Like most workplaces during the holidays, the office of neurosurgeon Neil Martin is filled with holiday gift baskets and greeting cards. But instead of “Seasons Greetings!” all of his cards begin, “Thank you for saving my life….”
“The brain is not just some gelatinous, amorphous mass; every bit of it has meaning. It’s a system that has a well-established configuration and logic to it,” says Martin of the day-to-day challenges of his job.
Martin is Chairman of the Department of Neurosurgery at UCLA’s Ronald Reagan Medical Center. His ocean-view corner office is part of the new medical center, which opened in 2008 as a replacement for UCLA’s half-century old and earthquake-vulnerable former hospital. Designed by I.M .Pei and his son C.C. Pei, the new facility incorporates three million pounds of travertine marble into airy spaces that are highlighted with blonde woods and large windows. Walking into the two-story lobby, you might think you were entering a luxury hotel or a concert hall, an impression reinforced by the valet parking.
But what if you can’t see a surgeon who’s as good as Martin or get to a hospital designed by the Peis that has rock stars like Roger Daltrey and Pete Townsend among its donors?
American medicine is notoriously ill-distributed, with heartbreaking differences between well-funded medical centers and under-funded inner city and rural hospitals. A visit with Martin demonstrates how technology may simultaneously widen and close that gap.
Neurosurgery itself is of necessity a technology-driver. “Many of the areas of the brain that require surgical intervention are not easily accessible,” Martin explains. “There can be a thicket of nerves and arteries between you and the tumor you want to take out.” As a result, neurosurgery keeps pushing the boundaries on imaging, one of its core diagnostic tools, “Two-dimensional imaging, three-dimensional imaging, computer imaging, plane x-rays – They all have to be integrated together for treatment planning,” he says.
The necessity of combining data sets to make an accurate diagnosis, for neurosurgery and other specialties, drove UCLA to re-vamp its IT infrastructure. “We designed a system that allows us to reach into all the independent systems in the hospital and integrate them so that at one glance you get a comprehensive view of the condition of the patient,” says Martin. The previous system required logging in and out of a dozen or more separate applications from lab studies to various modes of imaging. Now, data from the patient’s vital signs to MRI scans can be called up side-by-side on flat panel screens in doctors’ offices and operating rooms.
But in Los Angeles, even if you’re flown in by trauma helicopter, your surgeon may be stuck on the freeway. That’s why one of Martin’s most important pieces of tech is his iPhone (the hospital’s apps are not Android-friendly, but certainly could be if anyone wants to do the coding). On the smartphone, the images are displayed serially, but doctors are still able to consult on cases before they arrive at the hospital.
Given that minutes can make the difference for certain kinds of cases, this may be one of the most precious uses of wireless tech on the planet. “We don’t have anything that’s going to save anybody if they’re going to die within 30 seconds, but if you have three to six hours, then every minute does count. In acute stroke, it counts. In acute heart attack, it counts. In severe trauma, where you have ongoing bleeding, an hour or so makes all the difference,” says Martin.
Off-site diagnosis is also one area where technology can help even up the odds, at least somewhat, between a place like UCLA, ranked fifth in the nation by US News and World Report, and the hospitals where most Americans may unfortunately wind up. Through UCLA’s TeleStroke program, Martin and his colleagues review brains scans for patients in ERs throughout southern and central California. Stroke care has been revolutionized by the clot-busting drug tPA, which if administered within a few hours of an ischemic stroke can change a patient’s outcome from life-long disability to near or even full recovery. “People who were headed for nursing homes for the rest of their lives are walking out of the hospital in three days,” says Martin.
But there’s a terrible Catch-22: Not all strokes are caused by blood clots, which choke off blood to brain tissue. Crucially, strokes are also caused by internal bleeding. In those cases, administering tPA can lead to a fatal hemorrhage. “You can examine someone and see if they had a stroke. The question is was the stroke caused by bleeding or was it caused by a blockage?” explains Martin, “It’s a binary decision point: Is there any bleeding? If not, you give tPA. If there is, you have to go down a different pathway for treatment.”
As an experienced neurosurgeon, Martin can state that binary coolly, but imagine how it feels to a young resident on duty in the ER for the first time. “People are very nervous about giving tPA,” says Martin. That hesitation can be tragic: If giving tPA in the wrong circumstances can kill a patient, not giving it can leave a patient with a life barely worth living.
Fortunately, the effective window for tPA is now up to about four and half hours. That allows crucial time to take neurosurgical images, ranging from 2D brain scans that overview the landscape of the brain to 3D reconstructions of arteries, which vividly display structural anomalies. Through TeleStroke, those digital images are transmitted to UCLA neurosurgeons who remotely diagnosis and recommend how best to treat as many as 150 stroke patients a month.
Sometimes the remote diagnosis is done from within the hospital itself. UCLA doctors used to do rounds twice daily, but only the morning rounds were in person. In the afternoons, doctors would call in to nurses for updates on their patients. Now they still make in-person morning rounds, but in the afternoons the doctors remotely drive a robot from InTouch Health to patient’s bedsides. Through its two-way video monitor, a doctor can see and talk with patients and staff, as well as examine medical records.
Given the size of most modern medical complexes, leaving robots parked on patient floors or in ERs can mean a precious increase in response time, while doctors rush from offices that may be a 20-minute walk away. Robots don’t come cheap, however. While a robot’s ability to be remotely directed is a boon to a doctor’s autonomy, its traveling video communication likely could be duplicated by a volunteer walking with a laptop.
Martin, surrounded by the grateful greeting cards, counters that surgeons have a different way of looking at ROI, given the immense medical and personal costs of strokes, “The cost of a robot, which on the surface looks high, gets amortized over people who don’t have the need for lifetime rehabilitation,” he says.
For some types of operations, it is even possible to get a surgeon’s hands remotely. Ten years ago, there was a headline-generating proof-of-concept of telesurgery called the Lindbergh Project, in which US-based surgeons removed a gall bladder from a French patient. The operation was done with the same type of robot used for minimally invasive laparoscopic surgeries. “It’s a translation device to translate the movements of the surgeon’s hands into the robot’s hands, so you can introduce something that works like a hand into a very tiny part of the body,” explains Martin, about the joystick-controlled robots.
Nevertheless, telesurgery is not yet routine, due to network latency and limited haptic feedback. In Canada, it is being used as a remote back-up for local surgeons, according to news reports about Ontario-based laparoscopic expert Mehran Anvari, who assists in operations from over 400 miles away.
The ultimate hope is that telesurgery will assist in battlefield operations, but even when that hope is realized, tele-neurosurgery may still be years, if not decades, away. The challenge is that the “hands” of laparoscopic robots are only small enough to be used for abdominal and cardiac surgeries; they haven’t yet been scaled to an appropriate size for neurosurgery. “The target may only be a couple of millimeters and it’s deep in the brain,” says Martin of operations like implanting stimulating electrodes in Parkinson’s patients.
Instead of robots, neurosurgeons use a GPS-style coordinate-system and a manual jig to control the angle of the probe. “This isn’t technology making something simpler; this is technology making something possible,” says Martin of the GPS and deep brain stimulation. “Those patients were basically frozen; their motor systems couldn’t function, and they had severe tremors on top of that. The minute you put the electrode in and you turn the switch on the stimulator, their lives change forever.”
Martin is so reassuring and the hospital so gorgeous, you almost want to have surgery just to test it all out. But for all of UCLA’s technological marvels, Yelp! has quite an embittered list of complaints about the hospital’s billing systems. There’s an IT moral here: Too often, brand-new, glamorous “front end” tech gets funded and implemented, while day-to-day back-end systems such as billing lag behind. And while it’s understandable that a hospital would want to focus its budget on direct patient care, it’s painfully ironic that all of Martin and his colleagues’ life-saving work might be undone by what accounting software could do to a stroke patient’s blood pressure.
There’s one more irony: During our interview, Martin’s pager goes off. A pager? Are we suddenly on the set of St. Elsewhere? “Nothing beats pagers for reliability,” explains Martin. Indeed, the pager’s humble beep puts it all in perspective: “It’s not a technology exercise for technology’s sake, it’s all about taking care of the patient,” say Martin.
For all of this, Martin cautions that there is one important area where we must not delude ourselves: that technology alone will make the difference. “The cures for everything from pneumonia to stroke to Parkinson’s disease… Those cures only came from animal research,” says Martin, “Future cures are only going to come from studying complex, living biological systems; there is no computer that can replicate that.”
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