Telehealth Soars From Sea to Shining Stars
|From his offices 1,500 miles away, Dr. Mehran Anvari uses telementoring to talk an aquanaut aboard the Aquarius undersea habitat through a medical procedure on an artificial cadaver. The experimentation was part of the seventh mission of the NASA Extreme Environment Mission Operations (NEEMO) program. Anvari is the founder of the Centre for Minimal Access Surgery and co-principal investigator for NEEMO 7.|
In the age of Aquarius, emergency medicine for space exploration starts beneath the waves.
Research being conducted in the depths of the sea is revealing lessons in medicine that will help humankind in remote areas on Earth and allow future generations to travel to the far reaches of space. With capabilities provided by telecommunications, robotic and scuba equipment and an underwater habitat called Aquarius, space program personnel and medical doctors are examining the challenges of telemedicine in extreme environments. The information being gathered runs the gamut—from the unpredictable effects of the ambient atmosphere on devices to the need for improved human-machine interfaces to insights about the skills required to perform surgical procedures. And, while participants have their eyes on the skies, they readily attest that the lessons they learn undoubtedly can be applied in the battlefield to save not only lives but also limbs.
The work in telehealth, surgical telementoring and robotic surgery was the primary focus of the seventh mission of the NASA Extreme Environment Mission Operations (NEEMO) program. The research was supported by the Canadian Space Agency (CSA); McMaster University’s Centre for Minimal Access Surgery (CMAS) at St. Joseph’s Healthcare in Hamilton, Ontario, Canada; Cisco Systems Incorporated, San José, California; and others. NEEMO 7 allowed NASA scientists to explore how telemedicine could be used in future space missions if an astronaut falls ill while in space. The 11-day training mission took place on Aquarius, an underwater habitat situated off the coast of Key Largo, Florida, and operated by the National Undersea Research Center (NURC) of the University of North Carolina at Wilmington for the National Oceanographic and Atmospheric Administration (NOAA).
The NEEMO program, which is managed by NASA’s United Space Alliance, Johnson Space Center, Houston, began in October 2001. It was the brainchild of Bill Todd, whose admiration for the works of Jules Verne led him to craft a designation for the program with an acronym that would spell the name of the main character in 20,000 Leagues Under the Sea. Todd, who is the simulation supervisor of astronaut training for the United Space Alliance, is the NEEMO project lead and commanded the first NEEMO mission. For NEEMO 7, he worked on shore as the mission director.
In general, the purpose of the NEEMO program is to put astronauts in an environment that in effect replicates the conditions they will experience in space. This replica is referred to as an analogue environment. “What we’re trying to have is a platform experience that is a real environment, not a simulator. At 5 p.m., you don’t get to go home,” Todd explains.
Although the closest the astronauts-turned-aquanauts get to experiencing weightlessness is while swimming in the waters around Aquarius, it is about the only difference between living and working in the habitat under the sea and traveling in space. Small teams of individuals must live and work together in confined quarters for long periods of time. Leaving is not an option. Every team member has individual responsibilities that he or she must carry out. Each mission has a series of experiments that must be conducted according to a designated time line, and data must be collected. Both astronauts and aquanauts must learn how to observe the environment closely. And the danger of decompression sickness exists in both settings—when returning from the deep sea to land and when leaving a spacecraft to work “outside”—and cannot be ignored.
Also analogous in both environments is preparing for a mission. Before launch, a team must train to handle not only the scheduled work but also emergencies. Todd notes that this is one area where the NEEMO work has contributed greatly to priming astronauts for space travel. “No matter where you go, you will always find problems. So the real lesson has to do with learning how to solve the problems that are going to come up,” he says.
The NEEMO 7 mission dealt with how to handle one of the most serious problems that could arise on a deep space mission: a medical emergency involving a crew member. One option is to include a medical doctor as a permanent crew member. But the number of people who can fit into a spacecraft is limited, and specific specialists must be included as part of the roster to conduct the mission’s research. Even when a physician is part of the crew, other limitations must be overcome. The size of the spacecraft restricts both the amount of equipment that can be carried onboard and the room available to perform procedures.
Yet the issue of treating an ill crew member must be addressed as NASA prepares for future trips to the moon and to Mars, and NEEMO offers nearly perfect circumstances to explore one of the solutions: telemedicine.
Like all the NEEMO missions, NEEMO 7 included a six-person crew. Dr. Robert Thirsk, CSA astronaut, commanded the mission. Dr. Craig McKinley, a general surgeon at North Bay General Hospital, was the CSA’s co-principal investigator for NEEMO 7. James Talacek and Bill Cooksey, both from NURC, handled Aquarius operations. Dr. Michael Barratt and Lt. Col. Catherine G. Coleman, USAF, both NASA astronauts, were the principal trainees.
Dr. Mehran Anvari, founder of CMAS and co-principal investigator for NEEMO 7, designed the mission. In February 2003, Anvari, who is both a surgeon and a doctor of philosophy in gastric motor function and the influence of gastric surgery, performed a telerobotic-assisted operation. From his facility in Hamilton, Anvari performed laparoscopic surgery in the abdomen of a patient nearly 250 miles away at North Bay General Hospital. McKinley was on hand in the operating room to observe and assist if necessary. This experience inspired Anvari to explore the possibilities of applying telemedical techniques to space travel, and NEEMO appeared to be the ideal venue.
In addition to training CSA and NASA astronauts, the scope of the NEEMO 7 project involved assessing the feasibility and limitations of using commercial hardware for medical and surgical telerobotic and telementoring surgical techniques in space. For CMAS, the goals of the mission included testing concepts and procedures. The objectives for the CSA and NASA astronauts involved performing emergency diagnostic and surgical tasks on a simulated patient with the help of telementoring from medical experts located approximately 1,500 miles away at CMAS.
“Telemedicine is difficult enough, but when you’re trying to do it from this distance and under these circumstances, it is very challenging. We found out we could do it extremely successfully,” Todd says.
The effort required a plethora of technologies. In addition to the robotics, the NEEMO 7 team relied heavily on videoconferencing. A secure link was established using a broadband Internet protocol (IP) connection. The network used Cisco’s multiprotocol label switching and virtual private networking technology. The signal traveled over the IP backbone to Key Largo where it was relayed via a microwave transmitter to a buoy above Aquarius. A communications cable connects the buoy to the habitat. Communications were transmitted at 30 megabytes per second between the shore and the Internet service provider and then at 45 megabytes per second on the DS3 line.
Latency is an important issue that must be addressed in telemedicine because a delay in signals and messages relayed to the aquanauts or robots can have critical ramifications during a procedure. Todd relates that the latency rate for the links ran between 50 milliseconds and 500 milliseconds. “We wanted to get it down to 200 milliseconds, and we were finally able to level out at 100 milliseconds,” he says.
In terms of the technology alone, Todd notes, many lessons were learned during NEEMO 7. For example, 2.5 atmospheres of pressure cause computer hard drives to run at a slower speed. “I’d say 90 percent of the hard drives out there won’t work in this environment,” Todd relates. In addition, the crew found that the pressure inside Aquarius automatically presses down the touch buttons commonly found on medical devices. The crew solved this problem by inserting a syringe needle into each of the buttons and forcing air inside.
Even the robots, which are built to perform surgery in a hospital operating room and feature three arms, had to be redesigned. Because of the limited amount of space, the robotic surgeon could have only one arm, and Todd adds that even that had to be modified so it did not accidentally smack one of the aquanauts as it moved. In addition, because the robot relies on audible commands for instructions in some cases, exceptional voice recognition technology is crucial.
Anvari admits that information gained from NEEMO 7 answered many of his questions about the viability of telemedicine in space as well as in remote regions. His primary goal was to determine whether it is possible to enable a non-surgeon to perform surgery. As the designer of the experiments, Anvari chose a variety of procedures to examine, including diagnostics, gall bladder removal, vessel and nerve repair, and kidney stone removal. Surgical procedures were performed laparoscopically, which requires smaller incisions, and were accomplished either by using the robot or by telementoring one of the aquanauts.
The experiments also evaluated telehaptic software, which conveys the sense of touch to the surgical controls operated by a remote surgeon. The capability would allow surgeons to conduct more complicated surgical procedures from a distance but requires a broadband network, as latency would reduce telehaptic software effectiveness. Anvari was extremely pleased with the results from the telehaptics research.
From a robotics standpoint, the mission demonstrated that while current robotic platforms work well in a human environment, they do not necessarily work well with humans. Robots designed to work with humans in the future must be smaller so they can work within the confines of a spacecraft or a small clinic, Anvari says.
The telementoring work during NEEMO 7 yielded some results that surprised Anvari. “With telementoring alone, you are able to mentor a non-doctor to perform the task, and they can do it. It’s easier to telementor non-doctors than doctors because they come in with a blank slate. Family doctors and surgeons have their own techniques and come in with preconceived notions. You can’t take just anyone off the street and teach them to operate, but people with specific characteristics and skill sets can be mentored to perform surgery,” he says. Astronauts are especially adept at learning these techniques because their training and knowledge have prepared them to listen closely to instructions and to follow them, he adds.
The work conducted during NEEMO 7 also revealed insights about training strategies. Today, NASA spends months if not years teaching astronauts how to work on platforms like the International Space Station. The mission demonstrated that training can be improved by knowing the best way to share information, Anvari notes.
NEEMO 7 was a bit of a training experience for Anvari as well. To talk the aquanauts through procedures effectively, he had to break down the processes into steps, and he could not take anything for granted. This was not an easy task for an experienced surgeon, he admits. Additionally, the entire team had to consider what could go wrong and what to do if it did. These lessons also will be helpful in designing future surgical robots, he says, because one goal is to program robots to perform procedures semi-autonomously, so detailed instructions will have to be integrated into their circuitry.
Although the experiments were aimed at examining telemedicine and space travel, the entire experience will be extremely beneficial to people right here on Earth, Anvari emphasizes. Rather than traveling long distances to a health care facility that specializes in certain procedures, patients will be able to check into a local hospital and, with the help of telementoring, benefit from the knowledge of a doctor located thousands of miles away. “The Mayo Clinic can come to you,” Anvari states.
In regions with sparse populations, health care stations could be set up so local medical professionals could perform procedures assisted by surgeons through wireless technologies. This approach also could support researchers working in areas such as Antarctica where scientists could be talked through a procedure.
On the battlefield, the level of care that can be provided through telemedical techniques will save not only lives but also limbs, Anvari contends. Medics at the scene will be able to repair nerves and vessels guided by neurosurgeons able to view high-quality images transmitted over IP-based wireless links.
Dr. Dave Williams, CSA astronaut, was part of the shore support team for NEEMO 7. He says the team chose to use technologies that it “pushed to the edge.” Ironically, Williams, who is a physician, was scheduled to command NEEMO 7 but had to be replaced by Thirsk a week before the mission began because of a medical condition.
Platforms like the International Space Station and Aquarius are technology accelerators, Williams says, because they allow researchers to determine what does and does not work, lessons that can be used when designing new capabilities. The improved equipment can then be employed in facilities on Earth such as small hospitals or on the battlefield, he points out. “Robotics is exciting. From a military perspective, they can provide a well-equipped operating room and get people out of harm’s way, whether you’re looking at an Air Force environment, submarine, ship or in combat,” he notes.
But to reach its potential, telemedicine will require improvements in technology, the NEEMO 7 participants agree. Williams asserts that high-speed telecommunications technologies are required for telesurgery. Latency issues must be resolved, and doctors as well as engineers must determine which procedures can and should be attempted with existing links.
In addition to building robots that can be programmed to perform procedures autonomously, Anvari sees the need for developing modular robots. This approach not only would enable mission designers to construct robots that feature the capabilities required for specific environments but also would allow health care professionals planning medical facilities for isolated regions to add the capabilities they need.
Todd recommends that companies developing communications and telemedical equipment design products with both the user and environment in mind. “Industry, take your product and drop it out of a window, and if it survives, it’s worth something to me. Designing equipment that can be used only in an operating room is useless. Tabletop testing is of no use when it comes to operating in the real world,” he says. Technologies must be easy to set up and integrate, robust, efficient and inexpensive, he adds.
Currently, two NEEMO missions are planned for 2005. The first is tentatively scheduled for June and will examine life-sciences issues. The second is planned for October and will delve deeper into telemedicine.
Aquarius, the underwater habitat that has hosted more than 50 missions since 1988, is actually a three-part system. Situated nearly 3.5 miles off the coast of Key Largo, Florida, Aquarius comprises a semi-autonomous life-support buoy that is located directly above the 116-ton base plate and 85-ton habitat module. Personnel in Key Largo provide additional support for the underwater missions from the mission control center.
The life-support buoy includes a communication tower and nearly 230 square feet of inside workspace. It is connected to the habitat module by a 138-foot-long umbilical cord that carries air from compressors and oxygen from storage tanks. The cord also comprises power lines from generators as well as two coaxial cables and 12 twisted-pair wires that support communications capabilities.
A microwave telemetry system supplies wireless audio, video and data transmission between Aquarius and the shore station using SPEEDLAN 10ptp, a system developed by Wave Wireless Networking, a division of SPEEDCOM Wireless Corporation. The technology is a 10-megabit-per-second wireless point-to-point bridge that provides a secure wireless connection between the habitat module, life-support buoy and mission control center.
The habitat itself, located approximately 47 feet below the surface, is 9 feet in diameter and 43 feet long, providing approximately 400 square feet of living and laboratory space for a six-person crew. The laboratory is equipped with computers and videoconferencing capabilities as well as with Internet access, telephones and radios.
Aquarius allows scientists to conduct research using saturation diving, a technique that involves breathing under high-pressure conditions, which causes body tissue and blood to become saturated in inert gases. As a result, the amount of time needed for decompression before returning to the surface is the same whether the dive lasts two hours or two days. Aquarius aquanauts undergo a 17-hour decompression conducted within the habitat module before returning to the surface.
Operating at 47 feet below sea level in close quarters challenges humans in other ways as well. Bill Todd, simulation supervisor of astronaut training for the United Space Alliance, Johnson Space Center, Houston, points out that the Aquarius environment allows astronauts to experience firsthand what it is like to be cooped up with other astronauts for long periods of time.
“The human behavior aspect of training in Aquarius reveals what you will need when you send crews to Mars, for example, and they’ll be together for two years in the confined space of a spacecraft. Talk about reality TV! And efforts that are multinational and multiagency in scope like the International Space Station are also interesting. Different cultures solve problems in different ways,” Todd says.
Canadian Space Agency NEEMO 7: www.space.gc.ca/asc/eng/astronauts/neemo7/neemo7.asp
Centre for Minimal Access Surgery: www.cmas.ca
National Oceanic and Atmospheric Administration Undersea Research Program: www.nurp.noaa.gov/index.html
National Undersea Research Center: www.uncw.edu/nurc