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The Future of Emergency Medicine

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

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  1. The Future of Emergency Medicine Jonathon M. Sullivan MD, PhD Wayne State University Detroit Receiving Hospital

  2. 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

  3. 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)

  4. Science Fiction vs. Futurism

  5. Science Fiction vs. Futurism

  6. Science Fiction vs. Futurism

  7. Science Fiction vs. Futurism • “The difference between fiction and reality? Fiction has to make sense.” –Stephen King

  8. 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

  9. 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

  10. Futurism

  11. 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

  12. 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….

  13. 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

  14. 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

  15. And Voila! A Stunningly Accurate Prediction Emerges!

  16. 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

  17. Trend Trend Trend Trend Trend Trend Trend Trend Trend Trend Trend ?

  18. 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)

  19. 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

  20. 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

  21. 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?

  22. 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

  23. Work Tech Trends: ITInformation vs. Exformation  Information  Entropy ↑ Work “Value Added”

  24. 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, SETI@home, 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

  25. 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!

  26. 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

  27. 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

  28. 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

  29. 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

  30. Tech Trends: Point-of-Care Testing

  31. 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

  32. 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

  33. 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

  34. 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

  35. Who is this Man? Dr. K. Eric Drexler

  36. 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.

  37. 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

  38. Tech Trends: Nanotechnology Nanogears operating at room temp. Han and Globus, et al, NASA.

  39. Tech Trends: Nanotechnology Carbon nanotube deposits carbon on a diamond matrix.

  40. Tech Trends: Nanotechnology Carbon Nanotube Microarray for Chip Cooling (JPL)

  41. Tech Trends: Nanotechnology

  42. Tech Trends: Nanotechnology An example of an artificial microstructure created with carbon nanotube nanolithography

  43. 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

  44. Tech Trends: Nanotechnology

  45. 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

  46. 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

  47. 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

  48. 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.

  49. 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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