Providing medical care from afar using robotic technology is a fascinating concept that could save more lives in the battlefield. The technology still has a way to go, but it is starting to make its way into reality. One thing researchers are discovering is that autonomous technology could be a very attractive option for situations with limited access to medical care.
In 2005, the Defense Advanced Research Projects Agency (DARPA) funded Trauma Pod, a project to develop robotic diagnosis, life support, and surgical capabilities to remotely provide medical care to injured personnel in the field. During the first phase of the project, SRI International of Menlo Park, CA, developed the concept-car equivalent of a futuristic operating room in which the only human present in the room would be the patient. The system – consisting of a surgical robot, robotic assistants, an integrated life support system, and an intra-operative imaging system – was demonstrated to perform procedures common to the battlefield on a full-size-human mannequin patient. The dynamic choreography of a team of robots moving around a patient while exchanging tools and supplies demonstrated the feasibility of the concept. Now, some of the technologies envisioned during that project are starting to make their way into the field.
Remote Surgical Interventions: Then and Now
The first transatlantic remote surgical intervention took place in 2001. Using a Computer Motion system and a dedicated high-speed communication line to control a surgical robot, a doctor in New York removed the gallbladder from a patient located in Strasbourg, France. The operation was successful and proved that surgery over long distances was possible, although implications for the commercial market were less than clear. Isolated enclaves, the battlefield, and even space travel remain the prime candidates for benefiting from this technology because highly skilled medical resources are scarce in those settings. As a result, SRI, the University of Washington, and other researchers have been focusing on the development of smaller portable systems that can function in rugged environments.
One system developed by SRI consists of two lightweight 6-degrees-of-freedom (DOF) arms, each weighing 10 pounds, that can be carried in small, rugged cases and quickly deployed in the field. The arms were tested aboard a NASA C-9 research aircraft in parabolic flight to demonstrate surgical tasks in simulated microgravity conditions.
During the NASA Extreme Environment Mission Operations (NEEMO) 9 and 12 missions, a team of astronauts deployed and set up a surgical robot in the Aquarius habitat (located 60 feet underwater off the coast of Key Largo, FL). NEEMO 9 demonstrated that telesurgical procedures such as vascular suturing could be performed in an extreme underwater environment from 1,500 miles away in Ontario, Canada. During NEEMO 12, SRI demonstrated the feasibility of conducting an autonomous, closed-loop procedure consisting of an ultrasound-guided intravenous insertion on a simulated blood vessel. The advantage of a closed-loop procedure is that it provides constant feedback that supports remote operations with long communication delays.
In the summer of 2009, Lt. Col. T. Sloane Guy IV, M.D., a cardiothoracic surgeon with the 47th Combat Support Hospital in Mosul, Iraq, performed a complex and rare thoracic surgical procedure. At the same time, a specialist at Brooke Army Medical Center (BAMC) at Fort Sam in Houston, TX, looked over his shoulder to view live video footage of the procedure and offer real-time guidance. The system, developed by SRI, used a pan-tilt-zoom camera attached to the operating room lights and a camera on the surgeon’s head. The specialist providing the consultation had full control of the cameras and could manipulate the images to guide the surgeon working on the patient. X-rays and CT images were shared beforehand and discussed live to illustrate the steps for treatment required in this case. The software-based system could be downloaded within seconds to any machine within the military network. Today, this is the technology that could be used to provide remote surgical care in the field. In the meantime, research labs and companies are continuing to develop more technology to make remote surgical interventions possible.
Autonomous Life Support, Diagnosis, and Intervention
Remotely controlled interventions require high bandwidth and short communication delays. Guaranteeing a reliable communication link in the battlefield is not always possible, and coordinating with remote medical personnel can be very challenging. Furthermore, some monitoring functions and therapies are better suited to closed-loop computer control than to human supervision.
For example, when injured soldiers are airlifted over the ocean while hooked up to ventilators and vital sign monitors, they rely on the limited resources of the medical personnel onboard the aircraft. A closed-loop life support system could monitor the patient second-by-second and perform small adjustments based on the information collected. This would allow medical personnel to allocate their attention to the patients that have the most serious problems. Closed-loop ventilation has been demonstrated to be more precise and require less oxygen than ventilation controlled by medical staff. Similar studies have been performed for fluid administration and anesthetics. Systems integrating autonomous life support will make it into the market within the next few years.
Diagnosis capabilities in the field are another important consideration for researchers. As imaging is advancing into smaller CT and ultrasound machines, the limiting factor for per forming a clinical diagnosis becomes getting a radiologist to analyze the images. Given the size of the data sets and bandwidth limitations, developing a “front-line” computer that can provide a preliminary diagnosis is an attractive option that is actively being pursued in research.
Finally, one of the most important medical resources for injured soldiers is the medic or buddy who makes life-or-death decisions at the point of injury with very limited information and resources. Life-saving procedures such as securing an airway, starting an IV, or placing a chest tube require a significant level of training and skill. It only makes sense that technology could assist these individuals in performing life-saving procedures or making assessments on the conditions of patients. As such, researchers are developing devices that can perform these procedures autonomously; for instance, the device would contain sensors that help guide the medic in locating a particular vessel during a life-saving intervention.
The concept of remotely controlled medical care is moving toward one of human-supervised autonomous operations, in which robotic devices are capable of interpreting and acting on sensor data to provide better feedback to the surgeon. Autonomous or supervised procedures may make it into the field sooner than remotely controlled technologies due to bandwidth limitations and the potential to provide better performance than humanly possible. Even then, humans, not robots, will be in charge.