Finding NEEMO

Cisco Systems is helping prominent Canadian and United States research organizations find radical new ways for doctors to make house calls.

The NASA Extreme Environment Mission Operations 7 (NEEMO 7) used Cisco’s Internet Protocol (IP) networking technologies in October to test some of

the most advanced approaches for delivering remote medical assistance ever attempted.

“We were trying to see if we could use technology to do surgery and diagnosis by proxy, so to speak, by allowing lay people to act asdoctors and surgeons with the aid of telecommunications,” said Dr. MehranAnvari, who directed the medical experiments.

For the NEEMO 7 mission, a crew of three astronauts, one scientist and two habitat technicians lived for 11 days in Aquarius, a nine-foot by 42-foot capsule 50 feet under the ocean off the coast from Key Largo, Fl. Aquarius simulates the isolation and confinement of a space ship. Due to the pressure change in the habitat, the astronautsrequired 17 hours decompression before they could safely ascend to the surface.

As with astronauts in space, the NEEMO 7 crew’s contact with the outside world was mainly through a communications link.

The crew explored tele-mentoring and tele-robotics as ways to provide advanced medical assistance to people in isolated environments.While this project specifically examined how such techniques can help bring emergency medical aide to ailing astronauts in space, the work has wide-rangingimplications for delivering advanced medical assistance to remote or isolated locations, as well as rural communities throughout the world.

Tele-mentoring is a process in which an experienced surgeon or specialist uses a two-way video conferencing link to guide a lay person ordoctor at a remote location through an operation or procedure. Tele-robotics uses virtual-reality technology and robotics to allow a surgeon to remotelyoperate on a patient from hundreds or thousands of miles away. In both cases, a highly reliable and high-performance network is crucial for conveying thelife-saving information and dependably operating sensitive robotic surgical equipment.

With the aide of Drs. Mehran Anvari, Julian Dobranowski and Anil Kapoor, the crew on Aquarius practiced ultrasound examinations for suchconditions as kidney stones, performed mock laparoscopic surgery, and trialed life-saving vascular suture repair techniques, among other procedures.

The main participants in the project included the Centre for Minimal Access Surgery (CMAS) at St. Joseph’s Healthcare, which is affiliatedwith McMaster University, in Hamilton, Ont.; the Canadian Space Agency (CSA);and the National Aeronautics and Space Administration (NASA). Cisco and Bell Canada donated their expertise and equipment.

Dr. Anvari, who founded the CMAS and is a pioneer in tele-robotic surgery, said the success of the crew’s medical experiments depended on the quality and robustness of the communications link.

“The mission hinged in large part on the network,” Dr. Anvari said. “Many of the experiments were about communications andthe network needed to work at a very high level. Without Cisco’s vision, we would not have been able to do what we did.”

The 1,500 mile telecommunications link from Aquarius to Dr. Anvari at CMAS headquarters at St. Joseph’s, relied on Cisco technology for thehigh quality and high performance broadband IP connection. The IP network used Cisco’s advanced Multi-Protocol Label Switching (MPLS) and virtual private networking (VPN) technology. MPLS brings a new level of intelligence and flexibility to IP networks, making such medical-grade communications possible.The signal traveled over the IP backbone run by Bell Canada to Key Largo. From there, it was relayed via a microwave transmitter to a buoy above the Aquarius.An “umbilical” communications line ran from the buoy down to Aquarius.

On board the Aquarius, the crew used a Cisco 2950 switch and a Cisco 2955 switch to manage the communication network within the capsule. Theswitches had to withstand pressure over two times greater than earth’s atmosphere, high humidity and lots of jostling in the cramped quarters. Despitesuch unusual conditions and rigorous demands on the network and its equipment, Dr. Anvari says the entire communications infrastructure performed flawlessly.

During a phone conversation from inside Aquarius with [email protected], Dr. Robert Thirsk, commander of the NEEMO 7 mission, and crew member Dr. Craig McKinley, reported that the high quality video and audio feeds into the underwater chamber were playing a pivotal role in the success of the tele-mentoring experiments.

“The broadband video and audio make it seem like the consulting surgeon is in the capsule with us,” McKinley said.

The astronauts noted that only with the advent ofhigh-quality broadband networks are such remote medical procedures even possible. “Any snafus on a network can greatly undermine the effectivenessof these types of efforts,” Thirsk said.

The NEEMO 7 crew also evaluated highly experimental tele-haptic software. Tele-haptics conveys the sense of touch to the surgicalcontrols operated by a remote surgeon. The technology would allow doctors such as Dr. Anvari to perform much more advanced surgery by providing the feeling oftexture and tension over a broadband network. Time delays in a network can greatly undermine the effectiveness of tele-haptic software, but the Cisco MPLS IP communications link proved up to the task, Dr. Anvari said.

While the tele-mentoring experiments worked well and the tele-haptics tests provided important insights, the tele-robotics experiments were curtailed, the astronauts reported. The crew quickly discovered thatexisting tele-robotic equipment is not small, nimble, or rugged enough for use in a setting such as Aquarius. The NEEMO 7 organizations will be developing andtesting new robotic designs for use on Aquarius next year.

Though the tele-robotics experiments on Aquarius were limited by equipment issues, Dr. McKinley knows that this new technology offers great potential for medical aid in space and in any location far fromsophisticated hospital resources. He was the attending physician in North Bay, Ont., where Dr. Anvari performed the world’s first hospital-based tele-roboticoperation on February 28, 2003. That surgery was also performed over a Cisco network run by Bell Canada using MPLS technology, connecting Dr. Anvari inHamilton to the robot in the operating room in North Bay over 200 miles away.Since then, Dr. Anvari has performed 22 similar operations. “We learned that tele-robotics can give outside doctors a physical presence regardless ofwhere they are,” McKinley says.

Dr. Anvari says the experiments on Aquarius only hint at the potential of tele-medicine as advances in telecommunications and robotics combine to bring new capabilities to doctors. He expects tele-robotic operations to greatly increase over the next five years, in the process transforming the care provided to patients far removed from advanced medical services.

“These procedures will become an important use of telecommunications networks,” Dr. Anvari says. “There’s growinginterest in these technologies to bring medical services to areas from the Arctic Circle to the mountains of Bhutan to the remote towns of Canada, so the implications of NEEMO 7 go far beyond space travel. They address the very basic need of how to save lives.”

Charles Waltner is a freelance journalist in Oakland, Calif. This article was originally published in [email protected]

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