Lifelike simulations that make real-life surgery safer

What if I told you there
was a new technology

that when placed in the hands
of doctors and nurses,

improved outcomes
for children and adults --

patients of all ages --

reduced pain and suffering,

reduced time in the operating rooms,

reduced anesthetic times,

had the ultimate dose response curve

that the more you did it,

the better it benefitted patients?

Here's a kicker:

it has no side effects,

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

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

this would be a game changer for me.

That technology is lifelike rehearsal.

This lifelike rehearsal is being
delivered through medical simulation.

I thought I would start with a case,

just to really describe
the challenge ahead,

and why this technology is not just
going to improve healthcare,

but why it's critical to healthcare.

This is a child that's born --

young girl --

day of life zero, we call it.

The first day of life,

just born into the world.

And just as she's being born,

we notice very quickly
that she is deteriorating.

Her heart rate is going up,

her blood pressure is going down,

she's breathing very, very fast.

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

That's called a babygram,

and this is full X-ray of a child's body,

a little infant's body.

As you look on the top side of this,

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

As you look at the bottom end,

that's where the abdomen is,

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

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

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

And those are the intestines,

in the wrong place.

As a result, they're pushing on the lungs

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

The fix for this problem

is to take this child immediately
to the operating room,

bring those intestines back
into the abdomen,

let the lungs expand and allow
this child to breathe again.

But before she can go
to the operating room,

she must get whisked away to the ICU,

where I work,

and I work with surgical teams.

We gather around her,

and we place this child
on heart-lung bypass.

We put her to sleep,

we make a tiny
little incision in the neck,

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

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

the tip of a pen --

and then we have blood
drawn from the body,

we bring it through a machine,

it gets oxygenated,

and it goes back into the body.

We save her life,

and get her safely to the operating room.

Here's the problem.

These disorders --

what is known is Congenital
Diaphragmatic Hernia --

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

these disorders are rare.

Even in the best hands in the world,

there is still a challenge
to get the volume --

the natural volume of these patients

in order to get our
expertise curve at 100 percent.

They just don't present that often.

So how do you make the rare common?

Here's the other problem.

In the healthcare system
that I trained for over 20 years,

what currently exists,

the model of training is called
the apprenticeship model.

It's been around for centuries.

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

maybe several times,

you then go do that surgery,

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

An implicit in this model --

I don't need to tell you this --

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

That's a problem.

I think there's a better approach.

Medicine may very well be the last
high-stakes industry

that does not practice prior to game time.

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

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

that had been using this type
of methodology for decades.

This is nuclear power.

Nuclear power runs scenarios
on regular basis

in order to practice what they
hope will never occur.

And as we're all very familiar,

the airline industry.

We all get on planes now
comforted by the idea

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

training on scenarios
that we hope will never occur,

but we know if they did,

they would be prepared for the worst.

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

of simulation environments

because of the importance
of the team coming together.

This is an evacuation drill simulator.

So that again,

if that ever were to happen,

these rare, rare events,

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

I guess the most compelling
for me in some ways,

is the sports industry ...

arguably high stakes.

You think about how a baseball team,

baseball players practice.

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

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

They go to a spring training camp,

perhaps a simulator in baseball.

They're not on the real field,

but they're on a simulated field,

and they're playing
in the pre-game season.

Then they make they're way to the field
during the season games,

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

They go into the batting cage,

and they do batting practice for hours,

having different types of pitches
being thrown at them,

hitting ball after ball
as they limber their muscles,

getting ready for the game itself.

And here's the most
phenomenal part of this ...

and for all of you who watch
and sport event,

you will see this phenomenon happen.

The batter gets into the batter's box,

the pitcher gets ready to pitch.

Right before the pitch is thrown,

what does that batter do?

The batter steps out of the box,

and takes a practice swing.

He wouldn't do it any other way.

I want to talk to you

about how we're building
practice swings like this in medicine.

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

at Boston Children's.

I want to use this case
that we recently built.

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

and as a result,

had loss of developmental milestones --

neurologic milestones --

and the reason for this problem is here,

it's called hydrocephalus.

So a quick study in neurosurgery.

There's the brain,

and you can see the cranium
surrounding the brain.

What surrounds the brain actually
between the brain and cranium

is something called cerebrospinal fluid,

or fluid which acts as a shock absorber.

In your heads right now,

there is cerebrosprinal fluid
just bathing your brains

and making its way around.

It's produced in one area,

and flows through

and then is re-exchanged.

And this beautiful flow pattern
occurs for all of us.

But unfortunately in some children,

there's a blockage of this flow pattern,

much like a traffic jam.

As a result,

the fluid accumulates,

and the brain is pushed aside.

It has difficulty growing.

As a result,

the child loses neurologic milestones.

This is a devastating disease in children.

So the cure for this is surgery.

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

a bit of the skull --

drain this fluid out,

stick a drain in place,

and then eventually bring
this drain internal to the body.

Big operation.

But some great news is that advances
in neurosurgical care

have allowed us to develop
minimally invasive approaches

to this surgery.

Through a small pin hole,

a camera can be inserted,

led into the deep brain structure,

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

much like it would in a sink.

All of a sudden,

the brain is no longer under pressure,

can re-expand,

and we cure the child through
a single hole incision.

But here's the problem.

Hydrocephalus is relatively rare,

and there are no good training methods

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

But surgeons have been
quite creative about this,

even our own.

And they've come up with training models.

Here's the current training model.

(Laughter)

I kid you not.

This is a red pepper,

not made in Hollywood,

it's real, red pepper.

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

and they do what is called
a seedectomy.

(Laughter)

They use this scope to remove seeds

using a little tweezer,

and that is a way to get under their belts

the rudimentary components
of doing this surgery.

Then they head right into
the apprenticeship model,

seeing many of them
as they present themselves,

then doing it,

and then teaching it --

waiting for these patients to arrive.

We can do a lot better.

We are manufacturing
reproductions of children

in order for surgeons and surgical
teams to rehearse

in the most relevant possible ways.

Let me show you this.

Here's my team

in what's called the Sim-engineering
division of the simulator program.

This is an amazing team of individuals.

They are mechanical engineers.

You're seeing here, illustrators.

They take primary data
from CT scans and MRIs,

translate it into digital information,

animate it,

put it together into the components
of the child itself,

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

depending on the surgery itself,

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

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

that allow us to print the components
exactly to the micron detail

of what the child's
anatomy will look like.

You can see here,

the skull of this child being printed
in hours before we performed this surgery.

But we could not do this work without
our dear friends on the West Coast

in Hollywood, California.

These are individuals that are
incredibly talented

at being able to recreate reality.

It was not a long leap for us.

The more we got into this field,

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

We're doing filmmaking,

it's just that the actors are not actors,

they're real doctors and nurses.

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

in Hollywood California,

an Emmy-award winning
special effects firm.

This is Justin Rawley and his group --

this is not one of our patients.

(Laughter)

The kind of exquisite work that
these individuals do,

and we have now collaborated
and fused our experience,

bringing their group to Boston
Children's Hospital,

sending our group
out to Hollywood, California,

and exchanging around this

to be able to develop these
type of simultors.

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

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

And in fact,

this is also that reproduced child,

and I apologize for any queasy stomachs,

but that is a reproduction in simulation
of the child they're about to operate on.

Here's that membrane we had talked about,

the inside of this child's brain.

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

the actual patient,

and on the other side,

the simulator.

As I mentioned,

a scope,

a little camera needs
to make it's way down,

and you're seeing that here.

It needs to make a small
hole in this membrane --

allow this fluid to seep out.

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

but on the right is the simulator.

So surgeons can now produce
training opportunities,

do these surgeries as many
times as they want --

until their heart's content,

until they feel comfortable.

And then --

and only then,

bring the child into the operating room.

But we don't stop here.

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

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

Now we turn to Formula one.

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

and doing that time and time
again on this car,

but that is very quickly
going to be incorporated

within team training experiences,

now as a full team orchestrating
the exchange of tires

and getting this car back on the speedway.

We've done that step in health care,

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

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

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

and these individuals --

these native teams, operative teams --

are doing the surgery before the surgery.

Operate twice;

cut once.

Let me show tha to you.

(Video) Surgeon: You want
the head down or head up?

Lower the whole table down a little bit.

All right, this is behaving like a vessel.

Can I have the scissors back, please?

PW: It's really amazing.

The second step to this which is critical

is we take these teams out
immediately and we debrief them.

We use the same technologies

that are used in [Leen and Six-Sigma]
in the military,

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

but more importantly,

we talk about what didn't go well,

and how we're going to fix it.

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

Deliberative batting practice
in the moments when it matters most.

Let's go back to this case now.

Same child,

but now let me describe

how we care for this child
at Boston Children's Hospital.

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

At two o'clock in the morning,

we assembled the team,

and took the reproduced anatomy

that we would gain
out of scans and images,

and brought that team
to the virtual bedside,

to a simulated bedside --

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

and we have them do the procedure.

Let me show you a moment of this.

This is not a real incision,

and the baby has not yet been born.

Imagine this.

So now the conversations
that I have with families

in the intensive care unit
at Boston Children's Hospital

are totally different.

Imagine this conversation.

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

and now only have we done surgeries

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

but we have done your child's surgery,

and we did it two hours ago,

and we did it 10 times,

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

So a new technology in healtchare:

lifelike rehearsal.

Practicing prior to game time.

Thank you.

(Applause)