The Future of Emergency Medicine

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”

25. 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

26. 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!

27. 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

28. 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

29. 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

30. 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

31. Tech Trends: Point-of-Care Testing

32. 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

33. 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

34. 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

35. 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

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

37. 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.

38. 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

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

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

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

42. Tech Trends: Nanotechnology

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

44. 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

45. Tech Trends: Nanotechnology

46. 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

47. 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

48. 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

49. 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.

50. 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