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Articles / 2009

Robots' place in diagnostics, surgeries debated

Remote medicine

Ventura County Star
Sunday, 11/15/2009

When the doctor is out, the robot is in.

As part of a mechanical march stirring debate over the future of hospital care, an Ojai specialist heads a group of doctors who use a 5-foot-tall robot named ERNI for long-distance examinations of stroke patients in an Orange County hospital. In another procedure that would make Ray Bradbury proud, surgeons in a Ventura hospital simulate hand movements as if they were playing Wii. Their gestures control a walking spider of robotic arms that together remove a patient’s cancerous prostate gland.

Advocates — and there are many — say robotic technology can change the way healthcare is delivered, offering treatment from faraway cities, or countries, for soldiers in Afghanistan and intensive care patients in U.S. towns not big enough to attract specialists. They point to a day when micro-sized robotic organisms may be used to fight blood clots and thinking machines keep watch on frail seniors, alerting medics and doctors if they topple down the stairs.

Cynics — and they are a crowd, too — identify some of the procedures as gimmicks and say the daunting price will steer many hospitals away. Others worry about the loss of human contact.

“There is an impression that doctors are just technicians who use specific tests to diagnose and treat a specific disorder,” said Dr. William Goldie, a pediatric neurologist at Ventura County Medical Center. “The vast part of medical care involves personal attention, direct contact, good rapport and commitment that could never be provided by robots or computers.”

In a home overlooking the hills of Ojai, Dr. Herb Rogove argued that robots are designed to help doctors, not replace them. He toggled a computer’s joystick and piloted Emergency Room Neuro Initiative — ERNI — through an emergency room some 120 miles away at Fountain Valley Regional Hospital & Medical Center.

With an armless, gray torso, an LCD monitor for a head, WiFi antennae for ears and programmed punch lines like “Damn it, Jim, I’m a doctor, not a robot,” ERNI appears at first glance something out of science fiction.

Made by a Santa Barbara company, the robot can be piloted to the bedside of a critically injured patient. Intensive care specialists based off-site can use the robot’s video camera and high-powered magnification to assess a patient’s injury.

The doctor’s face is broadcast on the video monitor so he or she can talk to the patient and family members. ERNI can’t touch but the long-distance doctor uses nurses or emergency room physicians to check for abdominal pain or assess the possibility of paralysis.

The goal is to save time in treating stroke victims or other patients when delayed care can mean the difference between full recovery and life-changing injuries.

“Time is brain. Time is heart,” said Rogove, president of C3O, a small group of doctors who pilot robots in emergency rooms and intensive care units. He predicts the technology will grow explosively because many hospitals struggle to find specialists.

There are issues, like whether the long-distance doctor or the emergency room physician bears liability if a mistake is made. The system relies on the Internet, meaning a doctor can be disconnected in mid-examination.

Goldie, director of pediatric neurology at Ventura County Medical Center, worries about diagnoses based on hard-to-spot distinctions such as whether an eardrum injury is bleeding into the brain.

“Those are the sorts of decision that you couldn’t really expect to make 100 miles away,” he said, adding the distance also creates a buffer that affects what the patient confides to the doctor.

“A patient has to feel that you’re the specialist, that you know what you’re doing and that your decision is the right one,” he said.

Jerry Mayers of Ojai hasn’t met ERNI but he did allow a surgical robot to remove his prostate. And that doesn’t strike him as the least bit strange.

“I wanted it. I chose it,” said the retired military consultant of the procedure performed last week at Community Memorial Hospital in Ventura. “I chose it because of the technology and precision and the recovery time is very short.”

For five years, surgeons at the hospital have used the da Vinci Robotic Surgical System to operate on patients who need surgery on their stomach, colon and prostate. Gynecologists use the technology to remove tumors from a woman’s uterus or ovaries.

The doctor sits at a station apart from the operating room table, peering at a screen showing a three-dimensional view that can be magnified 10 times. The surgeon places his thumb and index fingers into glove-like controls where his movements guide four robotic arms. When the doctor simulates cutting, an articulated scalpel makes an incision.

Advocates say the procedure is easier to master than laparoscopic procedures in which a tiny video camera is placed in an incision. And the robotic systems allow for smaller incisions than traditional surgery, meaning quicker recoveries. A patient who stayed in the hospital six or seven days now may be home in two or three days.

Some doctors suggest the procedures offer no advantages over laparoscopy and are used more for the attention generated than medical effect.

“Overall it’s kind of a gimmicky thing,” said Dr. Tom Measles, a general surgeon from Thousand Oaks. “It’s not sweeping the ranks of surgeons.”

But the surgery brings the same advantages as any robotic system, said Dr. Gösta Iwasiuk, a Ventura general surgeon who learned the da Vinci system at the age of 62. Community Memorial keeps its robotic system on-site but the system could be used from anywhere.

“I can sit in another country. All you need is an electrical outlet and a phone line,” said Iwasiuk.

Yulun Wang, a Santa Barbara robotics pioneer who invented the first commercially used robotic surgical arm, said the technology allows a way to cope with a stagnant number of doctors trying to treat a population of patients that is both aging and growing.

Wang’s InTouch Health Systems has placed robots in about 250 hospitals across the world, from an emergency room in Lompoc to a system in Gabon, Africa, linked to Cedars-Sinai Medical Center in Los Angeles.

But in Ventura County, only Community Memorial uses robotic surgery, and no hospitals use robots for long-distance examination or care. One of the biggest barriers is money. Robots from InTouch can cost $5,000 a month, not including the price of the long-distance doctors. Computerized robot systems can be bought for about $1.4 million.

“Because of economics, it’s very questionable whether robotic surgery will have viability at all,” said Dr. Stan Frochtzwajg, chief medical officer at Community Memorial. “If the cost cannot come down substantially, I think we’ll see a long delay.”

But Wang said hospitals are realizing they can save money by spending on robots rather than paying specialists to be available at emergency rooms around the clock.

Convincing doctors is the hardest challenge, said Jim Lott, executive vice president of the Hospital Association of Southern California. He predicts support will grow as older doctors retire and technologically savvy physicians replace them.

That’s why Lott encourages his 10-year-old son to play video games with the same kind of controls used in high-tech operating rooms.

“My wife says we shouldn’t let him play those games,” he said. “I say, ‘No honey, he’s tomorrow’s surgeon.’”