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.
想像這會怎樣── 把一種新科技 交給醫生和護士使用, 它能改善兒童、成人, 所有年齡患者的治療效果; 它能降低病人的痛苦, 縮短手術的時間, 減少麻醉的次數, 獲得最佳的劑量反應曲線; 這技術被用得越多, 患者的獲益就越大。 意料之外的是:它不但沒有副作用, 且可用於任何治療。 身為波士頓兒童醫院 加護病房的醫生, 我認為局面會全然改觀。 我說的科技是 仿真的醫學模擬和練習, 用逼真的醫學模擬來練習。
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.
我先舉個實例 來確切說明醫學所面臨的挑戰, 為何這技術不但會改善醫療, 並且是不可或缺的。 這是一個剛出生的小女孩。 我們稱為「生命的首日」, 她降生到這世界的第一天。 她一出生, 我們立刻發現她的健康狀況 正急遽惡化。 她的心跳加速, 血壓下降, 呼吸非常急促。 這張 X 光片顯示病因。
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.
我們稱之為嬰兒圖像 (babygram), 是嬰兒全身的 X 光片。 圖片的上半 是心臟和肺臟應該在的位置; 下半是腹部和小腸應該在的位置。 看這塊半透明的區域, 一直延伸到右上方嬰兒的胸腔, 那是錯位的小腸。 小腸推擠肺部, 使得這可憐的嬰兒難以呼吸。
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.
解決之道是馬上為她動手術, 把小腸移回腹部, 讓她肺的空間擴大, 能夠恢復呼吸。 但在手術之前, 必須先火速送她進我的加護病房。 我和手術團隊圍繞著她, 為她接上體外心肺循環機 , 上麻醉藥, 在脖子上切個小口, 把導管伸入脖子的主動脈內。 這些血管的尺寸只有筆尖那麼細。 我們抽出她的血液, 導入一台機器,充氧, 再送回體內。 我們挽救她的性命, 把她安全送進開刀房。
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?
問題在此: 她罹患的病 被稱為「先天性橫膈疝氣」, 隔膜上有個洞使腸子得以向上移位, 是種罕見的疾病。 即使是世上最優秀的外科醫生 也難以累積足夠的經驗, 因為患者的數目太少, 醫師難以練到百分之百的技術曲線。 很難遇到這種病例。 那麼,怎樣變罕見為常見呢?
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.
另外還有一個問題: 我服務了二十多年的醫療系統, 現行的訓練模式稱為「學徒模式」, 已有數百年的歷史。 學徒模式的基本概念 是先看別人做一次或數次的手術, 然後自己動手術; 最終再把這技術傳承給下一代。 其實說白了, 相信大家也能想得到, 學徒模式是一面開刀、一面練習。 這是個大問題。 我認為有更好的方法。 醫療很可能是最後一門 不先訓練就實作的高風險行業了。 讓我闡述醫療模擬這個好辦法。
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.
我們先參觀其他已經使用這方法 數十年之久的高風險行業, 核電廠。 核電廠會定期演習, 練習和防範不樂見的未然; 還有大家熟悉的航空業。 現今大家搭機都很放心, 因爲機師和機組人員 已被飛行模擬器訓練過, 像這樣的模擬器, 他們知道要如何應對 但願永不發生的緊急狀況; 萬一不幸發生了, 我們有信心他們能應變。 事實上, 航空業甚至直接打造機艙模擬情境, 因為整體團隊的運作至關重要。 這是模擬的疏散演習。 我重申,一旦發生罕見事故, 他們能夠瞬間應變。
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.
我猜,最吸引我目光的 還是高風險的體育行業。 我認為棒球隊球員練習 是個漸進訓練的好例子。 他們先進行春季訓練。 春訓用的可能是棒球模擬器, 不是實體球場,而是模擬的球場。 他們打季前賽, 然後在正規賽季進入棒球比賽場。 開賽前他們先做些什麼呢? 先在擊球練習區揮棒幾個小時; 面對各式球路 一次又一次揮棒暖身, 為真正的比賽做準備。 最不凡的部分, 所有看球賽的人 都會看到這現象: 打者進入打擊區, 投手準備投球, 就在球被投出之前, 打者做什麼動作? 打者離開打擊區 練習揮棒。 打者必定這樣做。
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.
告訴你 我們如何為醫療行業建立練習系統, 建造打擊練習區, 為心繫的患者 建在波士頓兒童醫院裡。 我用最近建的案例說明: 這個四歲兒童的頭部逐漸漲大, 以致發育不如預期, 錯失了腦神經發育的里程碑。 問題出在這裡: 「腦積水」。
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.
快速簡介腦神經外科手術的做法。 這是大腦, 顱骨包圍著大腦, 在大腦和顱骨之間流動的 是「腦脊液」, 它的作用是緩衝撞擊力。 此刻你的大腦 浸泡在頭骨裡的腦脊液裡, 腦脊液繞著大腦流動, 在一個地方產生腦脊液, 流動,然後再循環, 每個人的腦脊液都美妙地流動著。 但不幸有些孩子的腦脊液 塞住不流動, 就像交通壅塞那樣。 結果腦脊液積聚, 腦被擠到一邊, 難以生長, 孩子因此腦神經發育遲緩, 這是種毀滅性的兒童病。
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.
治療方式是動手術。 傳統手術是取下一小塊顱骨, 一小塊頭骨, 安裝一條引流管排出腦脊液, 引流到身體的內部。 這是個大手術。 好消息是神經外科醫療 已經進步到 能讓我們施行微創手術。 相機可通過小針孔 進入深層的腦結構, 在腦膜上開個小孔引流腦脊液, 就像讓水槽排水一樣。 轉眼間,腦部不再受壓, 能夠伸展, 開一個小切口就能治療這孩子。
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.
但問題是: 腦積水相當罕見, 沒有好的訓練方法能讓我們 嫻熟地把鏡頭擺放在正確的位置。 對此外科醫生相當有創造力, 我們自己的醫生也是。 他們發明了訓練模型。 這是目前的訓練模型。
(Laughter)
(笑聲)
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."
我可沒開玩笑。 這是個紅椒,不是好萊塢做的, 而是真正的紅椒。 外科醫生把鏡頭伸入紅椒, 進行所謂「椒籽切除術」。
(Laughter)
(笑聲)
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.
他們用鏡頭和小鑷子摘除紅椒籽, 那是學會基本手術操作的方式。 接著他們直接進入學徒模式, 觀摩多次臨場的手術, 然後親自動手,接著傳授, 等待著新的患者。 我們有更好的方式。
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.
如今我們複製病童, 讓外科醫生和手術團隊 以最接近實況的方式一再練習。 讓我來展示。 這是我的團隊, 模擬計劃的模擬工程團隊。 團隊的每個人都很了不起。 有機械工程師, 和這裡看到的繪圖師。 他們把電腦斷層 和核磁共振掃描的原始數據 轉成數字資訊, 做成動畫, 整合做成兒童自身的器官。 根據手術本身的需求, 事先已掃描兒童的器官, 連同數據輸出到 最先進的三維列印機, 把兒童的器官列印出來, 細節精確到微米的程度。 這裡看到的是 兒童的頭骨 在手術前數小時被列印出來。
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 --
如果沒有西岸加州好萊塢的夥伴們 我們無法做到。 這些是特別擅長重製現實的人。 這不算是我們的大躍進。 在這個領域了解得越多就越清楚, 我們是在拍片, 在製作電影。 但不由演員演出, 而是如假包換的醫生和護士。 這些照片來自 任職於加州好萊塢 Fractured FX 的好朋友們, 那是個獲得艾美獎的特效公司。 這是賈斯汀·羅利和他的隊友, 那可不是我們的病人,
(Laughter)
(笑聲)
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.
而是他們的精湛作品。 我們現已融合雙方的經驗, 邀請他們團隊到波士頓兒童醫院, 也送我們的人去加州好萊塢, 交流和開發這類的模擬器。
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.
下面向大家展示這孩子的複製模型。 可以看到 孩子的每根頭髮都被複製了。 事實上,這也是複製的孩子。 若看了不舒服,我道歉。 那是為他們要動手術的孩子 所做的模型和模擬。 這是我們先前說過孩子的腦膜。 這裡看到的一邊是真實的病患, 另一邊是模擬的。 如我先前說的 要把小相機鏡頭像這樣向下伸, 在腦膜上開個小洞 排出腦脊液。 我不考你們哪邊真,哪邊模擬。 右側是模擬的。
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.
現在創造了訓練的機會, 讓醫生可以重複做無數遍的手術, 直到他們滿意、有信心之後, 才為孩子動手術。 不只這樣, 我們知道關鍵不侷限於手術的技巧, 而在結合手術團隊和技巧。
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.
現在我們轉看 一級方程式賽車的例子。 技師安裝輪胎, 一而再、再而三換車胎。 很快納入整個團隊的訓練中, 群策群力換車胎, 把車送回賽道。 在醫療領域我們也這麼做。 接下來看模擬手術。 把我剛才描述的模擬手術訓練 帶進波士頓兒童醫院的手術室裡, 本地手術團隊的這些人 正在進行手術前的模擬手術。 練習兩次; 實切一次。 請看。
(Video) Surgical team member 1: You want the head down or head up?
(影片)手術團隊成員之一: 頭放低還是放高?
STM 2: Can you lower it down to 10?
團員二:降低到 10 好嗎?
STM 3: And then lower the whole table down a little bit?
團員三:把整個手術台 降低點,好嗎?
STM 4: Table coming down.
團員四:正在降低手術台。
STM 3: All right, this is behaving like a vessel. Could we have the scissors back, please?
團員三:好,這像是條血管。 請把剪刀拿回來好嗎?
STM 5: I'm taking my gloves, 8 to 8 1/2, all right? I'll be right in.
團員五:我正脫除手套。 8 到 8 1/2 好嗎?馬上回來。
STM 6: Great! Thank you.
團員六:太好了!謝謝。
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.
(彼得·萬斯托克)真的很棒。 接下來是關鍵的第二步: 立刻請團隊出來聽簡報。 用和軍方一樣的 「精實六標準差」, 討論哪裡做得好, 更重要的是知道哪裡做得不好 以及要如何改正。 然後讓他們立刻回手術室再做一次。 是緊要關頭的刻意擊球練習。
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.
回到這個病例。 同一個孩子, 現在描述我們在波士頓兒童醫院 如何護理這個孩子。 這孩子在凌晨三點出生。 在凌晨兩點, 我們就集合醫療團隊, 把用掃描和影像所複製的解剖結構 及團隊送到虛擬病床, 也就是模擬的病床。 幾個小時後同一團隊 要為這孩子動手術, 先讓他們操作模擬一遍。 請看其中的片段, 不是真的切口, 嬰兒尚未出生。 想像一下,
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."
如今我與孩子的家人 在波士頓兒童醫院加護病房的對話 和以往截然不同。 想像這對話: 「我們不僅常在加護病房醫這種病, 不僅曾多次做過 將要為令郎/令嬡進行的手術, 而且,我們已為他/她手術過了, 兩個小時前做了十回。 我們已準備好進行真正的手術。」
So a new technology in health care: lifelike rehearsal. Practicing prior to game time.
新的醫療技術: 栩栩如生的模擬醫學演練, 賽前的練習。
Thank you.
謝謝。
(Applause)
(鼓掌)