Meditation on a Self-Extending Robotic Intestinal Flatworm

I'm trying to think about healthcare innovation generally, but I'm a detail person...

The ultimate goal for surgery, of course, is not to need it in the first place. In the case of my own appendectomy, for example, a high-fiber diet might have made it less likely. Hmmm..should high-fiber food be mandatory? I don't think so. I do support a supportive role for government, when externalities are involved: labeling, of course, but also massive data collection. Government could help provide the infrastructure for personal choice. In MyersWorld it would be easy at any time (and more common in a recession) for anybody to make a little extra money by signing up for a public health randomization study -- we really don't know what diet/exercise patterns work for whom and how well, and what testable/predictable/controllable (genetic? psychological? cultural? behavioral cues?) factors are involved. If I knew that the handful of nuts I just ate was bad for me, and in what way, I might or might not eat them anyway... I like nuts. For whom does Seth Roberts' weird Shangri-La diet work, in which of its primary variations (sugar, oil, nose-clipping, crazy-spicing...)? Such information would, I suspect, make a substantial difference to obesity and probably other healthcare factors, and it's something that could be done right now, but probably won't be. Well, the internet factor is helpful, I suspect (even though, when I mentioned having printed out a web page on appendicitis symptoms, the E.R. doc did say that ought to be illegal.)

At the other end of the spectrum, a true Singularitarian might insist on pointing out that once I get uploaded into a virtual universe, I will not only think faster and have more ways to have sex but will be completely immune to cell-based ailments 'cos I won't have any cells, and I'll be copied to multiple locations so that even if a black hole whacks the Sun some of me will be fine. But frankly I'm not sure which of me will actually be me at that point, if any of you see what some of me mean, and I'm not a true Singularitarian. I'm not even terribly interested in whether or not one or more entities a million years from now have a memory of having been me; I hope we can have better goals than that.

Still, I do expect something at least as good as my stemcell cyborg notion, if I happen to live long enough to see it.

And in between? Well, I'm really quite grateful for laparoscopic surgery; various people have expressed surprise at my being not only up and active but doing routine gardening stuff and such, but I feel fine. I'd like the principle of minimally-invasive surgery to go even further; I'd like to see an appendectomy or the like become an outpatient procedure, done at a local robotic clinic which may not even have a local G.P., just an R.N. (and it might be a room in the R.N.'s house, or then again inside Wal-Mart.) The R.N. has no specialized knowledge, but when you checked in to Google Health Searches with your Android phone, you checked off your symptoms and showed yourself to the camera in front of somebody who sent you to your local clinic. She will now get you passed via telepresence to a specialist in India, let's say, to a specialist in Costa Rica, then to a real expert in your condition who happens to be in Singapore, and then the initial incision is handled by a technician in Miami who passes it on to the actual surgeon who comes in from her Greek-island beach, puts a towel on the chair to avoid getting it wet, and starts supervising the robotic equipment. (Meanwhile, the R.N. keeps track of your case, and is your agent, as well as being the intermediary between you and geek-speak where needed.)

So what is that robotic equipment that's being supervised? Well, it's even less invasive than a current-generation laparoscopic setup, of course. And it's more general: it can go more or less anywhere in your body. How?

In laparascopic abdominal surgery, it seems you mostly put in three or even four holes, inflate the abdomen with carbon dioxide to get an almost-reasonable field of view, and push tools in on rigid arms ("trocars"). My self-extending robotic intestinal flatworms need only one hole and there's nothing rigid to push in except for the head(s); they grow into you via a version of 3d printing, replace the bad piece with a model of itself, and then the non-biodegradable parts are withdrawn. Then you sit quietly for a little bit and then somebody drives you home.

Details? Sure, but as with most not-yet-solved problems there are multiple solutions on the horizon; you can't tell which will actually arrive. The Self-Extending Robotic Intestinal Flatworm as I'm imagining it is part sensor and part Roto-Rooter. It has a flat beak, a flat head, a flat neck, and a long flexible flat tail with a row of flexible tubes, being an output tube for ground-up roto-rooted gunk, two input tubes for hydrogel components, and one or perhaps two optical fibers for laser use; the surgical cutting laser may have to be separate from the scanning laser, which does its scanning with a vibrating mirror in the head, like that of the Cornell pocket projector

The key to the technology is a small mirror, about half a millimeter across, suspended by carbon fibers. According to the Review, the fibers amplify the vibrations of a piezoelectric motor to move the mirror, which deflects a laser at different angles, causing it to sweep back and forth across a surface.

So the flatworm has a really good view of whatever it's about to cut; it can probably leave the scanner-laser inside the head, but might sometimes push it out in a transparent globe at the end of an eyestalk. Appetizing? Mostly, though, the flatworm gets its head to where it needs to be, slices through tissue and small blood vessels but plugs larger vessels with hydrogel before slicing the plugs, and butters that which it's going to remove with a layer of hydrogel (a relatively hard, tough hydrogel, now used for tissue engineering) before it starts a grind-slurp-replace cycle in which it extrudes about a cubic centimeter of hydrogel for each cubic centimeter it removes; sometimes the hydrogel input will be mixed with a stem-cell suspension.

And how does the flatworm get to the objective, e.g. from belly-button to appendix? Well, my suspicion is that at least part of the motive power can be managed if we form the tail by extruding hydrogel out a ring of little holes around the neck, forming rings: if you're turning right, you don't push as much out the right side, and so on. The tail material thus is automatically the right shape, and it never moves inside the body, although it is stretched just a bit at the end of the process when the cables and head are pulled out, leaving the hydrogel behind along with any sensors, effectors, and engineered tissue that may be the result of the surgery.

And do I really think this would work? Well, I've deleted a number of alternative approaches for the S-E RIF; even if I were an actual expert, I'd be sure to have deleted (or not thought of) some of the right ones. So I'm sure that the minimally-invasive surgery of ten (or, after healthcare reform, maybe twenty) years hence will be quite different from this image, different in detail. But it will be as good. We are getting good at sensors, getting good at micromachinery, getting good at biomimetics and tissue engineering with and without stemcells. There is no reason to think that we'll stop at this month's AnchorPort Single Incision Laparoscopy Kit. And the main takeaway here is in any case that the surgeon is not looking at the appendix, not cutting free-hand with a scalpel: he's looking at a screen, and manipulating controls for a waldo; probably just a couple of joysticks. Right there, that enables telepresence, and it already works. This in turn enables the specialization-economics of Adam Smith's pin factory. We could improve our healthcare outcomes at reduced cost, just by that. That could be done now, this year, with a steadily-increasing scale of operations over the next decade. As a later extension, the surgeon should not be viewing endoscopic imagery; he or she should be viewing a 3D model based on data from

• prior CT scan and sonography
• very-short-range optics
• sonography
• maybe teraherz radiation, capable of penetrating a bit into not-too-wet-tissue.

That would replace the field-of-view problem with a different, often-solvable problem. It couldn't be done this year, but it could be done soon.

Oh, well...then again, maybe not.

update: Maybe this is happening even faster than I thought: the NYT has produced an article on Healing by 2-Way Video - The Rise of Telemedicine.

update 2: Self-assembly from within might be better than self-extension from an external incision, and an Italian group is making progress according to Ingestible Surgical Robots—Hard To Swallow Concept? | Singularity Hub :

The ARES robot was designed to self-assemble inside the body after patients swallow up to 15 parts. Using a modular approach, each of these parts would have its own role to play—image control, communications, structural functions and diagnostics, among others—while forming whatever the structure needed to carry out a particular operation. Weighing in at 5.6g, each module is 15.4 mm in diameter and 36.5 mm in length, and each represents a single pill to be ingested by the patient.

Faster, please.

Health Care: personal experience

Given the extent to which I've blathered about healthcare lately, perhaps it was inevitable...

Well, today (Monday May 17th) I'm going off "clear liquids" and on to soft solids, but I probably shouldn't resume my exercises quite yet. I was doing three sets each morning at five minute intervals, and increasing some kinds of them fairly steadily; Monday was 60-then-50-then-40 pushups, more than I can remember doing, with some slower full-extension pushups in the afternoon. Tuesday was run-up-and-down-stairs-ten-times in each set...after which, the dental hygienist told me my blood pressure at 107/68 (or was it 108/67?) was the best it had ever been, but I need to clean behind my left rear molar better. Wednesday was 50-50-50 situps, with leg lifts in the afternoon. Thursday was 26-21-16 pullups, with 26-21-16 chinups in the afternoon. Friday I set the cross-trainer in the basement to fairly-steep-uphill to sprint 30 seconds in each set. And I thought I was doing fine on this schedule with a whey "protein shake" after each session, even though I know I could easily stand to lose ten pounds, or even twelve which would get me back to skinny-college-kid weight. Some people stay there all their lives; good for them.

And then it got to Friday lunchtime, and I didn't feel like lunch at all; my belly didn't hurt, didn't feel nauseated, but felt pressurized from inside. I had some dry toast with my vitamin pills, couldn't concentrate on work, took a bath and a two-mile walk, felt mildly worse. Went to bed with a microwaved hot-pad, realized about 3:30AM that pressure on the lower right was painful whereas pressure on the lower left was not. Waited for my wife to wake up, asked Google for "appendicitis symptoms", found webmd.com saying

Many people who have had appendicitis say the pain is hard to describe. It may not feel like any pain you have had before. It may not even be a very bad pain, but you may feel like something is wrong. If you have moderate belly pain that does not go away after 4 hours, call your doctor. If you have severe belly pain, call your doctor right away.

Well, I wasn't sure I would describe my general discomfort as "pain" at all, and it was quite moderate even being pushed. I wasn't sure. My wife had a very simple response: "Get in the car." It is interesting to think that if she'd joined her brother at our niece's graduation as once planned, I wouldn't have gone to the emergency room until it was an emergency. Hmm.

At the emergency room, I assured various people that I would be quite happy to be told I shouldn't be there; I imagine they'd heard that before. The ER doctor is Michael Jastremski , M.D.. A good guy, slow and careful, a listener; years ago he sewed up our hockey-son. He said that it was rather odd but we'd get a fairly-definitive result from a CT scan, and Bernie the ER nurse put an IV in my elbow in the belief that this would hurt less than one in the back of the hand (probably true, and I'm a coward), and I lay there in mildly-increased discomfort trying to remember late-1970s computer science lectures on tomographic reconstruction but couldn't recall much. Then Dr. Jastremski said yup, I had appendicitis, he'd call the surgeon to let him know.

When Dr. Martin Ernits showed up, he was less confident, saying in clear but not-native English (he's Estonian) that my symptoms were not typical and the scan was not 100% definitive, nothing is that good, but there was certainly some inflammation there and he couldn't think of a better explanation so he should go in, accepting that he wasn't sure what he would find. Actually I found this reassuring, maybe because it's my own attitude towards almost everything. So Christie and Kristen (I think), the OR nurses, took over, and my wife was most amused at my commenting that this "barium" drink had been salty and was it barium chloride or barium sulfate or what, and they didn't know but wikipedia thinks it probably does. Maybe so. Then we talked with Dr. Bhalodia, the anesthesiologist, except that there are two Drs. Bhalodia and they're semi-retired, with one on duty at any given moment, and they are the parents of one of my hockey-son's friends; this was Usha, Ravi's mom, and we briefly talked kids -- Ravi doesn't play hockey anymore, he's following his parents' footsteps and will probably be an anesthesiologist; his big brother works for Goldman Sachs. Small-town medicine is probably not typical American medicine, but everybody kept asking my date of birth and what I was there for; when Christie and Kristen said I had to tell them what I thought the surgeon was going to do, I replied "take me to pieces and put most of the pieces back together" and one of them said "but you have to say which piece he'll leave out." So I asked "You mean I have to say 'appendix'?" and was told "That'll do."

The next thing I knew, my wife was repeating what I had heard and already forgotten, namely that this had been a longer-than-normal operation because my appendix was a mess, "rotting" inside a "sac of adhesions" that was connecting it to all kinds of stuff it should have been floating free from, and it had certainly started at least a year before, probably several years. Very odd. Okay, I believe it. (Consider the complexities in the medscape descriptions, and even this PubMed claim that "Spontaneously resolving appendicitis occurs in at least one in 13 cases of appendicitis and has an overall recurrence rate of 38%, with the majority of cases recurring within 1 year." I suppose I'm a recurrence...people who've heard me talk would mostly agree.)

From Bernie to Christie/Kristen to Amanda (who wouldn't give me my Tylenol until I admitted my name and birthdate; I tried "John Hancock, sometime in the 1700s" but she wasn't having any) -- I won't pretend that I enjoyed the experience, but I do have a lot to be grateful for. Dr. Ernits stopped by to quiz me on the puzzling lack-of-prior symptoms, but I don't remember anything helpful; of course he also covered post-op instructions and the option of staying an extra night. He did comment that I shouldn't worry about nutrition for a few days, I could live on my belly padding okay. This is true, and it seems like an excellent excuse for not getting rid of my belly padding...not that I needed an excuse. He's a high-intensity sort of guy; are surgeons mostly that way? Ivan Gowan (the surgeon who kept putting my hockey-son back together) certainly is. Ramesh stopped by to explain that his and Usha's semi-retirement is more informal than I'd imagined: when the call for a Saturday surgery came in, she told him to go on mowing their (very large) lawn, and that's how she came to be my anesthesiologist.

My IV woke me up when the bag emptied and when the battery was dying, but mostly I dozed. My wife mostly stayed with me and the 13-year-old worked on her Latin Day movie project in iMovie; I'd converted the video files for iMovie import, but there were mistakes which she had to edit out or at least de-emphasize ("Aphrodite" was Greek, not Roman) if only via voice-overs, and then construct a bloopers reel. It was an extremely low-budget movie and Latin Day is today... (I'm raising a geek! Yay!)

So...I'm home; I had oatmeal for lunch; I have some delightfully gruesome pictures whereby to remember my appendix. Has any of this changed any of my opinions of US health care? No, I don't think so. Many parts of the system are in many ways awful, but it worked very well for me this past weekend.

And could have been better? Well, sure. And it will be, as Moore's Law spreads its way through robotics. In the near term, laparoscopy will of course get better, with a short-term emphasis on telepresence, in part as laparoscopy itself shades into telesurgery so that an atypical appendicitis is always handled by somebody, somewhere on earth, who does them by the dozen every day; that telepresence will be supported by diagnostic telepresence robotics. And the endoscopic-camera view will gradually be supplanted by a view of a computer model which is being continually updated by various sensors, including at first endoscopic cameras. Then we'll get more interesting robotics, for diagnosis and therapy--tiny gadgets that crawl around inside you. In the very long (not-quite-Singularity) term, I think we'll get what I years ago called stemcell cyborg technology unless of course we get something better instead. And in a case like mine, some microbot would go out with a stemcell and come back with a disease-affected cell being replaced, or even a bacterium, and the infection would probably be detected by, umm, very roughly the end of the first day in which 1000 cells had been affected, or the first hour in which 24000 had been affected. (Am I sure of that? Absolutely not.) And what I called the "stem cell center for cyborg operations" would send out a few thousand more, see what came back, and either say "we can handle this" or "heeeelp!" long before the enclosing human felt anything at all.

And as I've said, I think we just cut the resources available for innovation -- mandated care is intrinsically less experimental. But there's still a lot of innovation on the way. Maybe enough.

Update: Tuesday, third day after laparoscopic surgery and I haven't needed any of my Percocet, just ibuprofen as anti-inflammatory. I took a shower last night, after taking off the outer bandaging, and I can have solid food today; I made French toast for my daughter's breakfast but it doesn't tempt me. I really do have much to be grateful for.

upd Saturday again, finally thought to see how much reduction I'd achieved: down almost to 177, i.e. three pounds. This is clearly not an ideal diet program. Well, there's still a (very) little bit of discomfort, he says after walking a couple of miles and pounding fence-edging in to discourage the groundhog that lives between us and the golf course...I suppose there's still some swelling, so it might be a tiny bit more than three pounds. Still not a recommended diet program.

Penultimate Update: Monday, May 24th; walked the half-mile from home to Dr. Ernits' office which had no record of any appointment for me, but acknowledged that there should should have been one, must have been one, and if I said my wife said that it was today at 9AM then that's what it would be. I didn't even wait terribly long. He said the appendix had been "suppurating", which is a nice word, and that I should put Desitin on the incision-spots until they were fully healed: "If you are a grandfather, you will be familiar." Well, yes, I have applied a lot of Desitin in my time, but never before on myself. I can be moderately active now (good, 'cos I thought that was okay already) and start exercising again in a week or so. Okay. Now I await the really painful part: the bill. :-)