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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 Purpose of this Lecture Put away your pencils, class ... – PowerPoint PPT presentation

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Title: 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 wont be on the test
  • Raina Burke wouldnt stop bugging me
  • Sullydog just wants to have fun
  • Some of us might actually learn something

3
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)

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
    modelingsignficant 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 (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

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

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
My Wife
The Match
17
?
18
Enough CYA, Dog
  • Step One In This Fools 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
  • Moores 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
Tech Trends ITInformation vs. Exformation
? Information ? Entropy ? Work Value Added
24
(No Transcript)
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_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

26
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!
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 spectroscopymore info about
    chemical and physical properties of a region than
    MRI
  • Multinuclear imagingtweak 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 Im 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
Youre 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 ATPase-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

51
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.

52
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.

53
Social and Demographic Trends
  • Your patients getting older

54
Social and Demographic Trends
  • Your patients getting older

55
Social and Demographic Trends
  • Your patients getting more complex

56
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

57
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.

58
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

59
Apocalypse is boring.-Bruce Sterling
60
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)

61
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)

62
Economic and BusinessTrendsApocalypse Now
63
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

64
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)

65
Economic and Business Trends
66
Economic and Business Trends
67
Economic and Business Trends
68
Economic and Business Trends
69
Economic and Business Trends
70
Economic and Business Trends
71
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

72
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

73
  • 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

74
What are your predictions, Sullydog?
You havent been listening.
75
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

78
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

79
CONGRATULATIONS TO THE CLASS OF 2006!
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