WEBVTT

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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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And the good news is that I'm here
to tell you about this technology

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and that we're finding, as we apply
this technology in health care,

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we are having these exact outcomes
I've just described to you.

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That technology is lifelike rehearsal.

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Just in the times that matter most,

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and in the places that matter most,
and for the teams that matter most,

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and ultimately, for the patients
that matter most.

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And this technology,

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this lifelike rehearsal,

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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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You can see here,
it's a quick study in radiology.

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As you see here, the upper portion
of this child's --

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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(Laughter)

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I kid you not.

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This is a red pepper,

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not made in Hollywood;

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it's a 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)

NOTE Paragraph

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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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And I want to take you now into
what is veritably the Willy Wonka shop

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at Boston Children's Hospital,

NOTE Paragraph

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where 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.

NOTE Paragraph

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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 --

NOTE Paragraph

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(Laughter)

NOTE Paragraph

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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,

00:12:55.272 --> 00:12:57.678
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.

NOTE Paragraph

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

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This is not a real 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.

NOTE Paragraph

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So surgeons can now produce
training opportunities,

00:14:17.125 --> 00:14:20.678
do these surgeries
as many times as they want,

00:14:20.702 --> 00:14:23.544
to their heart's content,
until they feel comfortable.

00:14:23.668 --> 00:14:27.263
And then, and only then,
bring the child into the operating room.

00:14:27.287 --> 00:14:28.456
But we don't stop here.

00:14:28.480 --> 00:14:32.790
We know that a key step to this
is not just the skill itself,

00:14:32.814 --> 00:14:37.345
but combining that skill with a team
who's going to deliver that care.

NOTE Paragraph

00:14:37.369 --> 00:14:39.711
Now we turn to Formula One.

00:14:40.275 --> 00:14:43.525
And here is an example
of a technician putting on a tire

00:14:43.549 --> 00:14:46.758
and doing that time and time
again on this car.

00:14:46.782 --> 00:14:49.767
But that is very quickly
going to be incorporated

00:14:49.791 --> 00:14:51.722
within team-training experiences,

00:14:51.746 --> 00:14:55.955
now as a full team orchestrating
the exchange of tires

00:14:55.979 --> 00:14:59.476
and getting this car back on the speedway.

00:15:00.424 --> 00:15:03.701
We've done that step in health care,

00:15:03.725 --> 00:15:09.756
so now what you're about to see
is a simulated operation.

00:15:11.010 --> 00:15:13.397
We've taken the simulator
I just described to you,

00:15:13.421 --> 00:15:16.822
we've brought it into the operating room
at Boston Children's Hospital,

00:15:16.846 --> 00:15:20.501
and these individuals --
these native teams, operative teams --

00:15:20.525 --> 00:15:24.048
are doing the surgery before the surgery.

00:15:24.072 --> 00:15:25.809
Operate twice;

00:15:25.833 --> 00:15:27.039
cut once.

00:15:27.369 --> 00:15:28.765
Let me show that to you.

NOTE Paragraph

00:15:31.837 --> 00:15:34.950
(Video) Surgical team member 1:
You want the head down or head up?

NOTE Paragraph

00:15:34.974 --> 00:15:36.678
STM 2: Can you lower it down to 10?

NOTE Paragraph

00:15:36.702 --> 00:15:39.351
STM 3: And then lower
the whole table down a little bit?

NOTE Paragraph

00:15:39.375 --> 00:15:40.629
STM 4: Table coming down.

NOTE Paragraph

00:15:43.276 --> 00:15:45.981
STM 3: All right, this
is behaving like a vessel.

00:15:46.005 --> 00:15:48.092
Could we have the scissors back, please?

NOTE Paragraph

00:15:48.116 --> 00:15:51.417
STM 5: I'm taking my gloves,
8 to 8 1/2, all right? I'll be right in.

NOTE Paragraph

00:15:51.441 --> 00:15:53.842
STM 6: Great! Thank you.

NOTE Paragraph

00:15:54.856 --> 00:15:56.689
Peter Weinstock: It's really amazing.

00:15:57.113 --> 00:15:59.205
The second step to this,
which is critical,

00:15:59.229 --> 00:16:02.328
is we take these teams out
immediately and debrief them.

00:16:02.802 --> 00:16:04.266
We use the same technologies

00:16:04.290 --> 00:16:08.978
that are used in Lean
and Six Sigma in the military,

00:16:09.002 --> 00:16:12.087
and we bring them out
and talk about what went right,

00:16:12.111 --> 00:16:13.563
but more importantly,

00:16:13.587 --> 00:16:16.247
we talk about what didn't go well,

00:16:16.271 --> 00:16:18.206
and how we're going to fix it.

00:16:18.230 --> 00:16:20.984
Then we bring them right back in
and do it again.

00:16:21.008 --> 00:16:26.199
Deliberative batting practice
in the moments when it matters most.

NOTE Paragraph

00:16:27.808 --> 00:16:29.830
Let's go back to this case now.

00:16:30.453 --> 00:16:31.830
Same child,

00:16:31.854 --> 00:16:34.244
but now let me describe
how we care for this child

00:16:34.268 --> 00:16:35.731
at Boston Children's Hospital.

00:16:35.755 --> 00:16:38.241
This child was born
at three o'clock in the morning.

00:16:38.265 --> 00:16:40.272
At two o'clock in the morning,

00:16:40.296 --> 00:16:42.422
we assembled the team,

00:16:42.446 --> 00:16:44.247
and took the reproduced anatomy

00:16:44.271 --> 00:16:48.057
that we would gain
out of scans and images,

00:16:48.600 --> 00:16:51.366
and brought that team
to the virtual bedside,

00:16:51.390 --> 00:16:52.977
to a simulated bedside --

00:16:53.001 --> 00:16:56.542
the same team that's going to operate
on this child in the hours ahead --

00:16:56.566 --> 00:16:58.949
and we have them do the procedure.

00:16:59.616 --> 00:17:01.296
Let me show you a moment of this.

00:17:06.151 --> 00:17:08.311
This is not a real incision.

00:17:09.621 --> 00:17:11.821
And the baby has not yet been born.

00:17:13.283 --> 00:17:14.651
Imagine this.

NOTE Paragraph

00:17:21.203 --> 00:17:25.091
So now the conversations
that I have with families

00:17:25.115 --> 00:17:27.815
in the intensive care unit
at Boston Children's Hospital

00:17:27.839 --> 00:17:29.227
are totally different.

00:17:29.832 --> 00:17:31.568
Imagine this conversation:

00:17:32.719 --> 00:17:37.570
"Not only do we take care of this disorder
frequently in our ICU,

00:17:37.594 --> 00:17:39.772
and not only have we done surgeries

00:17:39.796 --> 00:17:42.231
like the surgery we're going
to do on your child,

00:17:42.255 --> 00:17:45.969
but we have done your child's surgery.

00:17:47.026 --> 00:17:49.556
And we did it two hours ago.

00:17:49.580 --> 00:17:52.312
And we did it 10 times.

00:17:52.336 --> 00:17:56.157
And now we're prepared to take them
back to the operating room."

NOTE Paragraph

00:17:57.801 --> 00:18:00.131
So a new technology in health care:

00:18:01.237 --> 00:18:04.105
lifelike rehearsal.

00:18:04.129 --> 00:18:07.683
Practicing prior to game time.

NOTE Paragraph

00:18:08.702 --> 00:18:09.882
Thank you.

NOTE Paragraph

00:18:09.906 --> 00:18:16.906
(Applause)