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.
如果我告诉你有一种新技术, 一旦医生和护士掌握了它, 就能改善儿童和成人, 所有年龄段患者的治疗效果, 能减少疼痛和折磨, 缩短手术时间, 缩短麻醉时间, 拥有最终极的剂量-效果曲线, 你用的越多 就对患者越有益,你信不信? 关键是:它没有副作用, 并且可以在任何治疗中使用。 我是波士顿儿童医院的 加护病房医生, 这对我而言是划时代的技术。 这项技术叫做生命模拟演练。 这种生命模拟演练 是通过医疗模拟实现的。
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 health care but why it's critical to health care. 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.
我会通过一个病例来开始讲述, 真实描述一下面临的挑战, 以及为什么这项技术 不仅会改进医疗, 而且对医疗至关重要。 这是一个刚出生的小女孩。 我们称为“生命首日”, 她刚刚来到这个世界, 经历生命的第一天。 刚一出生, 我们就发现她的状况在迅速恶化。 心率不断上升,血压不断下降, 呼吸非常急促。 病因就显示在这张X光片上。
That's called a babygram, a 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 into 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.
我们叫它婴儿透视, 是婴儿全身的X光片。 这张图靠上的部分, 是心脏和肺所处的位置。 靠下的部分是腹部, 是肠子所处的位置。 你们能看到这里有些半透明的区域, 向上移动到了孩子的右胸腔内。 那些是错位的肠子。 结果就是它们压迫肺部, 使这个可怜的孩子难以呼吸。
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. 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.
解决办法就是 马上送她进手术室, 把肠子移回腹部, 让肺扩张, 让孩子恢复呼吸。 但她进手术室之前, 必须先来重症监护室 ——我工作的地方。 我与手术团队合作, 进行会诊, 我们采用心肺体外循环的方法。 我们将孩子麻醉, 在她脖子上开个小小的切口, 把导管放入脖子的主血管内, 这些血管的尺寸也就钢笔—— 钢笔尖那么粗, 我们把血液抽出来, 导入一个机器,充氧, 再导回体内。 我们保住了她的性命, 把她安全送到了手术室。
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?
问题在于: 这种疾病, 我们称之为“先天性横膈疝气”—— 也就是隔膜上有一个洞, 使得肠子能向上移位—— 这种疾病很罕见。 即使是世上最优秀医生, 临床经验也不足, 因为患者的数量太少, 使得我们的技能曲线 很难达到百分之百。 因为这种病例就是很难遇到。 你怎样才能让罕见变得常见呢?
Here's the other problem: in the health care 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. And 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.
还有一个问题: 我在医疗系统中 接受训练超过20年, 现有的训练模式叫做学徒模式, 它已经存在几百年了。 它的基本概念是,你观摩手术, 也许一次,也许多次, 然后你亲自去做那个手术, 最后你再把这个手术传给下一代。 其实说白了, 相信大家也能想得到, 我们是在用患者进行练习。 这是个大问题。 我认为有更好的方法。 医疗很可能是实操之前不进行训练的 最后一个高风险行业了。 这个更好的方法就是医疗模拟。
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 a 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 again, if that ever were to happen, these rare, rare events, they're ready to act on the drop of a dime.
我们首先去参观了 其他高风险行业, 它们用这种方法已经几十年了。 这是核电厂。 核电厂会定期举行演习, 为他们希望永不发生的事情做好准备 以及我们都很熟悉的航空业—— 现在大家坐飞机都很放松, 是因为我们知道,飞行员和机组人员 在模拟器上进行了训练 为应对我们希望永不发生的情况, 而且我们知道,一旦发生, 他们也有能力应对。 事实上,航空业已经发展到 直接造一个机身进行模拟, 这样可以使整个团队一同训练。 这是疏散训练模拟器。 那么再次说明 一旦发生这种非常罕见的事故 他们能够瞬间作出反应
I guess the most compelling for me in some ways is the sports industry -- arguably high stakes. You think about a baseball team: baseball players practice. I think it's a beautiful example of progressive training. The first thing they do is 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 pregame season. Then they make their 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 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 any 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.
我想最吸引我的是体育行业了—— 有争议的高风险 你想想棒球队:棒球手训练。 我认为那是渐进训练的完美示例。 首先他们要做的是春季训练。 他们去春季训练营, 也许用棒球模拟器。 他们不在真实赛场, 但在模拟赛场上, 他们在赛前季节打球。 然后在赛季比赛中进入赛场。 开始比赛前他们做什么? 是去击球练习区做数小时的击打练习, 球以各种投掷方式投向他们, 一次接一次地击球,练习肌肉, 为真正的比赛做准备。 这是最令人震惊的部分, 所有观看任何体育比赛的人, 都会看到这种现象。 击球手进入击球位, 投球手准备投掷。 就在马上投球之前, 击球手做了什么? 击球手退出击球位, 练习一次挥臂动作。 他一定会这样做。
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.
我想告诉你的是, 我们在医疗行业是 如何像他们这样做击球练习的。 我们在波士顿儿童医院, 为我们的患者做一个击球练习区。 我想利用一下, 这个最近做好的病例。 这是四岁儿童头部逐渐扩大的病例, 作为结果, 这种病症会导致发育缺失,重要的神经功能缺失, 这个问题的原因在这里—— 它叫做脑积水。
So, a quick study in neurosurgery. There's the brain, and you can see the cranium surrounding the brain. What surrounds the brain, 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 cerebrospinal 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.
那么,简短解释下脑外科知识。 这是脑部。 你能看到包围大脑的颅骨。 在大脑和颅骨之间,围绕大脑的 是脑脊液, 它的作用是减震。 现在你的头部里面, 有脑脊液正在浸泡着你的脑部, 并围绕着脑部。 它在一个区域产生,流动, 然后再循环。 我们每个人都有这种美丽的流动通道。 但不幸的是,有些孩子, 这种流通通道受到阻碍, 就像堵车。 结果是,脑脊液积聚, 脑部被推到一边。 难以生长。 结果,孩子失去神经系统的重要功能。 这是对于儿童的毁灭性疾病。
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 pinhole, 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.
它的治疗方法是手术。 传统手术是取下一点颅骨, 头骨的一小部分, 排出液体,在适当位置安装排放管, 然后最终把这排放管引到身体内部。 大手术。 但好消息是,神经外科医疗的进步 让我们为这手术开发出 微创方法。 通过小针孔,可插入相机, 引导相机进入深层脑结构, 并在膜上开个小孔,让液体排出, 就像在水槽里排水一样。 转眼间,脑部不再受压, 能再扩大, 我们通过单孔切口治好了这孩子。
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.
但问题是: 脑积水比较少见。 并且没有好的训练方法 能让我们在把镜头 放入正确位置时相当熟练。 但外科医生对此特别有创造力, 甚至我们自己的医生也是。 他们发明了训练模型。 这是目前的训练模型。
(Laughter)
(笑声)
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."
我可没开玩笑。 这是红辣椒,不是好莱坞做的; 是真正的红辣椒。 外科医生把镜头伸到辣椒里面, 他们把这叫做“辣椒籽切除术”。
(Laughter)
(笑声)
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.
他们利用这个镜头, 用小镊子摘除辣椒籽。 那是一种方式,能够学会 做这个手术的基本操作。 然后,他们直接进入学徒模式, 现场观摩很多手术, 然后亲自做,然后传授—— 等待着新患者的到来。 我们可以做得更好。
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 the hours before we performed this surgery.
我们现在生产儿童的复制品 用于给外科医生和手术团队 用最接近的方式演练。 我来展示一下这个。 这是我的团队, 它是模拟器项目的SIM工程部。 这是多人组成的一个神奇团队。 他们是机械工程师; 这里看到的是演示器。 他们拿到CT扫描和MRI的原始数据, 翻译成数字信息, 使其动态化, 整合成儿童自己的身体器官, 根据手术本身, 已经按需要投射儿童的体表扫描元素, 然后将这个数字数据输出到 最新技术的三维打印设备, 该设备使我们能打印出 与儿童解剖结构的细微细节 完全一样的器官。 在这里可以看到, 在实施手术的数小时前, 打印出儿童的头骨。
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 FX in Hollywood California, an Emmy-Award-winning special effects firm. This is Justin Raleigh and his group -- this is not one of our patients --
但是如果没有加州好莱坞的西海岸朋友们, 我们做不到这样。 这是一些特别擅长 再造现实的人。 而这对我们来说并不是大步飞跃。 我们在这个领域了解越多, 就越清楚,我们在做的是摄影。 我们在拍电影, 只是演员并非演员, 而是真正的医生和护士。 这些照片来自 获得艾美奖的特效公司, 加州好莱坞的Fractured FX的朋友们, 这是贾斯汀·罗利和他的小组—— 这个可不是我们的病人——
(Laughter)
(笑声)
but kind of the exquisite work that these individuals do. 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 simulators.
而是这些人做的精湛的工作。 我们现在已经合作并融合了我们的经验, 请他们的团队到波士顿儿童医院, 将我们的团队送到加州的好莱坞, 做各种交换 以便能够开发这些类型的模拟器。
What I'm about to show you is 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 and 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 its way down, and you're seeing that here. It needs to make a small hole in this membrane and 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.
下面要展示的是这个孩子的复制品。 你会注意到,孩子头上的 每一根头发都被复制了。 事实上,这也是那个复制的孩子—— 我为造成的任何不舒服道歉, 但那是为他们要实施手术的孩子 所做的复制和模拟。 这是我们前面说过的膜, 这孩子的脑部里面。 你将看到的是 一侧是真实的患者, 另一侧是模拟器。 如我所说,镜头、小相机需要想办法下去, 你在这里能看到它。 需要在这个膜上开个小孔 让液体渗出。 我不会考你们哪一侧的真假, 右侧是模拟器。
So surgeons can now produce training opportunities, do these surgeries as many times as they want, to 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.
因此医生现在可以创造训练机会, 把这些手术做无数遍, 直到他们满意,直到有信心。 然后,并且只有在那之后, 再把孩子送进手术室。 但这不是终点。 我们知道,关键步骤不只是技巧本身, 而是将技巧与实施手术的团队相结合。
Now we turn to Formula One. And here is an example of a technician putting on 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 that to you.
现在我们看看一级方程式。 这是技术人员安装轮胎的例子, 一次又一次地在这个车上重复。 但这很快就结合到 团队训练之中, 现在作为整个团队来协调换轮胎, 把车送回赛道。 那么我们在医疗领域也这么做了 现在你要看的是模拟手术, 把我刚才描述的模拟器, 带到波士顿儿童医院的手术室, 这些人——本地团队,手术团队—— 在真正的手术之前 已经在做这个手术了。 操作两次;实切一次。 请看。
(Video) Surgical team member 1: You want the head down or head up?
(视频)手术队员1: 你想让头部降低还是升高?
STM 2: Can you lower it down to 10?
手术队员2:能降到10吗?
STM 3: And then lower the whole table down a little bit?
手术队员3:整个台降低一点?
STM 4: Table coming down.
手术队员4:手术台正在下降
STM 3: All right, this is behaving like a vessel. Could we have the scissors back, please?
手术队员3:好的,这里有类血管表现 请把剪子拿回来好吗?
STM 5: I'm taking my gloves, 8 to 8 1/2, all right? I'll be right in.
手术队员5:我正戴手套,8到8 1/2,马上加入
STM 6: Great! Thank you.
手术队员6:太好了!谢谢。
Peter Weinstock: It's really amazing. The second step to this, which is critical, is we take these teams out immediately and debrief them. We use the same technologies that are used in Lean and Six Sigma in the military, and we bring them out and 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 do it again. Deliberative batting practice in the moments when it matters most.
真的很棒。 这里的第二步,非常关键, 我们马上请这些团队出来, 听他们汇报。 我们使用的技术 与军方的精益和六西格玛 使用的技术相同, 让他们出来 讨论哪里做的正确, 更重要的是, 讨论哪里做得不好, 以及如何改正。 然后让他们马上回去, 再做一次。 在最重要的时刻, 做刻意的“击打”练习。
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.
现在我们回到这个病例。 同一个孩子, 但这次我要描述的是 我们在波士顿儿童医院 如何护理这个孩子。 这孩子在凌晨三点出生。 在凌晨两点, 我们集合队伍, 拿到从扫描和图像做出的 复制的解剖结构, 把团队带到虚拟病床, 模拟的病床—— 几小时后要为这孩子 做手术的同一个团队—— 让他们做一遍手术。 请看其中的片段。 这不是真的切口。 婴儿还未出生。 想象一下吧。
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 not 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."
那么现在,在波士顿儿童医院 的重症监护室, 我与孩子家长的对话 就完全不同了。 想象下这样的对话: “我们在ICU不仅 经常治疗这种疾病, 以及不仅做过 您孩子要做的这种手术, 而且,我们已经做过了 您的孩子的这台手术。 我们两个小时前做的。 并且做了10次。 现在,我们准备好真正的手术了。”
So a new technology in health care: lifelike rehearsal. Practicing prior to game time.
因此,医疗新技术: 生命模拟演练。 比赛之前的练习。
Thank you.
谢谢。
(Applause)
(掌声)