1. Telemedicine, Virtual Reality, and Other Technologies That Will Transform How Healthcare is Provided Richard M. Satava, MD FACS Professor of Surgery University of Washington School of Medicine and Program Manager, Advanced Biomedical Technologies Defense Advanced Research Projects Agency (DARPA) and Special Assistant, Advance Medical Technologies US Army Medical Research and Materiel Command 2nd CREST Symposium Telecommunication, Tele-immersion, and Tele-existance University of Tokyo Tokyo, Japan December 10, 2004

2. Figure 4 Scott Fisher wearing one of the first head mounted displays at the NASA Ames Research Center virtual reality laboratory – ca 1985. (Courtesy of Dr. Scott Fisher, PhD, Telepresence Research, Inc., Palo Alto, CA)

5. “The Future is here …... it’s the Information Age” Current Visions

6. New technologies that are emerging from Information Age discoveries are changing our basic approach in all areas of medicine... EXAMPLES Fundamental Concept

7. Holomer Total body-scan for total diagnosis Satava March, 2004 From visible human to Virtual Soldier Multi-modal total body scan on every trauma patient in 15 seconds

8. Why robotics, imaging and modeling & simulation Healthcare is the only industry without a computer representation of its “product” A robot is not a machine... it is an information system with arms... A CT scanner is not an imaging system it is an information system with eyes... thus An operating room is an information system with...

9. Total Integration of Surgical Care Joel Jensen, SRI International, Menlo Park, CA Minimally Invasive Surgery Pre-operative planning Intra-operative navigation Remote Surgery Simulation & Training

10. Prof. Jacques Marescaux, IRCAD Remote telesurgery Dr. Mehran Anvari, MD McMaster Univ, Toronto CANADA “Operation Lindberg” First remote and trans-Atlantic Telesurgery procedure ROUTINE telesurgery from Hamilton to North Bay 300 mile distant

11. “TriCorder” Point-of-care noninvasive therapy High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis HIFU Courtesy Larry Crum, Univ Washinton Applied Physics Lab

12. Medical Education “The resident knows everything (knowledge),...” Point-of-care ubiquitous knowledge

13. The LSTAT Courtesy of Integreated Medical Systems, Signal Hill, CA “...is aware of everything (patient)...” Defibrillator Ventilator Suction Monitoring Blood Chemistry Analysis 3-Channel Fluid/Drug Infusion Data Storage and Transmission On-board Battery On-board Oxygen Accepts Off-Board Power and Oxygen Total Patient Awareness

14. 212th MASH Deployed with LSTAT - Combat Support Hospital LSTAT Deployment to Kosovo - March 2000 Courtesy of Integreated Medical Systems, Signal Hill, CA

15. Classic Education and Examination

16. Laparoscopic Simulator with tactile feedback Courtesy Murielle Launay, Xitact, Lausanne Switzerland Laparoscopic hysterectomy Courtesy Michael vanLent, ICT, Los Angeles, CA LapSim simulator tasks - abstract & texture mapped Courtesy Andres Hytland, Sugical Science, Gothenburg, Sweden, 2000 Surgical Simulators Simulation and Objective Assessment

17. ENT Sinusoscopy Simulator Lockheed Martin 1999 Haptics Full System

18. “Blue Dragon” passive recording device Courtesy Blake Hannaford, University of Washington, Seattle

19. Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000 Novice Intermediate Expert Objective Assessment

20. “Penelope” – robotic scrub nurse Michael Treat MD, Columbia Univ, NYC. 2003

21. Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future Satava March, 2000 Surgeon Assistant Scrub Nurse Circulating nurse 100,000

22. The Operating Room of the Future

24. SATAVA 7 July, 1999 DARPA Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003 Predator 2003

25. “The Future is not what it used to be” ….Yogi Berra Disruptive Visions

26. The Information Age is NOT the Future The Information Age is the Present... There is something else out there...... SATAVA 7 July, 1999 DARPA

27. The Future of Science Information is critical but not sole-sufficient Science is moving toward interdisciplinary fields Science must encompass all dimensions (or domains) Must also include time and information ? BioIntelligence Age SATAVA 7 July, 1999 DARPA

28. Clayton M Christensen

29. BIO INTELLIGENCE AGE TECHNOLOGY DEVELOPMENT CONSUMER ACCEPTANCE AGRICULTURAL AGE INDUSTRIAL AGE BIOINTELLIGENCE AGE INFORMATION AGE TIME (year) 2000 BC02000 AD190018001500 Satava 29 July 99

30. BIOLOGIC PHYSICAL INFORMATION FUTURE Robotics HPCC/WWW MEMS/Nano Genomics Bioinformatics Biocomputation Biosensors Biomaterials Biomimetic Satava 2 Feb 1999 The BioIntelligence Age

31. Global Concepts ?? BioIntelligence Age (what are the implications) The entire world is becoming “smarter” - embedded intelligence RF-ID, “smart dust” Networking provides distributed intelligence (informatics, telecom) The next wave will be Bio…..X mimicking or incorporating biologic processes Understanding biologic processes is a cornerstone (4 1/2 Billion yrs) SATAVA 7 July, 1999 DARPA 7

32. Antenna IC circuit Connector Chip substrate RF-ID Radio-Frequency Identification Courtesy David Brock, Auto-ID and MIT, Boston, Mass

33. Government Inter-disciplinary Initiatives DARPA Fundamental Research at the [Bio:Micro:Info] Interface NASA BioAstronautics/Astrobiology NSBRI Human Systems Integration NCI Unconventional Projects NSF National Nanotechnology Initiative DoE Virtual Human Project Stanford Bio…X

34. Federal Investment in NanoTechnology Table 1. Summary of Federal nanotechnology investment FY 2002 Budget Request (in million of dollars)* Department/AgencyFY00 FY01 FY02 FY03 FY04 Department of Defense 70 110 133.0 Department of Energy 58 93 97.0 Department of Justice - - 1.4 Environ Protection Agency - - 5.0 NASA 5 20 46.0 NIH 32 39 45.0 NIST 8 10 17.5 National Science Found97150 174.0. Total 270422 518.9 738 847 *Source: National Nanotechnology Investment in the FY 02/03 Budget Request by the President

35. University of Montana, 1999

37. University of Wisconson, 1999

38. Biomimetic Micro-robot Courtesy Sandia National Labs

39. Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England

40. Greg Kovacs. Stanford University, 1990 “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003

41. Recorded activity for intended movement to a briefly flashed target. TARGETMOVEMENT Time PLAN Courtesy Richard Andersen, Cal Tech, Pasadena, CA Brain Machine Interface – Controlling motion with thoughts

42. Thoughts into Action Miguel Nicholai, Duke University, 2002 Satava March, 2000 Direct brain implant control of robot arm

43. Smart prostheses Neurosurgical MEMS for Monitoring of Spinal Fusion Spinal Instrumentation Electronics Module Strain Gauge Pressure Sensor Antenna Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy

44. Tissue Engineering Liver Scaffolding Artificial Blood Vessel J. Vacanti, MD MGH March, 2000 Artificial Ear

45. Courtesy of J. Vacanti, MD MGH March, 2000

46. Spider silk protein as biomaterial -BioSteel Nexia Biotechnologies, Montreal Canada Cross section of synthetic fiber Spinnerette of spider Orb spider - web

47. Cold Spring Harbor Laboratory, Long Island, NY Femtosecond Laser (1 x 10 –15 sec) Time of Flight Spectroscopy Cellular opto-poration Los Alamos National Labs, Los Alamos NM

48. BioSurgery Satava September 2003

49. Relative size of subjects Alaska Black Bear Artic Ground Squirrel Research in hibernation suspended animation hypometabolic states resuscitation reperfusion

50. Brian M. Barnes, Institute of Arctic Biology, University of Alaska Fairbanks 11/02 Suspended Animation Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope

51. metabolic rate 0.5 0.01 (2%) active hibernating body temp. 37 o C -2 o C gene ongoing transcription function and translation suppressed heart rate 300 3 resp. rate 150 <1 (breaths/min) (beats/min) (mlO 2 /g/h)

52. Confidential

53. Technology is Neutral - it is neither good or evil It is up to us to breathe the moral and ethical life into these technologies And then apply them with empathy and compassion for each and every patient The Moral Dilemma

54. The rate of new discovery is accelerating exponentially The changes raise profound fundamental issues Moral and ethical solutions will take decades to resolve Technologies will change the Future Differing responses to scientific discovery by various sectors TIME Rate of Change Society Business Sector Technology Healthcare

56. “The practice is contrary to human dignity and is criminal” French President Jacques Chirac Clonaid scientist Brigitte Boisselier said a baby girl - nicknamed Eve - was born in the US after the genetic material from a woman's skin cell was fused with one of her eggs. Dr Boisselier said four other women were due to give birth to baby clones in the coming weeks - one in Europe, another in North America and two in Asia. Demands grow for human clone ban Advocates argue cloning can help infertile couples There are growing demands for a ban on human cloning after claims that a girl born on Thursday is an exact genetic replica of her mother. Clonaid scientist Brigitte Boisselier said four more clones will be born soon. French President Chirac has called on all countries to rally behind a Franco-German proposal for a global ban on human cloning which has been submitted to the United Nations. US President George W Bush says the process is "deeply troubling". Scientists remain sceptical of the success claimed by the Clonaid company, which is linked to a sect that believes aliens created humans by cloning 25,000 years ago. But legislators in Britain and elsewhere say there has to be discussion and introduction of rules for the practice of scientific methods which could produce a cloned baby, even if Clonaid's claims are untrue. “These technologies... are raising new moral and ethical morasses for us.” Dr Ian Gibson British legislator Saturday, 28 December, 2002, 14:28 GMT.

57. February 12, 2004 South Korean team demonstrates cloning efficiency for humans similar to pigs, cattle | Thersa Tamkins After outlandish claims, a few media circuses, and some near misses by legitimate researchers, a team of South Korean researchers reports the production of cloned human embryos. The findings, were released Wednesday (Science, DOI:10.1126 /science.1094515, February 12, 2004).Wook Suk Hwang and Shin Yong Moon of Seoul National University used somatic cell nuclear transfer to produce 30 human blastocysts and a single embryonic stem cell line; SCNT-hES- 1. Using 242 oocytes and cumulus cells from 16 unpaid donors, the group achieved a cloning efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%). Human embryos cloned Chinese Cloning Control Required Tuesday 16 April, 2002, 10:41 GMT 11:41 UK Strict ethical guidelines are needed in China to calm public fears about new cell technologies such as cloning, the country's leading scientist said. Professor Ching-Li Hu, the former deputy director of the World Health Organization, was speaking at the Seventh Human Genome Meeting in Shanghai. His call follows recent reports that Chinese scientists are making fast progress in these research fields. One group in the Central South University in Changsa is said to be producing human embryo clones, while another team from the Sun Yat-sen University of Medical Sciences in Guangzhou is reported to have fused human and rabbit cells to make tissues for research.

58. Genetically “designed” child 1997 Gregory Stock Jeffery Steinberg, MD Fertility Institutes of Los Angeles Five "designer babies" created for stem cells Five healthy babies have been born to provide stem cells for siblings with serious non-heritable conditions. This is the first time "savoir siblings" have been created to treat children whose condition is not genetic, says the medical team.The five babies were born after a technique called preimplantation genetic diagnosis (PGD) was used to test embryos for a tissue type match to the ailing siblings, reports the team, led by Anver Kuliev at the Reproductive Genetics Institute in Chicago, US.The aim in these cases was to provide stem cells for transplantation to children who are suffering from leukaemia and a rare condition called Diamond-Blackfan anaemia (DBA)."It's a big step, because it gives people another option," says Mohammed Taranissi, at the Assisted Reproduction and Gynaecology Centre, London, UK, one of the team. "Before that the only option was to look in the siblings and immediate family to see if you had a match or alternatively to just keep trying [to have a baby which matches]."He told New Scientist that people trying to conceive a child naturally as a tissue match for a sick sibling had only a one in five chance. This method can also lead to terminations where the foetus is not a tissue match for the sibling."If you do it this way, the chance of finding a match is 98 per cent." 'Unlawful and unethical' However, the use of this technology to provide a "designer baby" to treat an ill sibling is highly controversial.A UK couple involved in this study travelled to the US for treatment after the UK's Human Fertilisation and Embryology Authority (HFEA) ruled that they could not create a tissue-matched sibling as a stem cell donor to their son.In-vitro fertilisation (IVF) and tissue-typing was used in the US to give the Whitakers a perfectly matched baby boy to help their son 1.Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079

59. Extending Longevity A strain of mice that have lived...... more than three normal lifespans Should humans live 200 years? Life extension Life extension consists of attempts to extend human life beyond the natural lifespan. So far none has been proven successful in humans. Several aging mechanisms are known, and anti- aging therapies aim to correct one or more of these: Dr. Leonard Hayflick discovered that mammalian cells divide only a fixed number of times. This "Hayflick limit" was later proven to be caused by telomeres on the ends of chromosomes that shorten with each cell-division. When the telomeres are gone, the DNA can no longer be copied, and cell division ceases. In 2001, experimenters at Geron Corp. lengthened the telomeres of senescent mammalian cells by introducing telomerase to them. They then became youthful cells. Sex and some stem cells regenerate the telomeres by two mechanisms: Telomerase, and ALT (alternative lengthening of telomeres). At least one form of progeria (atypical accelerated aging) is caused by premature telomeric shortening. In 2001, research showed that naturally occurring stem cells must sometimes extend their telomeres, because some stem cells in middle-aged humans had anomalously long telomeres. April 14, 2004

60. Gaak Courtesy Professor Noel Sharkey, Sheffield Unversity, London ESCAPED "Thinking" robot in escape bid Scientists running a pioneering experiment with robots which think for themselves have caught one trying to flee the centre where it "lives". The small unit, called Gaak, is one of 12 taking part in a "survival of the fittest" test at the Magna science centre in Rotherham, South Yorkshire, which has been running since March. Gaak made its bid for freedom after it had been taken out of the arena where hundreds of visitors watch the machines learning how to repair themselves after doing daily battle. Professor Noel Sharkey said he turned his back on the drone, but when he returned 15 minutes later he found it had forced its way out of the small make-shift paddock it was being kept in. He later found it had travelled down an access slope, through the front door of the centre and was eventually discovered at the main entrance to the car park when a visitor nearly flattened it with his car. TECHNOLOGY NEWS Intelligent “Living Robot” Uses genetic algorithms to “learn”

61. Will Machines become “smarter than humans? ROBOT Hans Moravec Ray Kurzweil Humans vs Machine Humans 4.0 X 10 19 cps Red Storm 3.5 X 10 15 cps Moore’ s Law “computer power doubles every 18 months” Do the Math !! Who is smarter now?? The Age of Spiritual Machines WHEN COMPUTERS EXCEED HUMAN INTELLIGENCE

62. CAN I REPLACE MY B O D Y ? If I replace 95% of my body...... Am I still “human”? Artificial organs Smart Prostheses Genetic engineering Regeneration What does it mean to be human ?

63. Moral and Ethical Issues Raised by Technological Success Summary Should we do research in areas we may not be able to control? (eg, genetics, cloning, nanobots, intelligent machines?) Will prolonging life through technology result in more disease in the overall population Can we change medicine from treatment to prevention of disease In defeating diseases, will technology change a human into a combination of man and machine - what does it mean to be “human” How will we decide who gets the technology, especially in 3rd World SATAVA 7 July, 1999 DARPA 6

64. For the first time in history, there walks upon this planet, a species so powerful, that it can control its own evolution, at its own time of choosing … … homo sapiens. Who will be the next “created” species? The Ultimate Ethical Question?

65. Do Robots Dream ?