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The Future of Emergency Medicine. Jonathon M. Sullivan MD, PhD Wayne State University Detroit Receiving Hospital. Purpose of this Lecture. Put away your pencils, class This won’t be on the test Raina Burke wouldn’t stop bugging me Sullydog just wants to have fun

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The future of emergency medicine l.jpg

The Future of Emergency Medicine

Jonathon M. Sullivan MD, PhD

Wayne State University

Detroit Receiving Hospital


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Purpose of this Lecture

  • Put away your pencils, class

  • This won’t be on the test

  • Raina Burke wouldn’t stop bugging me

  • Sullydog just wants to have fun

  • Some of us might actually learn something


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Outline

  • Science fiction vs. futurism

  • How futurism (doesn’t) work

  • Identifying trends:

    • Technological trends

    • Sociological and demographic trends

    • Economic and political trends

    • Global trends (megatrends)

  • Summary (how I failed to predict the future)





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Science Fiction vs. Futurism

  • “The difference between fiction and reality? Fiction has to make sense.”

    –Stephen King


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Futurism

  • Historical antecedents

    • 19th century Comte's discussion of the metapatterns of social change

    • Early 20th century systems science in academia,

    • National economic and political planning:

      • France

      • Soviet Union and Eastern bloc countries.

  • Emerged as an academic discipline after WWII


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Futurism

  • Two broad approaches:

    • American: “Quaterly Report/Bottom Line” mentality

      • applied projects

      • quantitative tools

      • systems analysis

        • analysis of complex, large scale systems and the interactions within those systems.

          • Identification of units, processes and structuresgame theory analysis and modeling—signficant $$$ apps

    • European: “What about our Great-Grandkids?” mentality

      • more speculative and interested in long-term future of humanity, planetary systems, etc

  • Increasing crossover



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Futurism

  • An increasingly dismal science

    • Wild cards (Asimov’s Mule)

    • Butterfly effects (chaos theory)

    • Uncooperative markets

    • Uncooperative societies and electorates

    • Self-organizing systems

    • Singularities – point at which f(x) = ∞; also describes historical or technological discontinuities:

      • Advent of agriculture

      • Printing press

      • Internet

      • 9-11

      • War, Famine, Plague, Bush

      • The odd asteroid


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Futurism

  • Anticipatory thinking (futures)

    • Causal layered analysis (CLA)

    • Environmental scanning

    • Scenario method

    • Delphi method

    • Future history

    • Monitoring

  • Backcasting (eco-history)

    • Back-view mirror analysis

    • Cross-impact analysis

  • Futures workshops

    • Failure mode and effects analysis

    • Futures biographies

    • Futures wheel

    • Relevance tree

  • Simulation and modelling

    • Social network analysis

    • Systems engineering

      • Thinklets

      • Visioning

  • Trend analysis

  • Morphological analysis

  • Technology forecasting

    If you can’t dazzle ‘em with prophecy….


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Futurism

  • The Delphi Method

    • An explicit approach developed by the Rand corporation for Defense/Strategic planning

    • Utilizes panels or pools of experts

    • Highly rigid methodology and information flow

    • Lousy track record


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Identify opposing

trends and

extrapolate

p

p

Extreme Scenario 

Extreme Scenario 

Extreme Scenario 1

Extreme Scenario 1

Extreme Scenario x

Extreme Scenario x

↑t, p

p

p



Slide16 l.jpg

Identify opposing

trends and

extrapolate

You want

fries wit’

dat?

p

p

I’d like to

thank the

Nobel

Academy…

↑t, p

p

p

My Wife

The Match


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Trend

Trend

Trend

Trend

Trend

Trend

Trend

Trend

Trend

Trend

Trend

?


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Enough CYA, Dog

  • Step One In This Fool’s Errand:

    • Identify Trends:

      • Technological trends

      • Sociological and demographic trends

      • Economic and political trends

      • Global trends (megatrends)


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Technological Trends

  • Information Technologies

  • Artificial Life, Genetic Algorithms, Cellular Automata

  • Molecular biology, proteomics, computational protein folding

  • Artificial organs

  • Medical imaging

  • Materials science and nanotechnology

  • Drug delivery technologies for deep organ and organ-spec txs

  • Point-of-care testing

  • Resuscitative adjunts


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Technological Trends: IT

  • More than just data storage and collection

  • Increasing penetration into EM is manifest

  • Pros: efficiency, safety, info availability

  • Cons: info overload, privacy concerns, infrastructure vulnerability

  • Important sub-trends:

    • Decreasing processor size

    • Moore’s law

    • Wireless networks

    • HIPAA considerations, security issues

    • Neural networks, diagnostic algorithms


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Technological Trends: IT

  • Question: does more information = better care?

    • Available evidence casts grave doubt on such a presumption

      • Swan-Ganz Catheters

  • Question: does increased information increase the resolution of the retrospectoscope?


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Tech Trends: ITInformation vs. Exformation

  • As disorder in a system increases:

    • The entropy of the system

      • increases

    • the amount of information “encoded” in the system

      • increases


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Work

Tech Trends: ITInformation vs. Exformation

 Information

 Entropy

↑ Work

“Value Added”


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Tech Trends: ITAccelerating Acceleration

  • Kurzweil:

    • Human technological progress tends to accelerate over the course of history

    • IT accelerates the rate of acceleration of technological progress

    • Have we passed the singularity?

      • 20 years ago, could we have predicted:

        • Internet porn, PDAs, MyYahoo!, the Y2K scare, [email protected], CIS, genetic algorithms?

      • 10 or so years ago we actually DID predict:

        • The Internet would make everything perfect forever

        • email, dial-ups and Yahoo! would free China and N. Korea

        • Less paperwork for everybody! Yipee!

        • A sudden return to neolithic civilization at midnight, 12-31-1999

          • (Cruz told me he was dissappointed when it didn’t happen)

        • A better informed public and more honest politicians

        • The Internet was going to change EVERYTHING!

    • Network evolution: emergent and unpredictable


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Trends: IT

Oppos. Trend

Overwhelming (Info Overload), low E/I

Decreased Efficiency

Used to enforce rigid protocols

Spawns non-pt-care “busywork”

Cart > Horse

Privacy at Risk

Pulls physician FROM bedside

Promotes balkanized healthcare

Streamlined information, hi E/I

Maximizes efficiency

Promotes innovation and flexibiity

Minimizes non-pt-care responsibilities

Transparent IT

Maximizes privacy

Pulls physician TO the bedside

Integrates healthcare systems

I am Dr. Borg.

Your files will deleted within 29 minutes. I may contain malicious programs. If you wish to continue, hit “pay.”

Hmm…650 delinquent charts, an expiring license and a transfer from Providence. There. All done. Back to patient care!


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Trends: Bioimaging

  • Ultrasound

    • More compact: every doc with a unit

    • enhanced resolution

    • contrast materials

    • expanded utilization by EPs

  • Continued evolution of computed tomography

  • MRI

    • Magnetic resonance spectroscopy—more info about chemical and physical properties of a region than MRI

    • Multinuclear imaging—tweak nuclei other than H

  • Internal imaging


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Tech Trends: Bioimaging

  • The M2A capsule endoscope

    • miniature video camera, light source, batteries and a radio transmitter.

    • Video images transmitted by radio telemetry

    • 50,000 images / seven-hour procedure.

  • Data recorder: walkman-like device worn by the patient

  • Computer workstation imaging software


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Tech Trends

  • Neural networks and pattern recognition

  • Currently used to look for Osama bin Laden at the JFK airport

  • Systems require mimimum processing power to “learn” complex patterns

  • Never miss a pneumonia on CXR again


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Tech Trends: TMS

  • Uses electromagnetic induction to set up currents in neuronal populations

  • Already being used in neuropsychiatry and brain research

  • This one could be a singularity



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Tech Trends: Point-of-Care Testing

“We got blind diabetics out there taking their own blood sugar, but JCAHO

says I’m not certified to do it.”

- Rick Bukata


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Tech Trends: Biomolecular Medicine

  • Comprises several fields:

    • Genomics, proteomics, computational protein folding, molecular genetics, molecular immunology, computational protein folding, etc.

    • Short-term effects on EM probably moderate, compared to disciplines like oncology, hematology and rheumatology

    • Long term effects are critical:

      • Molecular adjuncts to resuscitation

      • Molecular/genetic diagnostics

      • Rapid protein repair

      • Early prevention of cell-death triggers


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Tech Trends: Drug Delivery

  • Organ/tissue-specific delivery systems

    • Ability to deliver engineered or recombinant proteins to tissues will be key

    • Targeted tissue delivery will be a major step forward

      • innovations in interventional radiology

      • Computational protein folding

      • recombinant proteins, eg, active group + targeting domain

      • engineered virions

      • nanotechnology

      • engineered microorganisms

      • antisense RNA technologies

      • micelles, microspheres


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Tech Trends: Materials Science

  • New materials technologies will have implications for all areas of medicine:

    • Prosthetic limbs, organs and joints

    • Drug development and delivery systems

    • Medical imaging

  • Emerging technologies:

    • Superconducting materials, esp ceramics

    • Composites

    • Self-assembling layers/vapor deposition

    • Nanolithography and nanomatrices


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Who is this Man?

Dr. K. Eric Drexler


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Tech Trends: Nanotechnology

You’re going to feel a little prick now…

Note: This is NOT a nanomachine!

Note: You should NEVER say this to a patient.


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Tech Trends: Nanotechnology

  • Engineering at the molecular and atomic level

  • Progress is explosive:

    • nanomaterials: nanotubes, buckyballs, nanocomposites

    • elementary nanocircuits

    • nanophotonics and nanolasers

    • nanolithography

    • Preliminary work with ATP’ase-driven nanomotors hacked out of natural casettes

  • Holy grails: kinematic replicators, rod logic, molecular-level quantum processors


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Tech Trends: Nanotechnology

Nanogears operating at room temp. Han and Globus, et al, NASA.


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Tech Trends: Nanotechnology

Carbon nanotube deposits carbon on a diamond matrix.


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Tech Trends: Nanotechnology

Carbon Nanotube Microarray for Chip Cooling (JPL)



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Tech Trends: Nanotechnology

An example of an artificial microstructure created with carbon

nanotube nanolithography


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Tech Trends: Materials Science and Nanotechnology

  • National Nanotechnology Initiative

    • Instituted during the Clinton Admin

    • Bush increased funding to $3.63 B

    • Incorporates dozens of Federal agencies, including HHS and NIH

    • Already moving rapidly into the commercial sector

      • hydrogen sensors

      • chip manufacture

      • manufacture of night vision and solar-power technologies

      • textiles



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Tech Trends: Nanotechnology

  • Implications for Emergency Medicine:

    • Drug delivery

    • Antibiotics, antivirals

    • tissue stabilization and repair

    • Diagnostics and imaging

    • Microtelemetry

    • Thrombolysis

    • “cell surgery”

    • gene excision and repair

    • Artificial tissues and organs


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Tech Trends: Nanotechnology

  • Challenges:

    • New technologies always mandate new skill sets

    • Some nanotechnologies will be biohazards; handling and regulation

    • adverse reactions to nanomachines

    • potential for abuse: neo-protists, microexplosives, “Gray Goo” scenario


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Tech Trends: Artificial Organs

  • Continued progress with mechanical organs and tissues, especially pumps (hearts), tubes (vascular, ducts), joints, bone and muscle.

    • New materials and processes

  • A new generation of artificial tissues and organs, representing a confluence of several technologies


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Tech Trends: Artificial Organs

Here Be Dragons

Biodegradable Tissue

Scaffold

(see “nanolithography”)

Inoculate with tissue-specific

cultured cells or stem cells

Ya got ya kidney, there.


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Tech Trends: Resuscitative Adjuncts

  • Synthetic oxygen carriers

  • Hypothermia

  • Reperfusion cocktails

    • Cardiac, cerebral, renal, spinal cord, muscle

      • caspase and calpain inhibitors

      • insulin, growth factors

      • mitochondrial stabilizers

      • free radical scavengers

      • thrombolytics post-arrest?

  • Refinement of the EGDT approach


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Tech Trends: AL, GAs, CAs

  • How’s this for sci-fi….

  • You will use artificial life forms to plan for staffing and maximize ED patient flowthrough.


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Tech Trends: AL, GAs, CAs

  • Genetic Algorithms

    • a form of Artificial Life that uses principles of natural selection and fitness to evolve solutions to complex problems

    • Already being used to optimize “just in time” shipping strategies, flight plans, traffic volumes, etc.


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Social and Demographic Trends

  • Your patient’s getting older:


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Social and Demographic Trends

  • Your patient’s getting older:


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Social and Demographic Trends

  • Your patient’s getting more complex:


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Social and Demographic Trends

  • Your patient is smarter (maybe)

    • Patients have more access to medical information

    • Less trusting of doctors

    • More likely to ask questions

    • We treat them like customers, they act like customers


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Social and Demographic Trends

  • Your patient speaks Urdu. How’s your Urdu?

    • Actually, he/she probably speaks

      • Spanish

      • Chinese

      • French

      • German

      • Tagalog

      • Vietnamese

      • Italian

      • Korean

      • Russian

      • Polish

    • Notwithstanding all the rhetoric, America will become increasingly polyglot in the next century.

    • More important is the issue of cultural diversity.


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Social and Demographic Trends

  • Your Patient Does T’ai Chi and smokes Tigoba Root

    • New Age Freaks from Royal Oak will rock your world

    • Use of alternative medicine is increasing:

      • in 2002, 36% of Americans had used some form of alternative therapy in the past 12 months (NIH data)

      • Many issues of safety, efficacy and regulation remain unresolved

      • Increased immigration affects this trend



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Economic and Business Trends:Apocalypse Now

  • 114 million ED visits annually

    • more than 1 for every 3 people in the United States

    • 16 million per ambulance.

    • EDs have become preferred setting for many patients

    • Seen as an djunct to community physicians ("go to the ED for some labs")

      • (recent growth in ED use driven by patients with private healthinsurance)


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Economic and Business Trends:Apocalypse Now

  • Between 1993 and 2003:

    • population grew 12 percent

    • hospital admissions increased 13 percent

    • ED visits rose 26 percent

  • During the SAME PERIOD:

    • United States lost 703 hospitals

    • 198,000 hospital beds

    • 425 hospital Eds

      • "mainly in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payors.” (Institute of Medicine)



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Economic and Business Trends:Apocalypse Now

  • EDs are the principal sources of care for 45 million uninsured Americans.

  • Hospitals have little financial incentive to prevent ED overcrowding.

  • "The ED often serves as primary care provider, a role for which it is not optimally designed.“

  • Increasing unavailability/reluctance of consultants


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Economic and Business Trends:Apocalypse Now

  • Overloaded EDs

  • Waits of hours or days for inpatient beds.

  • Ambulance diversion daily problem in many cities.

  • EMS fragmented and disorganized

  • 45 million uninsured Americans.

  • System is ill prepared to handle large-scale emergencies

    • natural disaster (more common)

    • Influenza pandemic (more likely)

    • Acts of terrorism (imminent)








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Economic and Business Trends

  • Overall United States health care performance ranked 37th (WHO)

    • Far below the average of developed nations.

    • Health care “level” ranked 72nd in the world by WHO

      • worse than China

      • comparable to Iraq.

    • Euro Itchy and Scratchy:

      • Have far fewer uninsured

      • Get more bang for their health care buck

      • Have comparable waiting times and rationing

      • Achieve comparable patient satisfaction

      • Take it up the butthole on taxes, but don’t seem to mind


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Would require new taxes and at least some increase in Federal bureaucracy

People who hate it:

Doctors

HMOs, insurance cos

Big Pharma

Conservatives

in power

Libertarians

Trial Lawyers

The public

Current trends in American healthcare are unsustainable

Other systems have huge problems, but still work better than ours

People who want it:

Doctors

Progressives & Libs

Hate America

Employers

The public

Oppos. Trend

Universal Coverage: the Worst Possible System


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EM takes up more slack for a sick healthcare system Federal bureaucracy

More uninsured

Few social support systems

Lack of regionalization and nationalization

“Highest bidder” technologies crafted to make money, not sense

EM becomes MORE DIVERSIFIED and LESS FOCUSED

“I’m doing a fellowship in Emergency Podiatric Acupunture!”

EM loses its academic momentum

Increasing loss of hospitals and academic centers makes EM a “red-headed stepchild”

EM seen as an economic drain on govts, med schools and hospitals

EM not well integrated in local and national disaster/antiterro planning

EM integrated into a comprehensive national healthcare strategy

Innovated technologies selected and deployed to maximze patient care and departmental readiness

EM becomes MORE FOCUSED and LESS DIVERSIFIED

It’s called “EMERGENCY MEDICINE”

EM’s academic momentum continues

More academic chairs

More NIH funding

More translational research

New areas of investigation

Stabilization of hospitals and medical centers stabilizes the standing of Eds

EM seen as crucial to the success of local, regional and national health care systems, both operationally and financially

EM a keystone element in disaster planning

Oppos. Trend


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“What are your predictions, Sullydog?” Federal bureaucracy

You haven’t been listening.


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Okay, fine. Federal bureaucracy

  • Predictions the next 10-20 y

    • Technological innovation will proceed apace

      • significant deployment of nanotech, TMS, AI, neural nets, etc.

      • Biotech from Singapore

    • Emergency Medicine will continue its current academic trajectory

      • Resuscitology, heart failure, stroke, sepsis

      • Systems analysis, GAs, IT

      • Physician wellness

      • Creation of new National Institute for acute/emergency/trauma medicine (as recommended by IOM)


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Okay, fine Federal bureaucracy

  • Predictions for next 10-20 y

    • IT will streamline our workflow and help put us at the bedside

    • Increasing deployment of neural nets and AI-like systems to improve diagnosis and tx and reduce errors

    • Continued refinement and evolution of CQI

    • Appearance of more explicit multidisciplinary team approach to EM


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Okay, fine Federal bureaucracy

  • Predictions

    • EDs will continue to pick up the slack while America gets her s**t together

      • EPs and EDs will continue to do more primary care

        • Bad for Emergency Medicine

        • Bad for Primary Care

        • Bad for patients

      • Public health mandates (funded vs unfunded)?

      • Overcrowding will continue for the foreseeable future


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Okay, fine Federal bureaucracy

  • Increasing regionalization and nationalization of health care systems

    • Driven less by public health concerns than disaster / terror preparedness

      • What is the role of EM in govt surveillance of the public?

    • Gradual integration of hospital systems and IT networks (this will be rough and slow going)

    • Gradual evolution of single payer system(s)

      • Probably 50 of ‘em, regulated by Feds (carrot-stick)

      • Hospitals, pharmaceutical co.s, PGs, etc, continue to be operated on entrpeneurial models


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CONGRATULATIONS TO Federal bureaucracyTHE CLASS OF 2006!


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