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Lifelike simulations that make real-life surgery safer

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    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:
  • 16:32 - 16:35
    lifelike rehearsal.
  • 16:35 - 16:39
    Practicing prior to game time.
  • 16:40 - 16:41
    Thank you.
  • 16:41 - 16:46
    (Applause)
Title:
Lifelike simulations that make real-life surgery safer
Speaker:
Peter Weinstock
Description:

Critical care doctor Peter Weinstock shows how surgical teams are using a blend of Hollywood special effects and 3D printing to create amazingly lifelike reproductions of real patients -- so they can practice risky surgeries ahead of time. Think: "Operate twice, cut once." Glimpse the future of surgery in this forward-thinking talk.

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Video Language:
English
Team:
TED
Project:
TEDTalks
Duration:
16:58

English subtitles

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