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

譯者: Helen Chang 審譯者: S Sung

What if I told you there was a new technology

想像這會怎樣──

把一種新科技

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

交給醫生和護士使用，

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

它能改善兒童、成人，

所有年齡患者的治療效果；

reduced pain and suffering,

它能降低病人的痛苦，

reduced time in the operating rooms,

縮短手術的時間，

reduced anesthetic times,

減少麻醉的次數，

had the ultimate dose-response curve

獲得最佳的劑量反應曲線；

that the more you did it,

這技術被用得越多，

the better it benefitted patients?

患者的獲益就越大。

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

意料之外的是：它不但沒有副作用，

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

且可用於任何治療。

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

身為波士頓兒童醫院 加護病房的醫生，

this would be a game changer for me.

我認為局面會全然改觀。

That technology is lifelike rehearsal.

我說的科技是

仿真的醫學模擬和練習，

This lifelike rehearsal is being delivered through medical simulation.

用逼真的醫學模擬來練習。

I thought I would start with a case,

我先舉個實例

just to really describe the challenge ahead,

來確切說明醫學所面臨的挑戰，

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

為何這技術不但會改善醫療，

but why it's critical to health care.

並且是不可或缺的。

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

這是一個剛出生的小女孩。

"Day of life zero," we call it,

我們稱為「生命的首日」，

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

她降生到這世界的第一天。

And just as she's being born,

她一出生，

we notice very quickly that she is deteriorating.

我們立刻發現她的健康狀況

正急遽惡化。

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

她的心跳加速，

血壓下降，

she's breathing very, very fast.

呼吸非常急促。

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

這張 X 光片顯示病因。

That's called a babygram,

我們稱之為嬰兒圖像 (babygram)，

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

是嬰兒全身的 X 光片。

As you look on the top side of this,

圖片的上半

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

是心臟和肺臟應該在的位置；

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

下半是腹部和小腸應該在的位置。

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

看這塊半透明的區域，

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

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

一直延伸到右上方嬰兒的胸腔，

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

那是錯位的小腸。

As a result, they're pushing on the lungs

小腸推擠肺部，

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

使得這可憐的嬰兒難以呼吸。

The fix for this problem

解決之道是馬上為她動手術，

is to take this child immediately to the operating room,

把小腸移回腹部，

bring those intestines back into the abdomen,

let the lungs expand

讓她肺的空間擴大，

and allow this child to breathe again.

能夠恢復呼吸。

But before she can go to the operating room,

但在手術之前，

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

必須先火速送她進我的加護病房。

I work with surgical teams.

我和手術團隊圍繞著她，

We gather around her,

and we place this child on heart-lung bypass.

為她接上體外心肺循環機 ，

We put her to sleep,

上麻醉藥，

we make a tiny little incision in the neck,

在脖子上切個小口，

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

把導管伸入脖子的主動脈內。

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

這些血管的尺寸只有筆尖那麼細。

the tip of a pen --

and then we have blood drawn from the body,

我們抽出她的血液，

we bring it through a machine, it gets oxygenated,

導入一台機器，充氧，

and it goes back into the body.

再送回體內。

We save her life,

我們挽救她的性命，

and get her safely to the operating room.

把她安全送進開刀房。

Here's the problem:

問題在此：

these disorders --

她罹患的病

what is known is congenital diaphragmatic hernia --

被稱為「先天性橫膈疝氣」，

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

隔膜上有個洞使腸子得以向上移位，

these disorders are rare.

是種罕見的疾病。

Even in the best hands in the world,

即使是世上最優秀的外科醫生

there is still a challenge to get the volume --

也難以累積足夠的經驗，

the natural volume of these patients --

因為患者的數目太少，

in order to get our expertise curve at 100 percent.

醫師難以練到百分之百的技術曲線。

They just don't present that often.

很難遇到這種病例。

So how do you make the rare common?

那麼，怎樣變罕見為常見呢？

Here's the other problem:

另外還有一個問題：

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

我服務了二十多年的醫療系統，

what currently exists,

現行的訓練模式稱為「學徒模式」，

the model of training is called the apprenticeship model.

It's been around for centuries.

已有數百年的歷史。

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

學徒模式的基本概念

是先看別人做一次或數次的手術，

maybe several times,

you then go do that surgery,

然後自己動手術；

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

最終再把這技術傳承給下一代。

And implicit in this model --

其實說白了，

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.

學徒模式是一面開刀、一面練習。

That's a problem.

這是個大問題。

I think there's a better approach.

我認為有更好的方法。

Medicine may very well be the last high-stakes industry

醫療很可能是最後一門

不先訓練就實作的高風險行業了。

that does not practice prior to game time.

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

讓我闡述醫療模擬這個好辦法。

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

我們先參觀其他已經使用這方法

數十年之久的高風險行業，

that had been using this type of methodology for decades.

This is nuclear power.

核電廠。

Nuclear power runs scenarios on a regular basis

核電廠會定期演習，

練習和防範不樂見的未然；

in order to practice what they hope will never occur.

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

還有大家熟悉的航空業。

we all get on planes now, comforted by the idea

現今大家搭機都很放心，

因爲機師和機組人員

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

已被飛行模擬器訓練過，

像這樣的模擬器，

training on scenarios that we hope will never occur,

他們知道要如何應對 但願永不發生的緊急狀況；

but we know if they did,

萬一不幸發生了，

they would be prepared for the worst.

我們有信心他們能應變。

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

事實上，

航空業甚至直接打造機艙模擬情境，

of simulation environments,

because of the importance of the team coming together.

因為整體團隊的運作至關重要。

This is an evacuation drill simulator.

這是模擬的疏散演習。

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

我重申，一旦發生罕見事故，

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

他們能夠瞬間應變。

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

我猜，最吸引我目光的

還是高風險的體育行業。

arguably high stakes.

You think about a baseball team: baseball players practice.

我認為棒球隊球員練習

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

是個漸進訓練的好例子。

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

他們先進行春季訓練。

They go to a spring training camp,

春訓用的可能是棒球模擬器，

perhaps a simulator in baseball.

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

不是實體球場，而是模擬的球場。

and they're playing in the pregame season.

他們打季前賽，

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

然後在正規賽季進入棒球比賽場。

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

開賽前他們先做些什麼呢？

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

先在擊球練習區揮棒幾個小時；

having different types of pitches being thrown at them,

面對各式球路

hitting ball after ball as they limber their muscles,

一次又一次揮棒暖身，

getting ready for the game itself.

為真正的比賽做準備。

And here's the most phenomenal part of this,

最不凡的部分，

and for all of you who watch any sport event,

所有看球賽的人

you will see this phenomenon happen.

都會看到這現象：

The batter gets into the batter's box,

打者進入打擊區，

the pitcher gets ready to pitch.

投手準備投球，

Right before the pitch is thrown,

就在球被投出之前，

what does that batter do?

打者做什麼動作？

The batter steps out of the box

打者離開打擊區

and takes a practice swing.

練習揮棒。

He wouldn't do it any other way.

打者必定這樣做。

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

告訴你

我們如何為醫療行業建立練習系統，

in medicine.

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

建造打擊練習區，

為心繫的患者

建在波士頓兒童醫院裡。

at Boston Children's.

I want to use this case that we recently built.

我用最近建的案例說明：

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

這個四歲兒童的頭部逐漸漲大，

and as a result,

以致發育不如預期，

had loss of developmental milestones, neurologic milestones,

錯失了腦神經發育的里程碑。

and the reason for this problem is here --

問題出在這裡：

it's called hydrocephalus.

「腦積水」。

So, a quick study in neurosurgery.

快速簡介腦神經外科手術的做法。

There's the brain,

這是大腦，

and you can see the cranium surrounding the brain.

顱骨包圍著大腦，

What surrounds the brain, between the brain and cranium,

在大腦和顱骨之間流動的

is something called cerebrospinal fluid or fluid,

是「腦脊液」，

which acts as a shock absorber.

它的作用是緩衝撞擊力。

In your heads right now,

此刻你的大腦

there is cerebrospinal fluid just bathing your brains

浸泡在頭骨裡的腦脊液裡，

and making its way around.

腦脊液繞著大腦流動，

It's produced in one area and flows through,

在一個地方產生腦脊液，

and then is re-exchanged.

流動，然後再循環，

And this beautiful flow pattern occurs for all of us.

每個人的腦脊液都美妙地流動著。

But unfortunately in some children,

但不幸有些孩子的腦脊液

there's a blockage of this flow pattern,

塞住不流動，

much like a traffic jam.

就像交通壅塞那樣。

As a result, the fluid accumulates,

結果腦脊液積聚，

and the brain is pushed aside.

腦被擠到一邊，

It has difficulty growing.

難以生長，

As a result, the child loses neurologic milestones.

孩子因此腦神經發育遲緩，

This is a devastating disease in children.

這是種毀滅性的兒童病。

The cure for this is surgery.

治療方式是動手術。

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

傳統手術是取下一小塊顱骨，

a bit of the skull,

一小塊頭骨，

drain this fluid out, stick a drain in place,

安裝一條引流管排出腦脊液，

and then eventually bring this drain internal to the body.

引流到身體的內部。

Big operation.

這是個大手術。

But some great news is that advances in neurosurgical care

好消息是神經外科醫療

已經進步到

have allowed us to develop minimally invasive approaches

能讓我們施行微創手術。

to this surgery.

Through a small pinhole, a camera can be inserted,

相機可通過小針孔

led into the deep brain structure,

進入深層的腦結構，

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

在腦膜上開個小孔引流腦脊液，

much like it would in a sink.

就像讓水槽排水一樣。

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

轉眼間，腦部不再受壓，

can re-expand

能夠伸展，

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

開一個小切口就能治療這孩子。

But here's the problem:

但問題是：

hydrocephalus is relatively rare.

腦積水相當罕見，

And there are no good training methods

沒有好的訓練方法能讓我們

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

嫻熟地把鏡頭擺放在正確的位置。

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

對此外科醫生相當有創造力，

我們自己的醫生也是。

And they've come up with training models.

他們發明了訓練模型。

Here's the current training model.

這是目前的訓練模型。

(Laughter)

（笑聲）

I kid you not.

我可沒開玩笑。

This is a red pepper, not made in Hollywood;

這是個紅椒，不是好萊塢做的，

it's real red pepper.

而是真正的紅椒。

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

外科醫生把鏡頭伸入紅椒，

and they do what is called a "seedectomy."

進行所謂「椒籽切除術」。

(Laughter)

（笑聲）

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

他們用鏡頭和小鑷子摘除紅椒籽，

And that is a way to get under their belts

那是學會基本手術操作的方式。

the rudimentary components of doing this surgery.

Then they head right into the apprenticeship model,

接著他們直接進入學徒模式，

seeing many of them as they present themselves,

觀摩多次臨場的手術，

then doing it, and then teaching it --

然後親自動手，接著傳授，

waiting for these patients to arrive.

等待著新的患者。

We can do a lot better.

我們有更好的方式。

We are manufacturing reproductions of children

如今我們複製病童，

in order for surgeons and surgical teams to rehearse

讓外科醫生和手術團隊

in the most relevant possible ways.

以最接近實況的方式一再練習。

Let me show you this.

讓我來展示。

Here's my team

這是我的團隊，

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

模擬計劃的模擬工程團隊。

This is an amazing team of individuals.

團隊的每個人都很了不起。

They are mechanical engineers;

有機械工程師，

you're seeing here, illustrators.

和這裡看到的繪圖師。

They take primary data from CT scans and MRIs,

他們把電腦斷層

和核磁共振掃描的原始數據

translate it into digital information,

轉成數字資訊，

animate it,

做成動畫，

put it together into the components of the child itself,

整合做成兒童自身的器官。

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

根據手術本身的需求，

事先已掃描兒童的器官，

depending on the surgery itself,

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

連同數據輸出到

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

最先進的三維列印機，

that allow us to print the components

把兒童的器官列印出來，

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

細節精確到微米的程度。

You can see here,

這裡看到的是

the skull of this child being printed

兒童的頭骨

in the hours before we performed this surgery.

在手術前數小時被列印出來。

But we could not do this work

如果沒有西岸加州好萊塢的夥伴們

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

我們無法做到。

These are individuals that are incredibly talented

這些是特別擅長重製現實的人。

at being able to recreate reality.

It was not a long leap for us.

這不算是我們的大躍進。

The more we got into this field,

在這個領域了解得越多就越清楚，

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

我們是在拍片，

We're doing filmmaking,

在製作電影。

it's just that the actors are not actors.

但不由演員演出，

They're real doctors and nurses.

而是如假包換的醫生和護士。

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

這些照片來自

任職於加州好萊塢 Fractured FX 的好朋友們，

in Hollywood California,

an Emmy-Award-winning special effects firm.

那是個獲得艾美獎的特效公司。

This is Justin Raleigh and his group --

這是賈斯汀·羅利和他的隊友，

this is not one of our patients --

那可不是我們的病人，

(Laughter)

（笑聲）

but kind of the exquisite work that these individuals do.

而是他們的精湛作品。

We have now collaborated and fused our experience,

我們現已融合雙方的經驗，

bringing their group to Boston Children's Hospital,

邀請他們團隊到波士頓兒童醫院，

sending our group out to Hollywood, California

也送我們的人去加州好萊塢，

and exchanging around this

交流和開發這類的模擬器。

to be able to develop these type of simulators.

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

下面向大家展示這孩子的複製模型。

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

可以看到

孩子的每根頭髮都被複製了。

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

事實上，這也是複製的孩子。

and I apologize for any queasy stomachs,

若看了不舒服，我道歉。

but that is a reproduction and simulation

那是為他們要動手術的孩子

of the child they're about to operate on.

所做的模型和模擬。

Here's that membrane we had talked about,

這是我們先前說過孩子的腦膜。

the inside of this child's brain.

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

這裡看到的一邊是真實的病患，

and on the other side, the simulator.

另一邊是模擬的。

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

如我先前說的

要把小相機鏡頭像這樣向下伸，

and you're seeing that here.

It needs to make a small hole in this membrane

在腦膜上開個小洞

and allow this fluid to seep out.

排出腦脊液。

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

我不考你們哪邊真，哪邊模擬。

but on the right is the simulator.

右側是模擬的。

So surgeons can now produce training opportunities,

現在創造了訓練的機會，

do these surgeries as many times as they want,

讓醫生可以重複做無數遍的手術，

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

直到他們滿意、有信心之後，

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

才為孩子動手術。

But we don't stop here.

不只這樣，

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

我們知道關鍵不侷限於手術的技巧，

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

而在結合手術團隊和技巧。

Now we turn to Formula One.

現在我們轉看 一級方程式賽車的例子。

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

技師安裝輪胎，

and doing that time and time again on this car.

一而再、再而三換車胎。

But that is very quickly going to be incorporated

很快納入整個團隊的訓練中，

within team-training experiences,

now as a full team orchestrating the exchange of tires

群策群力換車胎，

and getting this car back on the speedway.

把車送回賽道。

We've done that step in health care,

在醫療領域我們也這麼做。

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

接下來看模擬手術。

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

把我剛才描述的模擬手術訓練

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

帶進波士頓兒童醫院的手術室裡，

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

本地手術團隊的這些人

are doing the surgery before the surgery.

正在進行手術前的模擬手術。

Operate twice;

練習兩次；

cut once.

實切一次。

Let me show that to you.

請看。

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

（影片）手術團隊成員之一： 頭放低還是放高？

STM 2: Can you lower it down to 10?

團員二：降低到 10 好嗎？

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

團員三：把整個手術台 降低點，好嗎？

STM 4: Table coming down.

團員四：正在降低手術台。

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

團員三：好，這像是條血管。

Could we have the scissors back, please?

請把剪刀拿回來好嗎？

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

團員五：我正脫除手套。 8 到 8 1/2 好嗎？馬上回來。

STM 6: Great! Thank you.

團員六：太好了！謝謝。

Peter Weinstock: It's really amazing.

（彼得·萬斯托克）真的很棒。

The second step to this, which is critical,

接下來是關鍵的第二步：

is we take these teams out immediately and debrief them.

立刻請團隊出來聽簡報。

We use the same technologies

用和軍方一樣的

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

「精實六標準差」，

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

討論哪裡做得好，

but more importantly,

更重要的是知道哪裡做得不好

we talk about what didn't go well,

and how we're going to fix it.

以及要如何改正。

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

然後讓他們立刻回手術室再做一次。

Deliberative batting practice in the moments when it matters most.

是緊要關頭的刻意擊球練習。

Let's go back to this case now.

回到這個病例。

Same child,

同一個孩子，

but now let me describe how we care for this child

現在描述我們在波士頓兒童醫院

at Boston Children's Hospital.

如何護理這個孩子。

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

這孩子在凌晨三點出生。

At two o'clock in the morning,

在凌晨兩點，

we assembled the team,

我們就集合醫療團隊，

and took the reproduced anatomy

把用掃描和影像所複製的解剖結構

that we would gain out of scans and images,

and brought that team to the virtual bedside,

及團隊送到虛擬病床，

to a simulated bedside --

也就是模擬的病床。

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

幾個小時後同一團隊 要為這孩子動手術，

and we have them do the procedure.

先讓他們操作模擬一遍。

Let me show you a moment of this.

請看其中的片段，

This is not a real incision.

不是真的切口，

And the baby has not yet been born.

嬰兒尚未出生。

Imagine this.

想像一下，

So now the conversations that I have with families

如今我與孩子的家人

in the intensive care unit at Boston Children's Hospital

在波士頓兒童醫院加護病房的對話

are totally different.

和以往截然不同。

Imagine this conversation:

想像這對話：

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

「我們不僅常在加護病房醫這種病，

and not only have we done surgeries

不僅曾多次做過 將要為令郎／令嬡進行的手術，

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

but we have done your child's surgery.

而且，我們已為他／她手術過了，

And we did it two hours ago.

兩個小時前做了十回。

And we did it 10 times.

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

我們已準備好進行真正的手術。」

So a new technology in health care:

新的醫療技術：

lifelike rehearsal.

栩栩如生的模擬醫學演練，

Practicing prior to game time.

賽前的練習。

Thank you.

謝謝。

(Applause)

（鼓掌）