I'm a process engineer, I know all about boilers and incinerators and fabric filters, and cyclones, and things like that. But I also have Marfan syndrome. This is an inherited disorder. And in 1992, I participated in a genetic study, and found to my horror, as you can see from the slide, that my ascending aorta was not in the normal range, the green line at the bottom. Everyone in here will be between 3.2-3.6, and I was already up at 4.4. And as you can see, my aorta dilated progressively, and I got closer and closer to the point where surgery was going to be necessary.
Sem procesni inženir. Vem vse o bojlerjih in sežigalnikih in tekstilnih filtrih in ciklonskih motorjih in podobnem, imam pa tudi Marfanov sindrom. To je prirojena napaka. In leta 1992 sem sodeloval v genetski raziskavi ter se zgrozil ob spoznanju, kot lahko razberete z grafa, da moja ascendentna aorta ni v normalnem razponu, kot označuje zeleni pas spodaj. Vsi znotraj tega pasu so med 3,2 in 3,6 cm. Jaz pa sem bil že na 4,4 cm. Kot lahko razberete, se je moja aorta vedno bolj razširjala, in bližal sem se točki, ko je bila potrebna operacija.
The surgery on offer was pretty gruesome. Anesthetize you, open your chest, put you on an artificial heart and lung machine, drop your body temperature to about 18 centigrade, stop your heart, cut the aorta out, replace it with a plastic valve and a plastic aorta. And most importantly, commit you to a lifetime of anticoagulation therapy. Normally, warfarin. The thought of the surgery was not attractive. The thought of the warfarin was really quite frightening.
Ponujena operacija je bila precej grozljiva -- anestezija, odprejo ti prsni koš, te priključijo na umetno srce in pljuča, znižajo telesno temperaturo na okrog 18 stopinj, ustavijo ti srce, izrežejo aorto, jo zamenjajo s plastično zaklopko in plastično aorto, in, najbolj pomembno, te obsodijo na doživljenjsko terapjo z antikoagulanti, običajno je to warfarin. Misel na operacijo ni bila privlačna. Misel na warfarin je bila v resnici prav strašljiva.
So I said to myself, "I'm an engineer, I'm in R&D, this is just a plumbing problem." "I can do this, I can change this." So I set out to change the entire treatment for aortic dilation. The project aim is really quite simple. The only real problem with the ascending aorta in people with Marfan syndrome is that it lacks some tensile strength. So, the possibility exists to simply externally wrap the pipe, and it would remain stable and operate quite happily. If your high-pressure hose pipe or hydraulic line bulges a little, you just wrap some tape around it, it really is that simple. In concept, though not in execution. The great advantage of an external support, for me, was that I could retain all of my own bits, all of my own endothelium and valves, and not need any anticoagulation therapy.
Tako sem si rekel, inženir sem, delam v raziskavah in razvoju, tole je le vodovodarski problem. To zmorem. To lahko spremenim. Tako sem si zastavil, da spremenim celotno zdravljenje aortne razširitve. Cilj projekta je prav preprost. Edini resnični problem z ascendentno aorto pri ljudeh z Marfanovim sindromom je, da ji manjka natezne trdnosti. Torej obstaja možnost, da bi preprosto od zunaj ovili cev. In bi ostala stabilna in delovala prav srečno. Če vaša visokotlačna cev ali vaša visokotlačna linija dobi izboklino, preprosto navijete nekaj traku okoli nje z zunanje strani. V zasnovi je to tako preprosto, ni pa tako v izvedbi. Zame je bila velika prednost zunanje opore v tem, da bi lahko obdržal vse svoje delčke, ves svoj endotelij in vse zaklopke, in da ne bi potreboval terapije s sredstvi proti strjevanju krvi.
So, where do we start? This is a sagittal slice through me. In the middle, you can see that little structure squeezing out, that's the left ventricle, pushing blood out through the aortic valve. You can see two of the leaflets of the aortic valve working there. Up into the ascending aorta. And it's that part, the ascending aorta, which dilates and ultimately bursts, which of course is fatal. We started by organizing image acquisition from magnetic resonance and CT imaging machines, from which to make a model of the patient's aorta.
Kje torej začeti? Tole je prerez mene skozi sredinsko ravnino. Na sredini lahko vidite tisto napravico, majhno strukturo, kako izstiska. To je levi srčni prekat, ki potiska kri navzgor skozi aortno zaklopko -- tamle lahko vidite, kako delujeta lističa aortne zaklopke -- navzgor v ascendentno aorto. In to je ta del, ascendentna aorta, ki se razširja in končno poči, kar je, seveda, smrtno. Začeli smo tako, da smo organizirali zajemanje slik z naprav za magnetno resonančno slikanje in z naprav za CT slikanje, da bi iz njih naredili model bolnikove aorte.
This is a model of my aorta. I've got a real one in my pocket, if anyone would like to look at it, and play with it.
Tole je model moje aorte. V žepu imam resnični model, če bi ga kdo rad pogledal in se z njim poigral.
(Laughter)
Kot vidite, je precej kompleksna struktura.
You can see it's quite a complex structure. It has a funny tri-lobal shape at the bottom, which contains the aortic valve. It then comes back into a round form, and then tapers and curves off. It's quite a difficult structure to produce. This is a sort of CAD model of me, and this is one of the later CAD models. We went through an iterative process of producing better and better models. When we produced that model, we turned it into a solid, plastic model, as you can see, using a rapid prototyping technique, another engineering technique. We then used that former to manufacture a perfectly bespoke porous textile mesh, which takes the shape of the former and perfectly fits the aorta. So this is absolutely personalized medicine at its best, really. Every patient we do has an absolutely bespoke implant.
Pri dnu ima hecno tristrano obliko, ki vsebuje aortno zaklopko. Potem preide nazaj v okroglo obliko, se zoži in se ukrivi dalje. Precej zapletena struktura, če jo hočeš izdelati. To je, kot sem dejal, moj CAD model, in to je eden kasnejših CAD modelov. Šli smo skozi iterativni postopek izdelovanja boljših in boljših modelov. Ko smo izdelali ta model, smo ga spremenili v otipljiv plastični model, kot vidite, in sicer z uporabo tehnike za hitro izdelavo prototipov, kar je še ena izmed inženirskih tehnik. Ta model kot kalup uporabimo za to, da popolnoma po meri izdelamo porozno tekstilno mrežo, ki posnema obliko kalupa in se popolnoma prilega aorti. Tole je torej absolutno personalizirana medicina v svoji resnično najboljši izvedbi. Vsak bolnik, ki ga obravnavamo, ima absolutno po meri izdelan vsadek.
Once you've made it, the installation is quite easy. John Pepper, bless his heart, professor of cardiothoracic surgery. Never done it before in his life, he put the first one in, didn't like it, he put the second one in. Happy, away I went. Four and a half hours on the table, and everything was done. So the surgical implantation was actually the easiest part.
Ko je enkrat izdelan, je namestitev preprosta. John Pepper, blagoslovljeno bodi njegovo srce, profesor kardiotorakalne kirurgije -- še nikoli prej ni tega naredil -- je vstavil prvega, nekaj mu ni bilo všeč in ga je vzel ven, in potem vstavil drugega. Odšel sem, srečen. Štiri in pol ure na mizi, in je bilo narejeno vse. Kirurška implantacija je bila dejansko lažji del vsega.
If you compare our new treatment to the existing alternative, the composite aortic root graft, there are one or two startling comparisons which I'm sure will be clear to all of you. Two hours to install one of our devices, compared to 6 hours for the existing treatment. As I said, the existing treatment requires the heart-lung bypass machine, and it requires a total body cooling. We don't need any of that. We work on a beating heart. He opens you up, he accesses the aorta while your heart is beating, all at the right temperature. No breaking into your circulatory system. So it really is great.
Če našo obravnavo primerjate z obstoječo alternativo, ki je zamenjava aortnega korena z vsadkom iz kompozitnega materiala, najdete osupljivo razliko ali dve, za katere verjamem, da vam bodo vsem jasne. Dve uri za vsaditev ene izmed naših naprav v primerjavi s šestimi urami pri obstoječi obravnavi. Obstoječa obravnava, kot sem že povedal, zahteva napravo za obvod srca in pljuč in zahteva znižanje telesne temperature. Ne potrebujemo ničesar od tega; delamo na utripajočem srcu. Kirurg te odpre, doseže aorto medtem ko srce utripa, vse pri pravi temperaturi. Nobenega vdora v krvni sistem. Torej je res enkratno. Vendar je zame absolutno najboljše dejstvo to,
But for me, absolutely the best point is, there is no anticoagulation therapy required. I don't take any drugs at all, other than recreational ones that I would choose to take.
da ni treba nobene terapije z antikoagulanti. Ne jemljem nobenih substanc za zdravljenje, razen kakšnih substanc, ki bi jih hotel jemati zaradi užitka. (Smeh)
(Laughter)
Dejansko vidite, če govorite z ljudmi, ki dolgoročno jemljejo warfarin,
And in fact, if you speak to people who are on long-term warfarin, it is a serious compromise to your quality of life, and even worse, it inevitably foreshortens your life. Likewise, if you have the artificial valve option, you're committed to antibiotic therapy whenever you have any intrusive medical treatment, even trips to the dentist require that you take antibiotics, in case you get an internal infection on the valve. Again, I don't have any of that, so I'm entirely free, my artery is fixed. I haven't got to worry about it, which is a rebirth for me.
da je to resna ovira za kvaliteto življenja. Celo huje, neizogibno skrajšuje življenje. In še, če imate opcijo z umetno zaklopko, ste obsojeni na terapijo z antibiotiki kadarkoli imate kakšen intruzivni medicinski poseg. Celo obiski pri zobozdravniku zahtevajo, da jemljete antibiotike, če bi morda dobili notranje okužbe zaklopke. Torej, ničesar od tega nimam, čisto svoboden sem. Moja aorta je popravljena, ni mi treba biti zaskrbljen zaradi nje, zame je to preporod.
Back to the theme of the presentation, multidisciplinary research, how on earth does a process engineer used to working with boilers end up producing a medical device which transforms his own life? Well, the answer to that is, a multidisciplinary team. This is a list of the core team, and you can see there aren't only two principal technical disciplines there, medicine and engineering, but also, there are various specialists from within those two disciplines. John Pepper was the cardiac surgeon who did all the actual work on me. But everyone else had to contribute one way or another. Raad Mohiaddin, a medical radiologist. We had to get good-quality images from which to make the CAD model. Warren Thornton, who still does all our CAD models for us, had to write a bespoke piece of CAD code to produce this model from this really rather difficult input data set.
Nazaj k temi moje predstavitve: multidisciplinarne raziskave. Kako neki procesni inženir, ki je vajen delati z bojlerji, na koncu naredi medicinsko napravo, ki spremeni njegovo lastno življenje? No, odgovor na to je multidisciplinarni tim strokovnjakov. Tole je seznam nosilceva tima. Kot lahko vidite, ne gre za zgolj dve poglavitni tehnični področji, za medicino in strojništvo, ampak gre tudi za različne specialiste znotraj teh dveh področij. John Pepper, tamle, je bil srčni kirurg, ki je dejansko opravil delo na meni, vendar so tudi vsi ostali našteti tamle morali tako ali drugače prispevati. Raad Mohiaddin, je na primer medicinski radiolog: morali smo priti do slik dobre kvalitete, da bi lahko iz njih izdelali model CAD. Warren Thornton, ki še sedaj za nas pripravlja vse modele CAD, je moral po meri napisati kodo za model CAD, da bi lahko izdelali ta model iz resnično precej zahtevnih vhodnih podatkov.
There are some barriers to this, though, there are some problems. Jargon is a big one. I would think no one in this room understands the first four jargon points. The engineers amongst you will recognize "rapid prototyping" and "CAD." The medics amongst you, if there are any, will recognize the first two, but there will be nobody else here that understands all those four words. Taking the jargon out was very important to ensure that everyone in the team understood exactly what was meant when a particular phrase was used.
Kar nekaj preprek je v zvezi z vsem tem. Kar nekaj problemov, strokovni žargon že je precejšnji. Najbrž nihče v tem prostoru ne razume prvih štirih točk iz žargona tamle. Tisti, ki ste inženirji, boste prepoznali izraza hitra izdelava prototipov in CAD. Tisti med vami, ki ste s področja zdravstva, če vas je kaj, boste prepoznali prva dva. Ampak v tem prostoru ne bomo našli nikogar, ki bi razumel vse štiri izraze. Zelo pomembno je bilo odstraniti žargon, če smo hoteli zagotoviti, da bo vsak član skupine natanko razumel, kaj je bilo mišljeno, ko je bil uporabljen določen izraz.
Our disciplinary conventions were funny as well. We took a lot of horizontal slice images through me, produced those slices and used them to build a CAD model. And the very first CAD model we made, the surgeons were playing with it and couldn't quite figure it out. And then we realized that it was actually a mirror image of the real aorta. And it was a mirror image because in the real world, we always look down on plans, plans of houses, or streets, or maps. In the medical world, they look up at plans. So the horizontal images were all in inversion. So, one needs to be careful with disciplinary conventions. Everyone needs to understand what is assumed and what is not.
Različna strokovna področja imajo različne dogovore, kar je bil prav tako hec. Posneli smo veliko slik, ki so prikazovale vodoravne prereze skozi mene, te prereze potem sestavili in iz tega potem zgradili model CAD. Čisto prvi zgrajeni model, iz plastike, so kirurgi obračali v rokah, pa niso mogli ugotoviti, kaj bi to bilo. Nakar smo ugotovili, da je bil model zrcalna podoba dejanske aorte. Zrcalna podoba pa je bil zato, ker v resničnem svetu načrte gledamo vedno navzdol, na primer načrte hiš, ulic ali zemljevide. V svetu medicine načrte gledajo navzgor. In zato so bili posnetki vodoravnih prerezov vsi inverzni. Torej je treba paziti na to, kakšne dogovore imajo različna strokovna področja. Vsak mora razumeti, kaj je privzeto, kaj pa ne.
Institutional barriers were another serious headache in the project. The Brompton Hospital was taken over by the Imperial College School of Medicine. And there are some seriously bad relationship problems between the two organizations. I was working with the Imperial and the Brompton, and this generated some serious problems for the project. Really, problems that shouldn't exist.
Pregrade med različnimi ustanovami so povzročale še eno vrsto resnih glavobolov v projektu. Bolnišnico Brompton je prevzela medicinska šola ustanove Imperial College, in bilo je nekaj hudih problemov v odnosih med tema organizacijama. Delal sem tako z ustanovo Imperial kot z bolnišnico Brompton, kar pa je bilo izvor resnih težav v projektu, težav, ki jih v resnici ne bi smelo biti.
Research & Ethics Committee. If you want to do anything new in surgery, you have to get a license from your local Research & Ethics. I'm sure it's the same in Poland. There will be some form of equivalent which licenses new types of surgery. We didn't only have the bureaucratic problems associated with that, we also had professional jealousies. There were people on the Research & Ethics committee who really didn't want to see John Pepper succeed again. Because he is so successful. And they made extra problems for us.
Komisija za raziskave in etiko: Če hočete v kirurgijo vpeljati nekaj novega, potrebujete dovoljenje od svoje lokalne komisije. Prepričan sem, da enako velja tudi na Poljskem. Gotovo imajo nekaj podobnega, kar odobri nove načine kirurških posegov. Ne samo, da smo v zvezi s tem imeli birokratske probleme, opraviti smo imeli tudi z zavistjo med strokovnjaki. V komisiji za raziskave in etiko so bile osebe, ki resnično niso želele videti, kako je John Pepper ponovno uspešen, saj je tako zelo uspešen. In so nam posebej delali probleme.
Bureaucratic problems. Ultimately, when you have a new treatment, you have to have a guidance note for all the hospitals in the country. In the UK, we have the National Institute and Clinical Excellence. You have an equivalent in Poland, no doubt. And we had to get past the NICE problem. We now have a great clinical guidance, out on the net. So any other hospitals interested can come along, read the NICE report, get in touch with us, and then get doing it themselves.
Birokratski problemi: Ko končno imaš nov način zdravljenja, moraš imeti objavljeno obvestilo z navodili, ki ga prejmejo vse bolnišnice v državi. V Veliki Britaniji imamo v ta namen ustanovo National Institute for Clinical Excellence, kratko NICE. Brez dvoma najdete nekaj podobnega na Poljskem. Morali smo preseči neprijetni problem z NICE. Sedaj imamo na spletu krasna klinična navodila. In tako lahko pristopijo vse zainteresirane bolnišnice, preberejo poročilo NICE, stopijo v stik z nami, in začnejo to izvajati tudi sami.
Funding barriers, another big area to be concerned with. A big problem with understanding one of those perspectives. When we first approached one of the big, charitable UK organizations that fund this kind of stuff, we essentially gave them an engineering proposal. They didn't understand it, they were doctors, next to God, it must be rubbish, they binned it. So in the end, I went after private investors, just gave up on it. Most R&D is going to be institutionally funded, by the Polish Academy of Sciences or the Engineering and Physical Sciences Research Council, or whatever. And you need to get past those people.
Prepreke s financiranjem: Še eno veliko področje, za katero je treba poskrbeti. Imeli smo velik problem z razumevanjem enega od naslednjih stališč: ko smo prvič zaprosili pri eni od velikih britanskih dobrodelnih organizacij, ki financira take reči, so oni pravzaprav videli prošnjo s področja tehnike. Enostavno niso razumeli; bili so zdravniki, bili so skoraj bogovi. Gotovo je zanič. Vrgli so v smeti. Na koncu sem šel do zasebnih vlagateljev, glede tistega pa vrgel puško v koruzo. Ampak večino raziskav in razvoja financirajo ustanove, na primer Poljska akademija znanosti ali Raziskovalni svet za tehnične in fizikalne znanosti ali karkoli že, in treba je priti okrog teh ljudi.
Jargon is a huge problem when you try to work across disciplines, because in an engineering world, we all understand CAD and RP. Not in the medical world. I suppose the funding bureaucrats ultimately have to get their act together. They've really got to start talking to each other, and exercise a bit of imagination, if that's not too much to ask.
Žargon je hud problem, ko poskušaš delovno povezati različna področja. Razlog je v tem, da na primer v tehniškem svetu vsi razumemo CAD in R.P. -- ne pa v svetu medicine. Najbrž morajo birokrati za financiranje nekoč le spraviti skupaj svoj dokument. Zares se morajo začeti pogovarjati med sabo in morajo pokazati kanček domišljije,
(Laughter)
če jih s tem ne prosimo preveč --
Which it probably is.
no najbrž jih.
(Laughter)
Skoval sem izraz "obstruktivni konzervativizem".
I've coined the phrase "obstructive conservatism." So many people in the medical world don't want to change. Particularly when some jumped-up engineer has come along with the answer. They don't want to change. They simply want to do whatever they've done before. And in fact, many surgeons in the UK are still waiting for one of our patients to have some sort of an episode, so that they could say, "Told you that was no good." We've actually got 30 patients. At seven and a half years, we've got 90 post-op patient years between us, and we haven't had a single problem. And still, there are people in the UK saying, "That external aortic root, it will never work, you know."
Mnogi ljudje v medicini se namreč ne želijo spremeniti, še posebej ne, kadar z odgovorom pride mimo kakšen povzpetni inženir. Nočejo se spremeniti. Preprosto hočejo početi to, kar so počeli do tedaj. Dejansko je še zdaj v Veliki Britaniji veliko kirurgov, ki še čakajo, da bi kateri od naših bolnikov imel kakšen zaplet, da bi lahko rekli, "Aha, sem rekel, da to ne bo dobro." Dejansko smo imeli 30 bolnikov. Pri meni je minilo sedem let in pol. Skupaj naberemo bolniki 90 let od operacije, pa nismo imeli niti enega problema. Pa še vedno v Veliki Britaniji obstajajo ljudje, ki rečejo, "Ja, tale aortni koren z zunanjo oporo, to ne bo nikdar delovalo, veste."
It really is a problem. I'm sure everyone in this room has come across arrogance amongst medics, doctors, surgeons, at some point. The middle point is simply the way that the doctors protect themselves. "Well, of course, I'm looking after my patient." I think it's not good, but that's my view.
Resnično je to problem. Resnično je to problem. Zagotovo se je že vsak v tem prostoru kdaj srečal z aroganco zdravstvenih delavcev, zdravnikov ali kirurgov. Posredi je preprosto način, kako se zdravniki zaščitijo. "Ja, seveda, pazim na svojega bolnika." Mislim, da ni dobro tako, ampak poglejte, to je moje stališče.
Egos, of course, again a huge problem. If you work in a multidisciplinary team, you've got to give your guys the benefit of the doubt, you've got to express support for them. Tom Treasure, professor of cardiothoracic surgery. Incredible guy. Dead easy to give him respect. Him giving me respect? Slightly different.
Ego je seveda spet velikanski problem. Če delate v multidisciplinarni skupini, je treba člane jemati malo z rezervo. Treba jim je izražati podporo. Tom Treasure, profesor kardiotorakalne kirurgije na primer je neverjeten človek. Prav lahko ga je spoštovati. Da bi on spoštoval mene? Malo drugačna zgodba.
(Laughter)
To je vse, kar se tiče slabih novic.
That's all the bad news. The good news is, the benefits are stonkingly huge. Translate that one! I bet they can't.
Dobra novica je, da so prednosti groziljansko velike. No, pa naj prevedejo to. Stavim, da ne znajo. (Smeh)
(Laughter)
Ko so na kupu ljudje,
When you have a group of people with different professional training, a different professional experience, they not only have a different knowledge base, but also a different perspective on everything. And if you can bring them together, and get them talking and understanding each other, the results can be spectacular. You can find really novel solutions that have never been looked at before, very quickly and easily. You can short-cut huge amounts of work simply by using the extended knowledge base you have. And as a result, it's an entirely different use of the technology and the knowledge around you.
ki so imeli različno strokovno šolanje in različne strokovne izkušnje, nimajo le različnih temeljnih znanj, ampak imajo različne poglede na vse. In če jih lahko spravite skupaj in jih pripravite do tega, da med sabo govorijo in se razumejo, so rezultati lahko spektakularni. Lahko odkrijete nove rešitve, resnično nove rešitve, ki jih še nihče ni oplazil s pogledom, in to hitro in lahko. Lahko skrajšate velikanske količine dela s tem, da preprosto uporabite razširjeno bazo znanja, ki je pri roki. In kot rezultat dobite popolnoma drugačno uporabo tehnologije in znanja okrog vas.
The result of all this is that you can get incredibly quick progress on incredibly small budgets. I'm so embarrassed at how cheap it was to get from my idea to me being implanted that I'm not prepared to tell you what it cost, because I suspect there are absolutely standard surgical treatments, probably in the USA, which cost more for a one-off patient than the cost of us getting from my dream to my reality.
Rezultat vsega tega je, da lahko dobite neverjetno hiter napredek z neverjetno majhnim proračunom. Tako nerodno mi je zaradi tega, kako poceni je bilo priti od moje ideje do tega, da sem dobil vsadek, da vam sploh nisem pripravljen povedati, koliko je stalo. Zato ker sumim, da obstajajo čisto standardna kirurška zdravljenja, najbrž v ZDA, ki stanejo več za povsem serijsko zdravljenje posameznega bolnika kot pa je stalo nas, da pridemo od mojih sanj do moje resničnosti.
That's all I want to say, and I've got three minutes left. So, Ewa's going to like me. If you have any questions, please come up and talk to me later on, it would be a pleasure to speak with you.
To je vse, kar sem hotel povedati, in tri minute so mi še ostale. To pomeni, da bom najbrž všeč Heather. Če imate še kakšna vprašanja, stopite do mene kasneje in me vprašajte. V veselje mi bo govoriti z vami. Hvala lepa.
Many thanks.
(Applause)