Long-distance surgery

Telemedicine allows doctors to be in several places at once.

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A young Bosnian girl is struck by flying shrapnel. A paramedic pulls a portable ultrasound unit out of his backpack and scans her injured thigh. The information is sent by cell phone to a German hospital and is converted into a digital ultrasound image that locates the buried metal fragment and also reveals a lacerated, briskly bleeding artery.

The girl is rushed to a field hospital and prepared for surgery. The
surgeon, hundreds of miles away, his hands moving in a virtual reality environment, guides a remote-controlled robot to make the appropriate incision and locate the bleeding artery. The
robot sutures the laceration; the girl lives. Her post-operative course is monitored by telesensors that record vital signs, fluid intake and output, and transmit video images of the wound. The German surgeon makes periodic rounds by downloading fresh
video images.

Later the girl is flown to Germany to meet the doctor. Neither recognizes the other, yet both are emotionally overwhelmed.

Science fiction? Not at all. Welcome to the new world of telemedicine. Using the same technological breakthroughs that allow streaming audio and video, doctors are now able to communicate directly with climbers on Mt. Everest and astronauts in space. Couple the real-time transmission of medical data with the ability to perform virtual reality-guided remote robotic surgery and you have a glimpse of the future of modern
medicine.

(During the war in Bosnia, the U.S. Department of Defense
successfully field-tested an ultrasound system that fits into a backpack. And remote robotic surgery was first accomplished in 1996 when a Belgian surgeon performed a hernia operation on a patient in Holland, 200 kilometers away.)

There are many other examples of what’s been accomplished already, most documented in the latest high-tech medical journal, Telemedicine and Virtual Reality.

A program in Greece brings the teledoctor to accident scenes where data such as electrocardiograms, blood pressure, oxygen saturation and images of patients can now be sent from
some emergency vehicles in Greece. A teledoctor (a doctor at a console receiving the data) can then give immediate advice.

Canadian researchers have developed home dialysis programs, monitored by phone, that allow patients to be treated while they sleep.

At Texas Children’s Hospital, a mobile van is equipped with a remote pediatric echocardiography (ultrasound of the heart and its valves) so that children in doctorless areas can be effectively
technician-screened for congenital heart defects.



Accuracy, so far, has not been an issue. In a 1995 British study of
teledermatology used to determine benign versus malignant skin lumps and bumps, the remote dermatologist viewing transmitted visual images of suspicious skin lesions did nearly as well as the
dermatologist directly examining the patient. The two doctors had a 93 percent agreement rate — essentially similar to what would have been expected if they had been examining the patient side by side. (And this was five years ago, long before better
resolution transmission became available.) A recent study of the accuracy of teleradiology for urologic studies (kidney stones, tumors) was 97 percent.

If a medical situation can be converted to digital data, physical absence of a qualified pathologist, dermatologist or radiologist should no longer preclude first-rate care. A video camera, various scanners, X-ray equipment and some basic recording devices will be the backbone of the new rural physician.

Even certain hands-on procedures once performed by specialists now can be relegated to nurses or medical assistants. Consider the dreaded colonoscopy, the butt of a million bad jokes. A pilot
study from London has shown that a nurse practitioner can perform the procedure with a video camera-equipped endoscope. The images are transmitted to a gastroenterologist at a
distant medical center. He can guide the nurse if necessary. The patients, when interviewed, indicated they preferred “the local touch” as opposed to traveling to a distant, impersonal medical center. The clinicians felt that the images were excellent and
reliable. Think of how many studies a first-rate gastroenterologist could interpret daily if he didn’t have to insinuate his way up some reluctant alimentary canal. The actual operators could
be hired according to coordination and gentleness, not MCATs and good-old-boy referral patterns.

Transmission of data is just the beginning. Even when the doctor is in the operating room, robots offer major advantages.

An anesthesiologist friend tells me that he judges the skill of cardiac surgeons on how gently and adroitly they “handle the tissues.” This combination of a calm temperament, good judgment
and fine motor control isn’t necessarily (read seldom) found in equal amounts in most surgeons.

Enter the dexterous, infinitely patient robot.

Robotic assistants are already being used for laparoscopic surgery. A robotic arm, controlled by a foot pedal or hand control, allows the surgeon to move the laparoscope while simultaneously
handling surgical instruments. One surgeon was quoted as saying, “It’s great. It’s an assistant who’s always there, who doesn’t have a tremor and doesn’t misunderstand your commands.” The
system is believed to shave 20 percent off surgery time and eliminate assistant fees.

In 1998, a robot successfully performed a coronary bypass. Three surgical arms were inserted into the chest cavity through small incisions less than a centimeter wide. One of the arms held a
miniature camera; the other two held standard surgical instruments. The surgeon watched a monitor with a magnified image of the heart and manipulated the robotic arms with two handles. The robot’s “motion-scaling” software translated large natural movements into precise micro-movements in the surgical instruments.

A few months ago, the world’s first closed-chest, robot-assisted beating-heart bypass surgery was performed at the London Health Sciences Centre. In conventional heart surgery, the chest
cavity is opened through a 12- to 15-inch incision, the heart is stopped and patients are placed on cardiopulmonary bypass. But with robotic surgery, there was no “chest-cracking.” The three
incisions were pencil-sized, and the robot was able to perform the bypass on a beating heart — no heart-lung machine was required. The patient went home four days after his surgery without the
usual protracted post-open chest surgery recovery period. The human element? The surgeon was able to directly communicate with the robot through a voice-recognition speech software system.

What about the most delicate surgery of all — neurosurgery? Would you want a robot fiddling inside your brain? Consider how a neurosurgeon performs his delicate procedures. He uses the
latest MRI techniques, including stereotactic guides to maximize the precision of his operating field. He develops a sense of the difference in tissue density to determine diseased versus normal tissue. (Tumors have a different “feel” than normal brain tissue.) He uses a magnifying loop or a microscope to visualize better detail. All of these functions can be reduced to algorithms and fed into computers.

The robotic surgeon can “learn” the characteristics of different kinds of tissues by using neural net software, which is the same kind of technology that helps focus camcorders. The “smart” computer program continues to “learn” as it gains more experience. The probes used on the robot are much smaller than standard probes and should further reduce brain damage. With
the robotic neural net procedure, the speed and maximum pressure are controlled by the computer program. If the probe encounters an artery, it can be programmed to stop before it
penetrates. (This is according to the robot’s developer, Robert W. Mah, Ph.D., of the NeuroEngineering Group at NASA’s Ames Research Center, Mountain View, Calif.)

Dr. Richard Satava, Yale Medical School professor of surgery, has suggested that future patient examinations might be done remotely via holograms. “Data gloves” and a variety of sensors will be able to build a three-dimensional picture of organs or any
physical aspect of a patient.

Perhaps that scenario is a bit extreme, but then so was cloning five years ago. As we have developed a global economy, medicine becomes globalized. All aspects of medical practice will be affected — even who and what we consider to be doctors.

Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon.

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