备，

that allow us to print the components

该设备使我们能打印出

exactly to the micron detail of what the child's anatomy will look like.

与儿童解剖结构的细微细节 完全一样的器官。

You can see here,

在这里可以看到，

the skull of this child being printed

在实施手术的数小时前，

in the hours before we performed this surgery.

打印出儿童的头骨。

But we could not do this work

但是如果没有加州好莱坞的西海岸朋友们，

without our dear friends on the West Coast in Hollywood, California.

我们做不到这样。

These are individuals that are incredibly talented

这是一些特别擅长

at being able to recreate reality.

再造现实的人。

It was not a long leap for us.

而这对我们来说并不是大步飞跃。

The more we got into this field,

我们在这个领域了解越多，

the more it became clear to us that we are doing cinematography.

就越清楚，我们在做的是摄影。

We're doing filmmaking,

我们在拍电影，

it's just that the actors are not actors.

只是演员并非演员，

They're real doctors and nurses.

而是真正的医生和护士。

这些照片来自 获得艾美奖的特效公司，

So these are some photos of our dear friends at Fractured FX

in Hollywood California,

加州好莱坞的Fractured FX的朋友们，

an Emmy-Award-winning special effects firm.

This is Justin Raleigh and his group --

这是贾斯汀·罗利和他的小组——

this is not one of our patients --

这个可不是我们的病人——

(Laughter)

（笑声）

but kind of the exquisite work that these individuals do.

而是这些人做的精湛的工作。

We have now collaborated and fused our experience,

我们现在已经合作并融合了我们的经验，

bringing their group to Boston Children's Hospital,

请他们的团队到波士顿儿童医院，

sending our group out to Hollywood, California

将我们的团队送到加州的好莱坞，

and exchanging around this

做各种交换

to be able to develop these type of simulators.

以便能够开发这些类型的模拟器。

What I'm about to show you is a reproduction of this child.

下面要展示的是这个孩子的复制品。

You'll notice here that every hair on the child's head is reproduced.

你会注意到，孩子头上的 每一根头发都被复制了。

And in fact, this is also that reproduced child --

事实上，这也是那个复制的孩子——

and I apologize for any queasy stomachs,

我为造成的任何不舒服道歉，

but that is a reproduction and simulation

但那是为他们要实施手术的孩子

of the child they're about to operate on.

所做的复制和模拟。

Here's that membrane we had talked about,

这是我们前面说过的膜，

the inside of this child's brain.

这孩子的脑部里面。

What you're going to be seeing here is, on one side, the actual patient,

你将看到的是 一侧是真实的患者，

and on the other side, the simulator.

另一侧是模拟器。

As I mentioned, a scope, a little camera, needs to make its way down,

如我所说，镜头、小相机需要想办法下去，

and you're seeing that here.

你在这里能看到它。

It needs to make a small hole in this membrane

需要在这个膜上开个小孔

and allow this fluid to seep out.

让液体渗出。

I won't do a quiz show to see who thinks which side is which,

我不会考你们哪一侧的真假，

but on the right is the simulator.

右侧是模拟器。

So surgeons can now produce training opportunities,

因此医生现在可以创造训练机会，

do these surgeries as many times as they want,

把这些手术做无数遍，

to their heart's content, until they feel comfortable.

直到他们满意，直到有信心。

And then, and only then, bring the child into the operating room.

然后，并且只有在那之后， 再把孩子送进手术室。

But we don't stop here.

但这不是终点。

We know that a key step to this is not just the skill itself,

我们知道，关键步骤不只是技巧本身，

but combining that skill with a team who's going to deliver that care.

而是将技巧与实施手术的团队相结合。

Now we turn to Formula One.

现在我们看看一级方程式。

And here is an example of a technician putting on a tire

这是技术人员安装轮胎的例子，

and doing that time and time again on this car.

一次又一次地在这个车上重复。

But that is very quickly going to be incorporated

但这很快就结合到

团队训练之中，

within team-training experiences,

now as a full team orchestrating the exchange of tires

现在作为整个团队来协调换轮胎，

and getting this car back on the speedway.

把车送回赛道。

We've done that step in health care,

那么我们在医疗领域也这么做了

so now what you're about to see is a simulated operation.

现在你要看的是模拟手术，

We've taken the simulator I just described to you,

把我刚才描述的模拟器，

we've brought it into the operating room at Boston Children's Hospital,

带到波士顿儿童医院的手术室，

and these individuals -- these native teams, operative teams --

这些人——本地团队，手术团队——

are doing the surgery before the surgery.

在真正的手术之前 已经在做这个手术了。

Operate twice;

操作两次；实切一次。

cut once.

Let me show that to you.

请看。

（视频）手术队员1： 你想让头部降低还是升高？

(Video) Surgical team member 1: You want the head down or head up?

手术队员2：能降到10吗？

STM 2: Can you lower it down to 10?

STM 3: And then lower the whole table down a little bit?

手术队员3：整个台降低一点？

STM 4: Table coming down.

手术队员4：手术台正在下降

STM 3: All right, this is behaving like a vessel.

手术队员3：好的，这里有类血管表现

Could we have the scissors back, please?

请把剪子拿回来好吗？

STM 5: I'm taking my gloves, 8 to 8 1/2, all right? I'll be right in.

手术队员5：我正戴手套，8到8 1/2，马上加入

STM 6: Great! Thank you.

手术队员6：太好了！谢谢。

Peter Weinstock: It's really amazing.

真的很棒。

The second step to this, which is critical,

这里的第二步，非常关键，

我们马上请这些团队出来， 听他们汇报。

is we take these teams out immediately and debrief them.

We use the same technologies

我们使用的技术

that are used in Lean and Six Sigma in the military,

与军方的精益和六西格玛 使用的技术相同，

and we bring them out and talk about what went right,

让他们出来 讨论哪里做的正确，

but more importantly,

更重要的是，

we talk about what didn't go well,

讨论哪里做得不好，

and how we're going to fix it.

以及如何改正。

Then we bring them right back in and do it again.

然后让他们马上回去， 再做一次。

Deliberative batting practice in the moments when it matters most.

在最重要的时刻， 做刻意的“击打”练习。

Let's go back to this case now.

现在我们回到这个病例。

Same child,

同一个孩子，

but now let me describe how we care for this child

但这次我要描述的是

at Boston Children's Hospital.

我们在波士顿儿童医院 如何护理这个孩子。

This child was born at three o'clock in the morning.

这孩子在凌晨三点出生。

At two o'clock in the morning,

在凌晨两点，

we assembled the team,

我们集合队伍，

and took the reproduced anatomy

拿到从扫描和图像做出的

that we would gain out of scans and images,

复制的解剖结构，

and brought that team to the virtual bedside,

把团队带到虚拟病床，

to a simulated bedside --

模拟的病床——

the same team that's going to operate on this child in the hours ahead --

几小时后要为这孩子 做手术的同一个团队——

and we have them do the procedure.

让他们做一遍手术。

Let me show you a moment of this.

请看其中的片段。

This is not a real incision.

这不是真的切口。

And the baby has not yet been born.

婴儿还未出生。

Imagine this.

想象一下吧。

So now the conversations that I have with families

那么现在，在波士顿儿童医院 的重症监护室，

in the intensive care unit at Boston Children's Hospital

我与孩子家长的对话

are totally different.

就完全不同了。

Imagine this conversation:

想象下这样的对话：

"Not only do we take care of this disorder frequently in our ICU,

“我们在ICU不仅 经常治疗这种疾病，

and not only have we done surgeries

以及不仅做过 您孩子要做的这种手术，

like the surgery we're going to do on your child,

but we have done your child's surgery.

而且，我们已经做过了 您的孩子的这台手术。

And we did it two hours ago.

我们两个小时前做的。

And we did it 10 times.

并且做了10次。

And now we're prepared to take them back to the operating room."

现在，我们准备好真正的手术了。”

So a new technology in health care:

因此，医疗新技术：

lifelike rehearsal.

生命模拟演练。

Practicing prior to game time.

比赛之前的练习。

Thank you.

谢谢。

(Applause)

（掌声）