On the Outside Looking into the Insides

The history of medicine is thousands of years old, but one thing remains constant: the curiosity of the physician. Surgeons would linger around battlefields looking for open wounds in soldier’s abdomens, to get a last look at a working organ. Of course, they could see corpses anytime, but most were shriveled or putrid or rigid with formaldehyde. There are stories of men who recovered from wounds but did not have their abdomens or stomachs totally closed, and they sometimes hired out to medical schools so the students could observe the live body in action. Certain things like eating and digestion had to be managed, of course, but it was not a bad living being a unique specimen for student observation.

For many centuries, surgeons trying to understand the human body (and hopefully fix it) tried to see inside. This is where the idea of a scope came in. Doctors felt they could safely make a small hole and stitch it up later, except when they ran into a bone…or an artery. But they could not see for two reasons: They were looking for small anomalies, and there was no light inside the body. For centuries physicians experimented with channeling candle light through a straight scope, with lenses in the scope for magnification. One can only imagine that sometimes doctors got their ears burnt as their eyes tried to peer through the scope at the same time.

The age-old curiosity still persists, but now doctors can see more, and even perform procedures inside the patient, under full view, with adequate lighting. One of modern medicine’s miracle tools is the flexible scope, by which physicians can explore around in various tubes and cavities such as the stomach, lungs, bladder, and the colon. The tip of the scope has a light and a lens in it, and the user manipulates dials to turn the scope head in various directions. Spies and criminals also use these flexible scopes of course, to worm around corners in internal housing ducts, to see through air vents and hear privileged conversations, but that is a story for mystery magazines, and my experience was in medicine. Not that I was a doctor or paramedic or anything remotely medical except that I took Latin in High School and was able to pick up a lot of medical words pretty quickly. Because I could say Endoscopic Retrograde Cholangiopancreatography in one breathe I could then abbreviate it to ERCP and even medical practitioners were glad to abbreviate that.

There are other ways of seeing inside a body, of course, with x-rays and various scans, and in some cases, such as angioplasty, it is possible to perform procedures inside remote veins and arteries. These days there are jazzy illustrations drawn from CT scan “slices” and it is possible to see your insides in almost realistic fashion. Almost, but not quite. The blood is not real. The bodily fluids do not sheen their sickly green, and the organs do not writhe with the pulse of life. And few doctors would be comfortable performing remote procedures on tissue they had only seen in cartoon representation.

The endoscope however, provides a real view directly on the inside passages. Various tools and baskets can be inserted through that tube to accomplish various routine procedures in a few hours that would have been quite risky under the surgeon’s knife and would have taken weeks or months to recover from. Colonoscopies are a good example, wherein the physician can spot cancerous polyps and burn them out – cauterize then – on the spot. All of this is very routine stuff now, and yet somehow doctors have to learn how to do it on live patients. Pushing and twisting the scope inside an intestinal tract can be dangerous in the hands of a novice. Puncturing the abdominal wall means a rapid trip to the operating room, and sometimes death to the patient. Our answer was to provide simulation to novices, so that their first hands-on procedures with an endoscope were not risky to unknowing patients.

We took on a simulation project with Merck Pharmaceuticals that was at the outset merely a promotion for shows, and for doctors to work with the scope outside of a patient before they invaded the patient with the tip of their scope. We were to build not only a training endoscope, but the simulated physical and video environment through which it traveled. In some ways, it was similar to flight simulation, with the tip of the scope “flying” through the internal passages with the point of view provided on video, in the same way it happens with the actual endoscope. No one had done this before. That seems to be my problem usually. And yet somehow, the client thought I could do it.

In the feasibility study, I portrayed in a videotape what it might look like if you could insert an endoscope in the mouth of a manikin and see in live video on a TV monitor what was inside the body. Then according to my feasibility study videotape, students could proceed through the esophagus, upper esophageal sphincter, stomach, upper duodenal sphincter, and upper duodenum with smooth precise moves and the minimum of stress on the patient. There would be utter reality in look and feel. Wow! No one had ever done that. No one ever even had the chance. Almost no one thought it was possible.

Feasibility studies are like hope come to earth in demo form. They are not real. Though my client thought it showed I could do it, in reality it had no basis in reality. If I can transgress for a minute on demos, there was a joke running through the high tech community about God and the Devil getting the opportunity to woo prospects when they first die. God would show them Heaven and how everyone is calm and pleasant and singing hymns. The Angels actually looked a little boring. Then the Devil took them on the down elevator, and opened out onto gorgeously landscaped seaside resort, with golf and tennis and sailing and little carts coming around with snacks and refreshments all the time. So the prospect came back to middle earth and was given the choice of places to go, up or down. He chose down, which looked like much more fun. The Devil escorted him down again, to a second level, assuring him that he had made a good decision. The door opened and a heat blast came at them. In front of them was a vast steaming, barren, fiery top of a volcano, with people in chains writhing and moaning and hyenas laughing and nipping off pieces of their flesh. “Hey, wait a minute”,said the prospect. “This isn’t what I saw here before!” “Oh,” said the Devil, unapologetically, “That was just the demo.”

Even if the demo looked good to everyone, there is often a point in such a project that you know you are in real trouble. Existential trouble. Trouble that means reality wants no further relation with you. In truth, I did not know about 1. Endoscopic explorations, 2. The Upper Gastronentestinal tract itself. 3. Various software that could change the video as fast as the surgeon’s hand, and 4. Video footage that could simulate where the scope should be when the hands made certain maneuvers, in and out, back and forth and in circles. Luckily a friend of Merck’s, a young gastroenterologist named Mark, was enlisted to help me. He took care of my first two ignorances, of endoscopes and the G.I. tract.

My old friend the videodisc gave me the lightning fast changes in picture that were required when the scope was inserted, or turned one direction or the other. By shooting video footage in patterns that included all possibilities of exploration at every 3 centimeters, we could cover everything that could be seen, in a realistic experiment. I set these patterns up geometrically, with a route to an outer circle that doubled back on the scope, a preferred way to look around to anomalies. Mark did the shooting perfectly, and I donated my Upper G.I. tract one afternoon one of our “models” did not show up.

Our internal landscape models were patients who agree to have their G.I. tract extensively photographed for a reduced bill. The Upper G.I. was fairly easy on the patient. Later, when we were testing a lower G.I. on live patients, we set up a scheme we called rent-a-rectum for the students to do simple endoscopies on the lower tract to compare their abilities before and after using our simulator. We would pay them 20% of their stipend for the first event, and 80% if they returned for the final one. Most returned, but had we not structured it that way, I fear they may not have offered up their internal landscape a second time.

We had to build a mock endoscope that would make signals that were sent to the computer to then present certain images, all in real time, no processing delays. The doctors could tell if there was the slightest delay between what they felt with their hands and what they saw with their eyes. Of course, most of this was a bit more than I budgeted for (another problem when no one has done it). The real problem, however, came with the manikin. “What manikin!!!” I said. I had only budgeted for a box with a hole the size of a mouth that had rollers in it to gauge the depth of the mock endoscope. However, the client had seen the CPR manikin I had instrumented a few years back, and assumed that the endoscopy simulator would have a realistic manikin on a bed with a sheet over her. I say her because I learned long ago that men are gross when used as medical models. Annie had been acceptable to all and damned if I was not going to use at least one principle that had worked before.

There comes a time in the life a business when you are impelled toward making a much more involved product than you had intended. You say to yourself, this will take almost all of my profit, but the client will be satisfied and perhaps it will win a few awards and between more business from this client and others who line up at my door, this extra effort will be worth it. Then, in the real world, the client company loves it and shows it off — and then reorganizes the company and lays off everyone involved with the simulator, while keeping the simulator as a showpiece. You collect your awards, but the line at your door is not companies with money, but students who want to do theses about this new phenomenon, and universities who feel all information should be free to them and want to allow you to present all your designs and software at their institution. There is a wonderful world of free that some people live in, I guess, but it is no reward for a businessperson which, as it turns out, I was not much of.

The doctors and the company that had enlisted their reviews on this simulator were of one voice. It had to look like a real patient on the outside. So in my real world of making simulated experience, I supposed buying a manikin from a department store could work. We could lay it on its side and carve a hole for the roller mouthpiece and put a sheet over it and a pillow under its head. Her head, for reasons explained before, and a few to come. I went to my friend Dale to see if there were surplus manikins in the movie business, and he suggested Izzy. Isadoro Raponi was part of the Dino De Laurentis Italian group that created a second, more spectacular, King Kong, and in Hollywood, Izzy and his partner Carlos Rimbaldi made the creatures in two movies for Steven Spielburg, Close Encounters of the Third Kind, and ET – Extra Terrestrial. When they broke their partnership up, Izzy moved about Hollywood with special skills in special effects. In his time at home in Italy, he helped build the Leonardo Da Vince museum in Rome. He suggested he could make a life mask to make the manikin look like an actual woman rather than a department store prop. We used Mark’s wife Martine, with her short black bangs and pleasant, undaunting face. In short, it looked like a real person with her eyes slightly closed.

Later, Mark, along with Merck, helped us to do ERCP, Endoscopic Retrograde Cholangiopancreatography, wherein we allowed the simulator user to maneuver down to the pancreas, to insert a catheter inside the endoscope with a basket tip, and to see themselves using that catheter to extract stones from the pancreas. To medicos, this was the most impressive feat, and won attention for our future projects. But at a human level, Martine made a distinct difference. Her face and hair were so real that once her young daughter mistook the manikin for her sleeping mother.

It was amazing how much better the whole project was received when the manikin, which received the endoscope through the mouth, was shrouded in sheets and laid on a hospital bed. Immediately the scope manufacturer Olympus, set up the working simulator in one of their display rooms. Mark took it to Hamburg to show off with some top medicos there, and apparently someone from the Nobel committee flew in to take a look.

I learned something valuable here. The technology may be accurate and work exquisitely, but it may fall short if there is no link to we humans at a simple level, in our case with a real face and realistic hair. The technology community must learn this over and over. Most recently a focus on human users allowed the iPhone to emerge through all the rest of the mobile phones. It worked, simply almost flawlessly, but it was also quite beautiful when it fit into people’s hands, and adorned them.

Copyright 2018 David Hon – All rights reserved

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