University of Illinois at Chicago
My experience in this program has been great. I’ve gotten to see behind the scenes of what goes into an operation with the perspective of an outside observer, which is pretty unique. Overall, I definitely feel that this program has given me a deeper understanding of the clinical environment.
I’ve realized that there are many factors that go into whether a medical device/software product is useful. There are the physical qualities, such as whether the device requires unreasonable hand-eye coordination or constant adjustment, or if performing a certain task requires too many clicks in the case of software. There are also workflow factors, as in whether a hospital has efficient processes to make sure equipment is kept track of and available when necessary, and patient compliance factors when the user of the device is the patients themselves.
In addition to this, there are many other aspects of the environment which can improve or impede the use of a device. In particular, communication between medical staff has many opportunities for improvement. As we move into the era of artificial intelligence, it will be interesting to see and work towards using more AI/software to facilitate communication between medical staff.
I’d like to thank both the anesthesiology and urology departments for their kindness and willingness to have us this summer, as well as the Clinical Immersion instructors for guiding us through the problem-finding process. It’s been a great experience, and I look forward to working in the field of innovation.
This week we headed down to the Sterile Processing Department (SPD) again to further investigate some of the equipment delay issues we’ve been observing. Upon initially hearing about the problem, and visiting SPD once, it was tempting to jump to conclusions about the reasons for equipment delays and missing equipment. Some theories we threw around were lack of training, lack of documentation to check whether each cart of instruments has everything required, high turnover rate, employee satisfaction, etc. However, upon visiting for a second time, we realized we were wrong on many fronts.
For example, SPD has a checklist for each cart that they send up to a surgery, listing exactly what instruments are required for that surgery. They also send up a sheet with the cart that lists the items that are missing from the cart but which were on the list of requirements. So, it would seem that both the OR and SPD have the information they need. However, it doesn’t always work out, as we’ve still observed equipment delays/missing equipment. Also, many of the people we talked to on the SPD team have been working there for many years, and seem to have a system, so it’s not necessarily just a case of untrained employees. We continued to observe more resource problems in SPD, which can be a contributor for the equipment delays. However, this is outside of our scope. In the end, it seems that human error might be a big factor in the equipment problem.
The investigation at SPD was a useful exercise because it displayed the many layers of a problem, and the importance of not jumping to conclusions. Even though it doesn’t seem like something we’ll continue working with, I definitely learned a lot about how to investigate a problem.
This week we continued to observe some of the common problems in the OR, including equipment delays. Often the missing equipment is something small, like a foam pad or some IV tubing, but it’s still essential for the surgery.
We also saw a few prostate resections, in which the prostate is completely or partially cut out, rather than fully removed along with the lymph nodes, as we had been seeing previously in the robotic prostate removals. In this procedure, a metal loop/hook is inserted through the urethra and used to scrape off portions of an enlarged prostate. This hook is connected via wires to a foot pedal, which has one pedal for cutting and one for coagulating. There’s a lot of hand-eye coordination involved, as the surgeon has to look at the screen, which is displaying video of the inside of the patient, control where the hook is going, and control the foot pedals at the same time to switch between cutting and coagulating. Devices such as this, which require the user the control many different parts, can be improved to be more user-friendly.
These past few days, we saw a few more robotic surgeries and spent some time in clinic as well. In the robotic surgery room, one problem we noticed is that the screens that come down from the ceiling have long arms that often bump into each other, which sometimes is an annoyance when trying to move the screens around. Also, people often bump their heads on the screens.
In the procedure we were watching, the patient is tilted, with their head pointed down, and an instrument stand is placed near their head to protect their face from the robot, because the surgeon controlling the robot has no way of knowing if the robotic arms are about to hit someone. However, this stand is not very good at protecting the patient, as sometimes the robot arms just go under the stand, and sometimes it’s in the way and has to be moved away anyways. So, there is a need for a way to prevent the robot from hitting the patient or others.
In clinic, we spent some time discussing with our resident mentor, Dr. Wadhwa, about the need for improved communication in medicine. Communication breakdowns are one of the biggest causes of delays, and there’s a lot of space in this field for improvement using technology. My group and I hope to specify this problem further by analyzing the different circles of communication we see.
Last but not least, we had the opportunity to see one of the newest and most expensive devices in the urology clinic, the urodynamics/uroflow machine. This device gives a comprehensive report on the patient’s urine volume, flow, and bladder function. The test takes about 2 hours to do, because it involves a lot of explaining the procedure to the patient, and patient input on how their bladder is feeling during various parts of the procedure. Some problems with the device are that the catheters they insert into the patient’s urethra have no securing mechanism, so they have to be taped on very tight. However, if the patient moves around or the tape is not secure or gets wet, the catheter slides out of place. According to the nurse practitioner who was graciously explaining all this to us, a ton of time during the procedure is just spent repositioning the catheter. Considering the fact that the test costs the hospital $4000-5000 to run each time, it would be
Last post, I wrote about the issue of delays due to problems with incorrect/delayed equipment. Here I’ll mention a few miscellaneous problems we’ve noticed during the urology surgeries:
Transferring the patient from the transport bed to the OR bed before the surgery, and back again afterwards, is a pretty unwieldy process. Especially in cases where the patient is obese (which is a lot of the time), it actually poses some risk to the OR staff, and can delay the surgery if the resident or even attending injures him/herself while moving a patient. There is a need for a safe way to get the patient onto a suitable bed for surgery.
We’ve noticed that it takes a long time to close up the incisions after the surgery is over, and from a non-medical perspective, the current suturing method seems kind of old-fashioned. My team and I would like to find out if there are new methods to close incisions without the need of sutures, which would definitely save a lot of time during the surgery.
Patient emergence time from their general anesthesia varies. Some patients take a long time to wake up after the surgery is over, which wastes a lot of time where the residents and anesthesiologists stand around and have to loudly say the patient’s name in an attempt to wake them up. It would be convenient if the anesthesiologists had a more exact way of knowing when a patient would awaken based on how much anesthetic they had been given, and adjust their doses accordingly.
Especially for urology surgeries, it often takes a long time to get the patient in the correct position for the surgery. Sometimes the patient’s head has to be tilted downwards almost to the floor, and it takes all kinds of rolled up blankets and tape put in different places to get the patient in the correct position. It would save a lot of time to have a way where the surgery team can quickly place a patient into the correct position without using many different types of materials to hold them in place.
My team and I are enjoying urology so far, and look forward to next week.
Our first few days in urology, we’ve seen a few surgeries and tried to investigate on some common problems that occur. A big problem is obviously delays in surgery, which are often caused by equipment not being in the correct place when needed. Our team was lucky enough to investigate this process and learn about some of the bottlenecks.
We visited the Sterile Processing Department (SPD), where instruments are decontaminated, sterilized, sorted into trays, and sent to the OR. They have a mini elevator that is supposed to be used to transport dirty carts directly down from the OR, and clean ones directly up. It requires no humans to actually enter the elevator, the only thing that goes in is the cart. It would be pretty convenient, except the elevator breaks down at least once a week. When this happens, a member of the SPD has to physically wheel the carts/supplies through the halls, up the elevator, to the OR, then come back down. With so much work to do, this wastes a lot of manpower and resources.
Another bottleneck in the sterilization process is physically scanning in the trays with supplies. They only have one computer for scanning inventory, and all supplies need to be checked in at 3 points in the process. This creates a lot of wait time where the SPD team members are waiting just to scan in instruments. They used to have 3 computers, one for each point in the process, but they also broke down and have yet to be repaired.
Additionally, as with the rest of the hospital, there is a general lack of space in the SPD, which also slows down the process and reduces safety.
On the OR side of the story, as I mentioned above, a big problem they have with equipment is just getting the correct equipment for each procedure. For example, having the correct instruments for a robotic laproscopic GI surgery vs. a knee replacement surgery. Sometimes this is due to a lack of education on what instruments are used for each surgery, and it’s also caused by incorrect entering of supply requests into the system, as well as unplanned changes in the procedure.
We hope to continue to investigate this issue, and are really grateful to everyone who has helped us in our search so far.
In our rotation in Anesthesiology, we noticed a lot of problems related to the three themes of communication, technology/layout, and sterility. A lot of the communication problems we saw were between anesthesiology and the other surgery staff. It showed an insight into the culture of how anesthesiologists are viewed by other physicians.
We realized that problems with technology are multi-faceted: they are connected to funding, administration, layout, and other factors. So, when investigating a particular technology need further, an important next step is to determine whether the need has already been solved elsewhere, and is simply not being implemented at a particular hospital.
With sterility, there’s also a lot of factors playing into it. An important next step could be to determine the official sterility guidelines at UIC, and dig deeper into people’s attitudes regarding sterility. These attitudes could be examined in other hospitals as well, for comparison.
We enjoyed our stay in the anesthesiology department, and I look forward to urology!
At the end of last week, we got to see a spinal procedure. These procedures pose extra challenges because the patient starts off on their back, are then intubated and their arterial lines, etc. are placed. Then, once they have several lines and tubes sticking out of them, the team needs to flip over the patient onto the spinal procedure bed, so that they’re lying on their belly with their spine facing up. The surgeons then begin the procedure. However, one problem with this position is that in the event of an emergency, the patient would need to be flipped back over with their spine open in order to perform CPR. This is a very dangerous situation which could most definitely paralyze the patient, and everyone hopes it would never occur. It would be better if there was a safer procedure for dealing with emergencies during spinal cases.
For procedures such as scoliosis surgery, where they insert rods, hooks, and screws to hold the spine, they do continuous monitoring of the nervous system to ensure that screws are not accidentally hitting a nerve. Dr. Edelman explained that they used to have to wake the patient up during the middle of the operation and have them wriggle their fingers and toes to check on this, but now they have electrodes with which they can non-invasively and continuously monitor the patient.
This week, we got to see a cardiac procedure, in which the heart is “turned off”, the lungs are deflated, and the patient is placed on the heart-lung machine pictured at the top of this post. The heart-lung machine is pretty cool, as it oxygenates and pumps the blood for the patient. However, the problem is that the blood flow it produces is mostly laminar flow, while our organs are accustomed to the pulsatile flow that our heart produces. So, being on the heart-lung machine can sometimes cause neurological deficits in a patient.
One annoyance I noticed during the cardiac procedure was that the cauterizing-cutting device, which was attached to an “energy platform”, beeped really loudly every time the surgeon was cutting. It was even louder than the anesthesia monitors. Since the surgeon cuts a lot during the procedure, it is not useful for such a commonly used device to have a loud beeping sound produced.
Additionally, when the surgeon was opening the chest to begin the procedure, he had a sharp, flat instrument which he held against the chest, then used a metal mallet to hit it and crack open the chest. It was sort of medieval, and I thought it was interesting that there’s not a more advanced instrument used for this part.
Looking forward to the future, I’ve been thinking about ways that AI and robotics can eventually be useful in the OR. A lot of setup and retrieval of instruments can be done by robots. Eventually, we probably won’t need a person to keep fetching supplies from drawers, a robot can just retrieve it instead. One of the anesthesiology doctors even said that a lot of the work an anesthesiologist does can be done by a computer, because it’s mostly monitoring the patient and reacting to changes in their vitals. It will be interesting to see how robots play a role in the OR of the future.
This week started off with an insightful talk given by a physician in the urology department about the value in finding the right problem. A good problem, he said, must be both simple and impactful. I’ve been keeping this in mind these past few days, and have realized that finding the right problem is a challenge in itself.
On Wednesday we had the chance to speak to a physician about the use of augmented reality (AR) in medicine. He explained that augmented reality would be much more useful in medicine compared to virtual reality, and that a lot of innovation is underway in this area. For example, this AR ultrasound: https://www.youtube.com/watch?v=hKH1e38B1is is much more useful than regular ultrasound, because it superimposes the ultrasound image in one’s own line of sight, rather than having to look back and forth between ultrasound monitor and patient.
We also spoke about the use of Google Glass in the OR for educational purposes. For example, a resident can perform a procedure while the attending physician looks on from a different room through the Google Glass monitor. However, the current problem with this is that the line of sight of the Google Glass points too high: unless the user looks directly downwards, it would be hard to see any of the actual surgery. I would definitely like to research more into the use of AR in the OR.
We saw an interesting procedure today in which a patient’s mandible had to be removed and reconstructed. In preparation for this, the entire procedure had been mapped out in 3D using VSP ® Reconstruction technology. Not only this, but a custom 3D printed model had been made for the patient’s new mandible, to use as a guide during the surgery. This was really cool, especially the interaction between surgeons and engineers that occurs in order to make all this preparation happen.
During the reconstruction procedure, it seemed that the instrument the surgeon was using to get a graft from the leg was getting too hot, and the surgeon had to actually put it down a few times to let it cool down. There was also some annoyance with the scope used to see into the trachea: it seemed from afar that it was spraying water to rinse the area, which is technically a feature of the instrument but was currently unwanted by the resident.
In terms of workflow, the patient seemed to have a translator before the surgery, but the translator did not accompany the patient into the operating room. This seemed like a problem, because right before they start the surgery, the nurses/techs are required to do a final verbal confirmation from the patient of what surgery they are having done today. It appeared that the patient did not understand what the nurse was saying when asked what surgery they were having done. One of the residents attempted to translate, and the message got across eventually, but a few minutes later the anesthesiology team was telling the patient to take deep breaths, and it was unclear whether the patient understood or not. I asked our mentor, Dr. Edelman about this, and he explained that it’s not worth it for the translator to get into scrubs and come into the procedure, especially since there’s only one human translator, and most of the doctors have picked up some clinical foreign language experience along the way.
Additionally, we also got to see the MRI scanners this week. Since pediatric patients can’t sit still long enough for an MRI scan, they go under general anesthesia to get an MRI. The biggest concern with the MRI is safety – one of the radiology techs had plenty of horror stories to tell us about accidental patient deaths that have occurred in other hospitals due to lack of care around the strong magnet. Although they have plenty of signs up warning of the danger, it seems interesting that it’s left up to humans to keep ferrous metals away from the magnet.
In the world of ultrasound for neural block anesthesia, we heard from Dr. Chiang of the current problems with ultrasound. Mainly, it’s annoying and inefficient for the anesthesiologist to hold the ultrasound probe with one hand, control the needle with another hand, and have to pump drug into the needle at the same time. There are plenty of improvements that can be made to this.
This week we got to check out the simulation lab, where the residents and students go to practice procedures on a mannequin. Our mentor, Dr. Edelman, explained that although the mannequin is obviously not a real human, research has shown that simulation still gets students’ stress hormones flowing, and can mimic the feelings of a live procedure effectively enough. They have both adult and child mannequins in the lab, but no obese mannequins. I thought that was interesting, as obese patients usually pose a much bigger challenge, especially for anesthesiologists in terms of intubation and maintenance of the patient.
In the OR, we saw a gastric bypass surgery, in which part of the stomach is stapled off and removed, which helps curtail hunger and allows obese patients to get to a much healthier weight and lifestyle. At the beginning of the procedure, there was a major hiccup: the tech/nurse (not sure of the exact position) was unsure of the exact prep procedure. In all the hustle and bustle before the surgery, she didn’t have a chance to ask how to prep the patient, which involves applying iodine and drapes/tarp to the surgical area. The surgeon was all scrubbed in just about to start when it came to his attention that the patient was not even prepped for the surgery. Understandably, this caused considerable frustration, as it took about 15 more minutes for the techs to then prep the patient, who was already under general anesthesia. This wasted time, and as the surgeon mentioned, was not good for the patient to be under anesthesia for any longer than completely necessary.
The reason this situation occurred was because the nurse/tech was scheduled to this room was usually in an entirely different department, so she was completely unfamiliar with laproscopic gastric bypass procedure prep. The surgeon said this situation has been occurring more often, and that the techs should be assigned only to rooms whose procedures they’re familiar with.
We had the opportunity to speak with the surgeon about the equipment he uses for laproscopic procedures. Of course, there is the laproscope: a long, thin instrument with pincers at the end, which they stick into the patient. There are many problems with this tool. Firstly, it has no flexibility, which makes getting around intestines, etc. very challenging. It also is counterintuitive: if you want to grasp something with the instrument and move it to the left, you would actually have to move your hand towards the right. Tools such as this should be as similar to human motion as possible, but that it not the case.
Additionally, I’ve noticed a few small hassles each time: the OR beds have detachable foot ends/head ends, but they’re really clunky and take considerable pushing to actually attach, which seems annoying. Also, the entire process to transfer the patient from the transportable bed to the OR bed (and vice versa) seems kind of medieval compared to all the other technology present: one person stands on each side of the patient, and there is basically a “1, 2, 3…pull” moment. It would be nice to have a machine do this job instead.
On Thursday and Friday, we got to see a kidney transplant and a hernia repair, both performed using a DaVinci robot, which was very impressive. The surgeon sits at the robot controller in the corner, where he/she has a 3D monitor showing the insides of the patient. There’s another surgeon sitting by the patient, who controls the camera. The view from the camera is displayed on multiple HD TV screens. Very cool.
Using the robot allows for better control, and prevents the need to make a large incision on the patient. However, one problem is that the camera gets splattered with fluids/blood on the inside of the patient, so it needs to be removed and cleaned often during the surgery. This seems annoying and wastes a lot of time. It would be good to have a mechanism for the camera lens to wipe itself when dirty.
Looking back on the week, here are some common themes/problems my group and I observed:
Annoyance with machines
I had the opportunity to speak with a very helpful anesthesiology doctor about the different needs of the regular hospital floor vs. the OR. Simply put, in the OR, every second counts. So, when screens on IV pumps and other machines take too long to load, or it takes many clicks to get to the important screen, it’s a big problem for the doctors. Another big problem is that the screen on the anesthesiology monitor lags behind reality by about 15 seconds. So, the effects of administered drugs aren’t apparent for awhile after they appear, and if a patient’s blood pressure suddenly shoots up, the won’t know until the monitor tells them 15 seconds later.
Cost vs. convenience
For many small problems we’ve observed, there actually is a solution available, but the hospital hasn’t implemented it, because either the problem is not big enough, or the solution is too expensive. We are interested in knowing how the decision is made on whether to adopt a new technology for the hospital.
Lack of space
There is a huge lack of space in the hospital. Walking down the halls of the OR, you see an equipment room, but it’s more like equipment hallway, with imaging equipment, beds, cribs, etc. lined up throughout the halls. In the locker rooms, people are doubled and tripled up on sharing a locker. Meanwhile, in the surgicenter, where patients go right before they’re wheeled into the OR, there’s not enough space to have proper rooms, so there are 17 slots roped off by curtains. It works out, but could be better.
Since this was the first week, we were just getting started on identifying problems. Will post new insights next time. Thanks for reading!
On our first day of the program, we met as a group in the morning and went over the importance of needs assessment and the innovation process. The anesthesiology group then proceeded to the hospital building for the beginning of our first rotation.
They had actually closed the operating room for a few days in order to reorganize supplies. Our mentor, Dr. Edelman, explained that it was worth it to lose out on those days of surgery, because in the long run it would improve efficiency and save more than they lost. We also spoke about the overall hospital design of UIC – it’s not very large, especially compared to Rush hospital down the street. However, this is actually a benefit for UIC, as it takes less time and effort to wheel patients from place to place.
We checked out the surgicenter, where patients go before the surgery. There are 17 slots for patients, but there’s not enough computers to track each patient, which becomes a major bottleneck. After leaving the OR, patients are wheeled to the recovery room. At this point, there is a transition in care from the OR staff to the recovery room nurses. This transition is ripe for miscommunication, as the OR staff verbally explains all about the patient and how the surgery went.
On Wednesday morning, we arrived bright and early at 6:30 am to listen to the morning lecture given to the med students on how to handle difficult airways in patients. I noticed that during the practical demonstration part, the presenter had trouble with the mannequin – the material it was made of was too stiff/sticky for her to demonstrate effectively.
We then got into our scrubs and proceeded to the OR to watch surgeries. The first surgery was a Medtronic drug pump replacement. Since the battery on the Medtronic pump lasts only for 7 years, the patient needs to come in every 7 years to get the entire pump replaced. I am curious to know what the challenges are in producing the pumps with a longer lasting/rechargeable battery in the first place. It took awhile to get the pump reprogrammed; it seemed that there was some electrical interference with the product rep’s programming device, causing it to freeze up//slow down.
During the procedure, the anesthesiologist checks the patient response using a neural stimulator. If there is no response, they first check to make sure the device is working properly by testing it on themselves. So, the anesthesiologists have to give themselves a small shock with the device often just to check if it’s working.
Since this was the first day or two, it took some time to get acclimated to the OR environment. Will update again with the next few days’ observations. Thanks for reading, until next time!