Skynet is Here

I saw this and could help but wonder how similar technology might be applied to atrial fibrillation ablation some day:



From IEEE Spectrum:

Being able to do this is all about communication, as Professor Nathan Michael discussed today at the IEEE International Conference on Robotics and Automation (ICRA) in Shanghai. As he and fellow researchers Matthew Turpin and Vijay Kumar have discovered, the robots have to not just know exactly where they are, but they also have to broadcast that information to their neighbors to maintain the integrity of the formation. This processing is all done on each individual quadrotor, so there's no all-seeing computer watching everything and telling each robot where to go. The accuracy is impressive: 50 percent of the time the quadrotors are within a mere two centimeters of where they should be.

Well, these robots haven't been miniaturized nor tested in blood so they're not ready for atrial fibrillation ablation yet, but it's still fascinating to see what creative minds can develop.

"Thinking" robots.

Uh, oh.

Then again, maybe I'm just reminded of scrubbing bubbles.

-Wes

The Eroding Physician Brand

It came as a Twitter 'follow' this morning from '@coldfeet65,' a self-proclaimed 'Nurse Practitioner Hospitalist.'

I had never heard this term before.

Does it mean a Nurse Practitioner who cares for Hospitalists? Or is it a Hospitalist who is a Nurse Practitioner? Or maybe it's a Nurse Practitioner who helps Hospitalists? (Honestly, I think I know which one she means, but you get my point.)

Perhaps this is a prescient glimpse to health care of the future, where our more typical nurse and doctor labels are supplanted by more and more monikers that serve to confuse, rather than clarify, each of our roles in health care delivery. As specialists in cardiology, we've seen a similar trend with cardiology hospitalists.

But we should be clear what this means to the patients and doctors going forward.

No doubt most people in America still expect to see a doctor when they come to the hospital. Increasingly, it appears that might not be the case. Your doctor might be a robot while a nurse (aka, nurse practitioner) will be the one providing the hands-on care in the inpatient setting. Is that a good thing?

Honestly, I'm not sure.

No one argues that the costs in health care need to be cut. No doubt the Central Authority has deemed that doctor salaries will be a big part of that effort. Already, 20 states have cut physician Medicaid payments for fiscal year 2010 and, given the current economic pressure on our states both now and after they start feeling the financial impact of the "Affordable" Care Act in 2019, this trend is not likely to improve anytime soon. As a result, we are seeing that the world is full of "creative solutions" to our health care access crisis and the evolution to Nurse Practitioner Hospitalists might be one of these.

But what are Doctors of Medicine becoming as a result? Are our current cohort of primary care doctors becoming little more than nurse managers and fact-checkers of mandated protocols, treatment guidelines, and care directives?

Hopefully not.

But increasingly it appears that those without a hands-on, invasive skills in medicine (like surgery) are being marginalized in the health care models going forward. This trend now appears to even be affecting the much-heralded inpatient hospitalist care model as the doctor shortage intensifies. Consequently, the image of "doctor" as we knew it is changing, not only for what patients can expect to encounter when they come to a hospital, but for the type (and caliber) of the doctor we attract to our profession going forward.

-Wes

Robots Getting Rusty

There can be no denying that the highlight of the Boston Atrial Fibrillation Symposium was the lively debate between Andrea Natale, MD and Carlo Pappone, MD. It was a spirited affair between the soft and the stiff - catheters that is - of the Sterotaxis robotic system vs. Hansen Medical's system. Pappone argued that Hansen was not safe due to its stiffness. Natale countered that it is safer than conventional techniques. Pappone said "I don't believe you." Natale related Pappone's data to a little boy who though he saw a Ferrai because he saw a white horse on a red car as his father had mentioned. At least until he showed him the picture of what he had seen:



To which Pappone countered that after hearing Natale tell this story so often that he decided to have a real Ferrari made to order, custom, and had Natale's name imprinted on it.

Both seemed happy with their good-hearted performance.

But the winner of the debate between the two came from an audience member who, after sitting throught the many earlier sessions devoted to tackling afib ablation, asked the pointed question: "Can either of the robotic systems accommodate a cryo balloon or multi-electrode catheter to evaluate for CFE's (continuous fractionated electrograms)?"

The room was briefly silent. The audience knew the importance of this question, particularly since no one is fooling them selves any longer just how demanding (physically and emotionally) these procedures can be for the operator. The audience was looking for a means to make these procedures not safer, but more effective on the first attempt, and they had heard promising news on other technical fronts.

Natale and Pappone had to admit that neither robotic system could not accommodate these other catheters.

And suddenly, the both robotic systems started to look a little rusty.

-Wes

With Robotics, Perception Trumps Reality

Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, MA explains:

Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.

And they wonder why health care costs are so high?

-Wes

Addendum: Here's Mr. Levy's first post questioning the technology.

Zombie Housestaff

Imagine, a hospital administrator's dream come true:

No more handwashing.

No more spread of MRSA.

No more spread of Clostridium dificile.

No need to even touch the patient!

And all for only four to seven thousand dollars a month as operating salary with no more malpractice insurance payments.

Residents and doctors never have to leave the friendly confines of their desk as they sit before the Almighty Electronic Medical Record nor expose themselves to unseemly odors.

What is it?

Welcome to the new world of Zombie Housestaff.

It won't be long 'til they place appendages carrying stethoscopes, thermometers, blood presure cuffs, EKG stickers and pulse oximeter probes complete with operational diagrams for the patient. It will be the ultimate in patient empowerment!

But there remains one question: will it come with a cup holder?

-Wes

Robotic Marketing

Imagine buying a Mercedes Benz luxury car to take a trip. You save your hard-earned cash and spend handsomely for the car because of its human engineering, reputation and admire its comfort during a test drive. You drive it from the dealer and find the car’s the rage as it sits in your driveway. You gloat over its finish and detailing. You’re the envy of the neighborhood.

And then you find out the trip is a transatlantic one, and you should have bought a boat instead.

Such is the lure of technology in medicine. It seems all too often the development, manufacturing, and marketing of devices, especially high-tech robotics, has exceeded our understanding of the mechanisms and etiologies of the very diseases we hope to treat. And it is sexy.

But others have argued that such technology does nothing but contribute to hospitals' technical arms race.

Such is the case of atrial fibrillation ablation.

I am struggling with the decision of obtaining a device to perform robotic-assisted catheter ablation of atrial fibrillation. There are several devices now on the market. One is a mechanical robotic sheath system from Hansen Medical that purports to "extend my reach" to locations within the left atrium better and with more precision, and the other a system from Stereotaxis that uses a powerful magnetic field to provide "a softer touch to the treatment of heart disease."

Both systems have their pros and cons. Both are expensive.

But despite huge leaps in our understanding of atrial fibrillation and its mechanisms, the more I understand the arrhythmia, the more I have come to believe that we still don’t understand the mechanisms at play in the individual patient. For instance, why do some patients with normal-sized hearts get atrial fibrillation while others do not? Why do some patients with huge left atria from mitral stenosis sometimes never manifest the arrhythmia, while others are debilitated by it? What are the long-term mortality data with ablation compared to drug therapy? With the complications of the procedure (which admittedly are rare in skilled hands), are these still less than the complications of anticoagulation or drug therapy? What really is the role of neurologic (ganglionic) inputs to the heart at supporting atrial fibrillation versus fibrous remodeling or pulmonary disease?

And while these robotics are ingenious instruments, can they really replicate the remarkable tactile feedback of the human hand and assure the safety of these uncharted waters? Will they respond as quickly to visual and tactile clues afforded by our senses at the patient's bedside? And where should we ablate? Do we really need such complicated and expensive machinery before more basic questions are answered?

Certainly the FDA has approved these devices as safe. But this does not guarentee improvements in ablation efficacy. These early approvals to little to reassure those of us in the day-to-day clinical grind of these devices' cost effectiveness. For instance, despite all of the testing in human volunteers of the magnetically-driven system by Stereotaxis, I was left to wonder how this system was approved with its propensity to developing large char formation compared to more conventional approaches. Was this not seen in earlier trials? Didn't this affect the movement of their catheter as it welded to the left atrial surface? Wasn't this considered important? How much additional time did correcting these problems add to the procedure?

Perhaps in the end it won’t matter. Perhaps the ablation lesion sets during atrial fibrillation ablation procedures will be so defined so accurately through brute force trial-and-error that we will simply push a button and, like a car wash, a catheter will be dragged through a pre-defined course that’s the same for everyone and everyone's atrial fibrillation will be magically cured. As if everyone's atrium was the same size and shape.

But then again, maybe before buying our "Mercedes," we should first look to see if we need a boat instead.

-Wes

Biobots

Here's something special - a new "bio-bot" - a tiny biologic robotic element made from living heart muscle that can move in a coordinated fashion:



This robot, developed by Sukho Park and his colleagues at Chonnam National University, Korea, uses the contraction of heart muscle cells for movement:

The robot has three short front legs (400 micrometres long) and three longer back legs (1200 micrometres long), which are all attached to a central rectangular body. As the heart cells contract, the longer rear legs bend inwards. This creates a difference in friction between the front and rear legs, which pushes the robot forward. The scientists measured the robot's average speed at about 100 micrometres per second.

Park says these crab-like robots could be used inside the body to clear blocked tubes or arteries. The robots could travel along the length of a blocked vessel, releasing a dissolving agent to clear the blockage as they go.

Amazing.

But the thought of these things crawling around inside me feels a bit like a scene from Aliens.

-Wes

h/t: Waziwazi

Reference: Jinseok Kim, et al. Establishment of a fabrication method for a long-term actuated hybrid cell robot. Lab Chip, 2007 DOI: 10.1039/b705367c.