The Future of Emergency Medicine

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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 wont be on the test
• Raina Burke wouldnt 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 (doesnt) 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
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Science Fiction vs. Futurism
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Science Fiction vs. Futurism
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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
  modelingsignficant 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
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Futurism

• An increasingly dismal science
• Wild cards (Asimovs Mule)
• Butterfly effects (chaos theory)
• Uncooperative markets
• Uncooperative societies and electorates
• Self-organizing systems
• Singularities point at which f(x) 8 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

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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
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And Voila! A Stunningly Accurate Prediction
Emerges!
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My Wife
The Match
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?
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Enough CYA, Dog

• Step One In This Fools 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
• Moores 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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Tech Trends ITInformation vs. Exformation
? Information ? Entropy ? Work Value Added
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(No Transcript)
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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,
  SETI_at_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 didnt
  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
Overwhelming (Info Overload), low E/I Decreased
Efficiency Used to enforce rigid protocols Spawns
non-pt-care busywork Cart gt 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 Transparen
t 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.
Hmm650 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 spectroscopymore info about
  chemical and physical properties of a region than
  MRI
• Multinuclear imagingtweak 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
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Tech Trends Point-of-Care Testing
We got blind diabetics out there taking their
own blood sugar, but JCAHO says Im 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
Youre 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 ATPase-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
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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
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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

• Hows 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 patients getting older

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Social and Demographic Trends

• Your patients getting older

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Social and Demographic Trends

• Your patients 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. Hows 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 Tai 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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Apocalypse is boring.-Bruce Sterling
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Economic and Business TrendsApocalypse 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 TrendsApocalypse 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 BusinessTrendsApocalypse Now
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Economic and Business TrendsApocalypse 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 TrendsApocalypse 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
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Economic and Business Trends
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Economic and Business Trends
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Economic and Business Trends
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Economic and Business Trends
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Economic and Business Trends
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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 dont seem
  to mind

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Universal Coverage the Worst Possible System

• 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

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• EM takes up more slack for a sick healthcare
  system
• 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
• Im 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
• Its called EMERGENCY MEDICINE
• EMs 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

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What are your predictions, Sullydog?
You havent been listening.
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Okay, fine.

• 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)

76
Okay, fine

• 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

77
Okay, fine

• Predictions
• EDs will continue to pick up the slack while
  America gets her st 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

• 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 THE CLASS OF 2006!