Nerves of Steel
ALAN ALDA If this guy were real, he'd need surgery fast. On SCIENTIFIC
AMERICAN FRONTIERS, we'll see how he gets it - from a surgeon
who isn't even here.
ALAN ALDA (NARRATION) We'll also see how computers give a surgeon
X-ray vision... ...and help cure a fear of heights. We'll see
how a human gene helps save a leg... and how legs once paralyzed
are made to walk again.
ALAN ALDA I'm Alan Alda. Join me for a glimpse of 21st century
medicine, on SCIENTIFIC AMERICAN FRONTIERS.
back to top
ALAN ALDA On the eve of the 21st century, medicine, along with
the rest of society, is being transformed by the computer.
At the heart of every story we'll be doing in this episode
is the computer's ability to process vast amounts of information.
In the operation being performed here today, the critical
location is the exact location of a brain tumor that's threatening
the life of a young woman named Lynda Tolve.
ALAN ALDA (NARRATION) Without that information, the operation that's
about to begin - and through which Lynda will be awake - may
not even have been attempted - leaving her 2 years to live.
It's a few days after the East Coast's Blizzard of '96. Lynda,
her fiancée and parents have journeyed from New Jersey to Boston's
Brigham and Women's Hospital. For 8 months, Lynda has had daily
seizures from a tumor that's slowly pushing into the part of
her brain that controls movement and feeling.
LYNDA TOLVE When I found out the tumor was growing, the doctors
in New York didn't want to touch the tumor. So I wrote to
Dr. Black and he told me to come on up and he said with his
new technique that he could do it. And that's when we came
up here and that's what we're here now for.
ALAN ALDA (NARRATION) Neurosurgeon Peter Black is ready to take on
Lynda's case because of a powerful new technique for peering
into her brain.
BLACK It's a very interesting process. I think you'll like
seeing how it works.
ALAN ALDA (NARRATION) The process begins with what is now a standard
technique for scanning the brain - magnetic resonance imaging.
The MRI makes cross-sectional pictures of Lynda's brain, and
in separate scans also locates its major blood vessels. The
information is combined and processed to create a 3-dimensional
image of Lynda's head, revealing the brain inside. This technique
has been pioneered at Brigham's Radiology Department as part
of an ambitious program to give physicians unprecedented power
to see inside their patients - both before and during surgery.
In Lynda's virtual brain, the veins are colored blue, and the
tumor - located in the region that controls her ability to move
her body - is marked in green.
LYNDA TOLVE My biggest fear in having surgery is that I might
become paralyzed, and not be able to walk. That is my biggest
ALAN ALDA (NARRATION) This fear that cutting out the tumor will
damage her motor skills lies behind another innovative test
- an attempt to pinpoint her brain's motor region with the
aid of a magnetic wand.
Okay, five, four, three, two, one, go. Okay, fine.
ALAN ALDA (NARRATION) Placed on her skull, the wand stimulates
the brain beneath. In this case, they are searching for the
spot that controls movement in her left hand. By moving the
wand - and tracking its location with flashing lights - Lynda's
motor region is precisely located.
DOCTOR Okay, very good Linda. We found the motor strip. We
are all done.
ALAN ALDA (NARRATION) This is the first time this method of mapping
the brain has been used here, and an eager crowd of researchers
awaits the results.
DOCTOR If you start going down towards where the ear would
normally be you see a little red spot, which is almost slightly
off-center on this little strip of cortex.
ALAN ALDA (NARRATION) The day before Lynda's surgery, I shared the
remarkable experience of seeing inside her head with the help
of 3-D glasses.
ALAN ALDA Is this the first time you've seen this 3-D picture of
TOLVE Yeah. It's amazing.
ALAN ALDA (NARRATION) The 3-D image, plus the mapping of the motor
strip, gives Peter Black much more insight into what he will
ALAN ALDA So this is helpful in making sure you don't invade that
motor area, right?
BLACK This tells us that it is reasonable to go ahead, assuming
that the tumor is now behind the motor strip and not in it.
If it were in it, we would say this would not be a possible
ALAN ALDA So this gives you a chance to know whether or not to
do the procedure and then it also guides you during the procedure
so that you don't...
PETER BLACK Yes.
ALAN ALDA Are there any other parts of the brain that, like blood
vessels, or something, that this could guide you in...
BLACK Yes. I think there are two other important areas. One
are the veins, which are extremely important not to injure,
and we know where they are now, and the second is the fact
that the tumor itself appears to be in the sensationary of
the brain. And the question of what implications that has
for Lynda's recovery after the surgery are fairly important.
TOLVE Isn't that something? Amazing! Thank you very much.
It's a good thing you did your homework, Lynda.
LYNDA TOLVE What do you mean I did my homework? Dr. Black
did his homework.
ALAN ALDA (NARRATION) Eight am on the day of the surgery. Lynda is
sedated but awake, her head uncomfortably clamped at the best
angle for getting at the tumor.
ALAN ALDA When I saw you yesterday, I thought you had a tremendous
amount of courage, and I still see it in you. I see you riding
She is an excellent patient.
ALAN ALDA (NARRATION) By this point in the surgery, a piece of Lynda's
skull has already been removed and her brain exposed. A video
camera has been set up to peer over the surgeon's shoulders.
It's now that the computer image of Lynda's brain puts in an
almost magical appearance. Because by carefully aligning the
virtual brain with the real one, the tumor's location is revealed.
ALAN ALDA There, there's the vein. Right there. Can you see the
PETER BLACK Yes, it's right exactly where we predicted that
it would be. The only area that I'm not sure about is an area
that we thought was a motor strip and the question is, does
the tumor impinge on that, and we will be testing that in
about 1 minute. Linda, we want now to test your movement,
okay, hon. You're doing great, everything is going very well.
We see the tumor. No question about that. It looks like it's
going to be removable, but we want to just check some of the
things about movement and feeling. I want you to tell me now
if there is any movement in your hand or your arm on the left
side, okay. Got it, perfect. Right on it. This is exactly
where they found movement yesterday, by the way, with the
mag stim. And so lets try four here. Lynda, this is very good
news in terms of what we can do here.
ALAN ALDA (NARRATION) The testing confirms that the motor strip is
next to the tumor but separate from it. But now there's another
concern - the tumor seems to occupy a spot that normally would
allow Lynda to feel sensation in the left side of her body.
BLACK We're now stimulating her wrist. That stimulus is being
picked up by that grid. So, each of those locations has a
number on it so you can tell if the stimulation of the hand
is being picked up under a number you know exactly what part
of the brain is receiving that stimulation. If you found that
the tumor was receiving signals, what would that do to the
operation. Well, this would be a situation we talked with
Lynda a little bit about. We talked before the surgery about
that issue. And she said she would rather have as much tumor
taken out as possible, even if it ended up with some trouble
with sensation for a month or two.
ALAN ALDA (NARRATION) Lynda's wrist is stimulated.
ALAN ALDA You feel anything, Lynda, in your thumb, in your hand?
TOLVE An electric shock.
ALAN ALDA An electric shock. The fact that your getting this typical
pattern on every part of the grid. None of it's on the tumor
BLACK No, I think we're probably below the tumor.
ALAN ALDA (NARRATION) As they move the grid around, they get more
good news. The tumor doesn't seem to be receiving signals when
Lynda's wrist is stimulated.
ALAN ALDA He was very excited when he got that report on what areas
were stimulated, because it seemed to be exactly what he hoped
it would be.
TOLVE Dr. Black did very good work. He's a very good doctor.
She should have complete resection without any weakness after
the surgery. We are all very excited about that.
TOLVE I went to a lot of doctors at a lot of hospitals. Everyone
refused to do this kind of operation. That's why when Dr.
Black wanted to do it on television, I didn't have a problem
with it. If it can help other people besides me, it will be
It's really a team approach, as you can see.
PETER BLACK I have to show you something.
ALAN ALDA Okay, I'm coming over.
ALAN ALDA (NARRATION) It's now about 2 hours since the operation
PETER BLACK We outlined the tumor, here in blue, but you see
how it's lifting itself out now, almost, it's really bulging
out of the rest of the brain on it's own. Okay, so that's
the first part of the tumor that we've just taken out.
ALAN ALDA How much of the tumor do you think that is?
BLACK It's about 1/4 to 1/3.
ALAN ALDA (NARRATION) Peter Black now switches to an instrument that
first breaks up tissue with ultrasound, then sucks the scraps
away. By now the hospital's pathology lab has confirmed the
tumor isn't malignant.
ALAN ALDA Now, I still see little white spots in there, I presume
you're going after them - other little spots of the tumor.
It seems it's not malignant, is there less of a need to get
every last drop of it out of it there?
BLACK Well, in a way, you want even more to get every last
drop because the surgery is the definitive treatment in that
ALAN ALDA In other words, you're saying that because it's not malignant
and you wont be radiating it, or doing anything to it...if
you leave anything in there, it could grow again.
BLACK And even though it is not malignant, it still may tend
to grow again. That is why we would like to see if we can't
get all of it out at this time. Now, the big question, Alan,
is the one you asked yesterday. How do you know how deep to
go? The advantage of the 3-dimensional reconstruction becomes
particularly apparent here because this small cyst is something
that we see in the 3-dimensional picture which you don't appreciate
so much in the regular MRI. It identifies the base of the
deepest part of the tumor.
ALAN ALDA (NARRATION) Using the virtual cyst in the image to guide
them to the real thing in Lynda's brain, Peter Black and his
colleagues over the next 40 minutes scour out the tumor. All
the while, Lynda's motor and sensation responses continue to
BLACK I think we are pretty happy with that, in terms of the
resection. I think now it's just a matter of making sure everything
is nice and dry. We're essentially done.
Lynda, Dr. Black has just completed the resection of the tumor.
And we're going to be finished very shortly. Yes, we're almost
finished. The tumor has been removed.
ALAN ALDA That's great. Congratulations.
TOLVE Good doctor, huh?
ALAN ALDA (NARRATION) Just three weeks after the tumor was removed,
we met with Lynda again.
TOLVE It's hard to believe that, not only the surgery was
3 weeks ago, it's hard to believe that I'm alive, everything
went well, everything went great. I have no more seizures,
and I can go to sleep at night knowing that I'm not going
to wake up having a seizure, I can drive a car knowing that
I'm not going to have a seizure, I can walk out my front door
knowing I'm not going to have a seizure. It's fantastic. I'm
going to get married, and I'm going to have children, and
I'm going to get rich, hopefully. Those things I could never
do, because I wouldn't be here to do those things. It all
seems like a dream, a dream that came true.
back to top
ALAN ALDA For a lot of people, what I am about to do is pretty
much impossible. This elevator goes up 47 floors in about
30 seconds, and the view is fantastic. But for people with
a fear of heights, this ride would be a nightmare. The best
way to treat phobias, like fear of heights or of flying, is
to expose people to just a little of what bothers them, and
to have a therapist along to help get them through it. And
then bit by bit the stakes are raised. Of course bringing
a therapist with you every time you get on an elevator can
get to be unwieldy, not to mention a little strange for the
other guests. But in the 21st century the elevator may not
have to be real.
ALAN ALDA (NARRATION) At Georgia Tech in Atlanta, Larry Hodges has
built a virtual version of that same hotel elevator. The helmet
gives me a 3-D computer-generated view that moves when I move
ALAN ALDA Oh, you know what I hate, is looking up. LARRY HODGES
That's what I've always said. Looking up is much scarier than
looking down. You can look down over the rail.
ROTHBAUM Your holding onto the railing, you can look down.
ALAN ALDA Look at that. Is it okay if I spit?
ROTHBAUM No, ha ha.
ALAN ALDA Well, okay. It's pretty realistic.
ALAN ALDA (NARRATION) The question is: is it realistic enough to
help someone like Christopher Clock?
We are going to dinner at the Sundial. But we were wondering
if there is an elevator that was inside instead of outside?
HOTEL CLERK No, this is the only one.
CLOCK You don't have one going up inside.
HOTEL CLERK No sir.
Do you think you can do it?
CLOCK No, I'm going to take the stairs.
You can face the other way.
CLOCK No, no I can't. I'm going to take the stairs. I've been
afraid of heights for as long as I remember. Since I was real
young, we went to New York and tried to climb the Statue of
Liberty and got half way up and just was too terrified and
had to crawl back down the stairwell. And I avoid hotels:
if I have to sleep above the second story I throw a big fit,
and not around windows. It's kind of bad.
ROTHBAUM How you doing?
CLOCK It's kind of scary actually.
ROTHBAUM All right. Your doing fine. We'll take it a little
bit at a time.
ALAN ALDA (NARRATION) Chris Clock is a patient of Emory University
psychologist Barbara Rothbaum.
ROTHBAUM You want to give me a rating?
CLOCK Ah, 70, 80.
ROTHBAUM Okay, what's bothering you about it?
CLOCK Just being over the traffic, the moving traffic.
ROTHBAUM What are some of your fears?
CLOCK Falling, the bridge collapsing.
ROTHBAUM Are you ready?
CLOCK Ha, Ha, yea, I guess.
ROTHBAUM Can you get a little closer?
ALAN ALDA (NARRATION) By asking her patients to keep reporting how
they feel and offering sympathetic reassurance, Barbara is working
on gradually lessening their fears.
ROTHBAUM You want to give me a rating?
CLOCK Um, 90, 95.
ROTHBAUM Okay, if you feel like you want to, you can go ahead
and lean over. Good job. You want to give me a rating when
you did that.
CLOCK About 100.
ROTHBAUM 100. Okay, you're doing real well.
ALAN ALDA (NARRATION) Barbara Rothbaum is collaborating with the
Georgia Tech virtual reality researchers to see if patients
like Chris find virtual height as scary as the real thing.
ROTHBAUM You want to get a little closer to the front railing.
And if you want to look over a little bit. You want to give
me a rating of your anxiety 0-100 now?
CLOCK Um, about 90 I guess.
ROTHBAUM About 90. And where are you feeling that in your
CLOCK Kind of weak in the knees. Hard to breath.
ROTHBAUM What scares you to look at?
CLOCK The tables. You can see that they are lower.
ALAN ALDA How long does it take somebody who's got a really solid
fear of heights to work through it in this kind of a situation?
ROTHBAUM Well, we take it slowly. In the study we did 8 sessions
about 35-40 minutes each. We would take it up to whatever
floor they felt comfortable with, stay with that until their
anxiety came down and when they felt comfortable...
ALAN ALDA Wait a second, excuse me, I'm sorry to interrupt you.
I can't understand anything your saying because when I took
the helmet off I was really disoriented.
ROTHBAUM You're disoriented.
ALAN ALDA I mean you guys are like... I'm standing on this floor
inside this railing instead of being in the elevator, I got
really used to the elevator.
ROTHBAUM Well, that's what a lot of people say, you know it's
animated, how can that really do it? How can that make me
feel that I'm there?
ALAN ALDA I want to go back to Oz.
ALAN ALDA I like it better in here. Oh, now I'm home again.
ALAN ALDA (NARRATION) Chris Clock has now been through all eight
sessions in these virtual environments - and here at least,
his fears are almost gone.
CLOCK I can actually look over and not be terrified.
ROTHBAUM You're doing a great job. You want to look up at
the next bridge? See where that is. Good. How is it when you
look up at that?
CLOCK It's not too bad.
ROTHBAUM All right. Rob, can we go to the top bridge, please.
We are there.
ALAN ALDA (NARRATION) The first time up here, Chris rated his fear
ROTHBAUM You want to give me a rating?
CLOCK Um 25.
ROTHBAUM Yea, it still catches you a little bit when you go
CLOCK It does.
ROTHBAUM How does it feel looking down and seeing the open
CLOCK Kind of scary, actually. But, it's manageable.
ROTHBAUM Give me a rating.
CLOCK Um, 20.
ROTHBAUM 20. 'Cause keep in mind what we talked about before,
that anybody is gonna feel it in their body if they are up
on a bridge this high and with open slats. I mean that's what
some people call thrilling, exciting. Just because you feel
something in your body when your up this tall, doesn't mean
it's fear. Doesn't mean that your scared. It means you're
ALAN ALDA (NARRATION) Of course, the real test of virtual environment
therapy is whether it helps in the real world. Chris was now
at least confident enough to try.
CLOCK I think the virtual environment helped me because I
was able to get up into a high situation and feel like I was
up high, but in the back of my mind know I was still on the
ground. And with that safety feeling, deal with the anxiety
and cope with it.
RECORDING In a few seconds you will arrive at the top of Atlanta,
our tri-level Sundial restaurant and lounge.
CLOCK It's such a weight off my shoulders knowing that I can
come up and I've conquered my fear of heights. I can go out
and come up 72 flights and look out. I'm not afraid of it
ALAN ALDA (NARRATION) The Georgia researchers are now constructing
a virtual airplane. I got to try out the prototype.
ALAN ALDA The plane is moving here.
ROTHBAUM Right, look out the window and you see the wing,
and we are moving.
ALAN ALDA (NARRATION) It still lacks some crucial details.
ALAN ALDA I don't have a seatbelt.
ALAN ALDA (NARRATION) The plan is to use the virtual plane to help
some of the millions with a fear of flying, without having to
take real flights with a therapist on board. The thunderstorm
was pretty convincing - but for thrills, I still preferred the
ALAN ALDA Make me go real fast. I like, where's the hand?
ROTHBAUM I think we've got a virtual junkie here.
ALAN ALDA Here we go. Well, that's pretty fast. Wow, look at that.
Wow. Oh, that is great!
ROTHBAUM Do you want to dangle your foot over the edge? How
does that feel?
ALAN ALDA It feels pretty good.
ALAN ALDA (NARRATION) With the price of computing power coming down
fast, it won't be long until virtual reality systems could be
cheap enough for every therapist to have one in their office.
And it will become even harder to tell where the virtual world
ends and the real one begins.
ALAN ALDA Wow, wow, you know that is really something. I had my
eye on the floor and the floor really came up at me. Don't
do this at home kids.
back to top
ALAN ALDA (NARRATION) By 7:30 in the morning, long before the stores
are open, this shopping mall in Natick, Massachusetts, is already
humming with activity. One of the most enthusiastic of the mall
walkers used to be Lillian Cooper.
COOPER I started about 7 years ago, and I could walk 5 miles
every morning. I don't want to be immodest, but I was a good
mall walker. I was usually at the head of the group.
ALAN ALDA (NARRATION) But for 2 years now, Lillian has been sidelined
by a badly narrowed artery in her left leg.
COOPER If I don't find a way to get it fixed, I'm gonna lose
the leg. I've been advised of that by two doctors. And I'm
not ready for that.
ALAN ALDA (NARRATION) Lillian has already had all the standard therapies
for her blocked artery. But now there's something new: involving
a form of therapy many believe will revolutionize medicine in
the 21st century. At Boston's Saint Elizabeth's Hospital, her
doctor is Jeffrey Isner.
ISNER We are only numbing that because we like you Lillian.
ALAN ALDA (NARRATION) She's been through this procedure often. A
catheter is being slipped into the main artery of her leg, and
then a dye that shows up on x-rays is injected. The resulting
angiogram shows the dye reaching the blood vessels in her lower
ISNER This is where the problem is. It takes a long time for
that dye to wind it's way all the way down to her calf muscle
and foot. That's why she's having all the pain. And so the
need here is to find a way to somehow deliver a significantly
larger volume of blood flow down to the lower leg.
ALAN ALDA (NARRATION) Restoring blood flow in a blocked blood vessel
is usually attempted with by-pass surgery or by inflating a
small balloon in the artery. But for Lillian, these have already
ISNER The main vessel, the main street, is totally blocked.
COOPER So, then what do you think you can do for me?
ISNER I know you've heard about gene therapy.
COOPER Yes, I have.
ISNER And in this case what we are going to do is use gene
therapy to try to make new blood vessels grow from this artery
that's right about in the middle part of your leg.
ALAN ALDA (NARRATION) Gene therapy has been highly touted as the
future of medicine. A huge research project to locate and read
all the 100,000 or so human genes is now in full swing. It's
another dramatic example of how information - in this case the
spelling of the operating instructions for the human body -
is transforming medicine. And its led to the hope that human
genes can themselves be used to treat people. One of these genes
manufactures a chemical that can make blood vessels grow. Jeffrey
Isner's idea is to see if putting this gene into blocked arteries
will cause them to develop shoots that will bypass the blockage.
ISNER The idea that people could grow their own bypass is
an intriguing one because there is nothing like letting nature
do the surgery.
ALAN ALDA (NARRATION) To deliver the gene, Isner employs a narrow
balloon, that can be slid into Lillian's artery to a point just
above the blockage and inflated to squash the gene into the
blood vessel's walls. Hundreds of millions of copies of the
gene are coated onto the balloon, then dried so that they stick
ISNER Seems like a lot. But we know that not all of the DNA
is going to come off of the balloon and onto the wall or into
the wall of the artery. And even all that gets into the wall
of the artery will not necessarily find it's way into the
cells, the smooth muscle cells, of the arterial wall. And
even the amount that gets into the cells will not all become
operative, in terms of making the growth factor.
ALAN ALDA (NARRATION) Everything is ready for the genes to be delivered.
A pump inflates the balloon. Now all everybody can do is wait
and see - if the genes got in...if they work...if new blood
vessels bypass Lillian's blockage.
COOPER My immediate dream is to go back to the mall walkers
and be able to walk right in. And I'm sure they are all going
to be there hoping for the same thing. That means I'll start
my life again, doing the things that I've always wanted to
ALAN ALDA (NARRATION) If the gene therapy grows a bypass for Lillian's
blocked leg artery, it has implications for other places bypasses
are needed - most obviously, the heart. Jeffrey Isner's ultimate
goal is to use gene therapy as an alternative to bypass surgery
in people with coronary artery disease. It's been 4 weeks since
COOPER Yesterday I walked from the hospital down the main
street - over a half a mile - and I kept going. I feel that
there have to be new blood vessels forming because what else
would cause this? My leg is better, my foot is better, I can
walk better. Has to be that. NURSE We'll have to use that
cane as kindling.
COOPER Ha, Ha.
ALAN ALDA (NARRATION) To find out if more blood is flowing to Lillian's
leg, she has yet another angiogram. The result at least partially
justifies her optimism. While before it took 15 seconds for
blood to reach her calf, now it takes only nine.
ISNER Now we are not seeing tufts of new vessels, and we're
not seeing splashes of arteries we've never seen before. It's
possible that the new arteries that are developing are of
a size that they're a little too small for us to see on these
angiograms. But yet, they're still enough of them, and they're
still functional enough that they're producing new conduits,
new avenues, for blood flow to the lower leg.
ALAN ALDA (NARRATION) Gene therapy is still in its infancy - and
so far most of the 100 or more clinical trials using genes have
been disappointing or inconclusive. But this one just might
ISNER Whenever you try something like this for the first time,
you always wonder: is it science fiction, or is it going to
be real therapy? A lot of things we try turn out to be science
fiction, they make good movies, but they don't help too many
patients. I think this has the potential to be great science
fiction, but now we are seeing a few indicators that suggest
that it actually might be useful, might actually be therapeutic
for certain patients.
ALAN ALDA (NARRATION) Six months after Lillian's gene therapy, and
she's back at the mall.
COOPER It feels wonderful to be walking again. There were
times when I thought walking a few steps with a cane would
be about it. But now I can walk around the mall, mostly without
stopping. So, I'm really thrilled with the way everything
has turned out. And I'm hoping that it will get better all
the time, and I'm sure it will.
ALAN ALDA (NARRATION) There was once a television series set in a
Mobile Army Surgical Hospital near the front lines of the Korean
War. Although you may not have known it from watching the show,
MASH units like this were a major breakthrough in battlefield
medicine. Before the early 1950's - and the helicopter - many
soldiers wounded in battle didn't survive simply because they
couldn't be treated by a trained surgeon quickly enough.
SATAVA That was our first opportunity to get closer to the
casualty where he was wounded in what we call the golden hour.
ALAN ALDA In the Korean War, that was the first time you could
get a patient under the knife that fast?
SATAVA That was one of the main advances that we had there.
The absolute evacuation from the far forward area quicker
to where the surgeon is.
ALAN ALDA (NARRATION) Fast forward to the 21st century, as viewed
through a promotional video made for the Pentagon's Advanced
Research Projects Agency, where Colonel Rick Satava heads a
program to bring new technology to battlefield medicine. The
goal is to shorten still further the time between a soldier's
being wounded and his getting expert medical attention - because
of a starkly dramatic statistic.
SATAVA We looked at the data from the Vietnam database and
the Korean database and found out that of those who died,
the soldiers who died, approximately half of them could have
been saved. Because they bled to death, most of them bled
to death, or had wounds or injuries that could have been treated
had a) the medic been there quickly enough or if the medic
got there but didn't have the expertise, we could have projected
the surgeon to him.
ALAN ALDA (NARRATION) And when Colonel Satava talks about projecting
the surgeon, he means it almost literally.
ALAN ALDA If this person had been wounded in the battlefield and
he happened to be lucky enough to have a surgeon here, what's
wrong with him?
ALAN ALDA (NARRATION) Jon Bowersox is a surgeon. He's working with
scientists and engineers to project his hands into the battlezone
while he himself is miles away.
BOWERSOX What it looks like is there is about an inch long
hole in the small intestine. If we didn't treat that, what
would happen is the casualty would develop a severe infection
and die in a relatively short period of time. So what's needed
to take care of this is emergency repair of the intestinal
ALAN ALDA (NARRATION) These are pig intestines from a local butcher's
shop colored with red paint. Jon's substitute hands are poised
ALAN ALDA What do these things do? They get right down in the wound?
This is the machinery?
BOWERSOX As you see, why don't we move them into position
here if you just move our position control.
ALAN ALDA That's this red button?
BOWERSOX It is. Stop please. Good, Good. So as you can see,
just like the surgeon's hands, they're placed right over the
site of the wounding and these are instruments the surgeon
ALAN ALDA (NARRATION) Right now the armored operating room is connected
to this tent by cable, but soon a wireless system will allow
OR and surgeon to be many miles apart.
BOWERSOX So this is a surgeon's work station, instead of being
at the patient's side in the normal operating room. I put
on these polarized glasses that give me 3-D vision. Instead
of talking directly to my assistant, I put on a pair of stereo
headphones, and instead of picking up the actual surgical
instrument handles, I put my hands, into the halves of the
instruments that are attached to the console. And now, it's
like being at the patient's side.
ALAN ALDA (NARRATION) What Jon sees is a 3-D version of the image
shown on the monitor.
ALAN ALDA How much like the real experience is it when you were
BOWERSOX Well, I think the most telling thing is that every
surgeon that has used the system, after working with it for
about 15 or 20 minutes, will move their hand out of the instrument
handles and try to push bowel out of the way, it's getting
in the way.
ALAN ALDA (NARRATION) Jon appeared to be as dexterous with the remote
instruments as he was with the normal ones, aided - as he would
be in a regular operation - by a skilled assistant. Jon sees
Michelle in a small monitor in his work station, and together
they speedily repair the wound.
BOWERSOX As you can see now, I am able to tie the knots in
the suture just as if we were in the actual operating room.
So, would you like to have a go at this?
ALAN ALDA Ah, yea. Let me try. I can't wait. This is the going
to be the first time I've ever done this.
ALAN ALDA (NARRATION) Despite years of doing fake operations in a
fictional MASH unit, this was the first time I'd tried anything
like the real thing. Fortunately, it wasn't the real thing.
ALAN ALDA Oh, oh my God! Oh wait a minute. I'm terribly sorry,
I banged into the instrument and jammed it into the guy's
intestines. Wait a minute. Michelle, control yourself. Snip,
Alan, you're ruining my image of you as Hawkeye, you know
ALAN ALDA I am not a real doctor, I just play one on TV. Now, I
need to pick this side up.
Yea. Pick it up. Right where you are. Okay.
ALAN ALDA Okay, Oh it went through.
ALAN ALDA Do I have too little of it?
No, that's just fine.
ALAN ALDA Oh, pull it with this?
ALAN ALDA Oh, I see, I see, pull it with the right hand. Okay.
ALAN ALDA (NARRATION) The most remarkable thing about the experience
was that the computer interface between the instruments and
my hands allowed me to feel what I was doing.
ALAN ALDA There I got it. Look at that.
Yes, you did great.
ALAN ALDA I made a stitch. But the poor guy; I mean he's gonna
have cramps from that stitch. I'm not really good at sewing,
anyway. But, I could feel it, I could feel the resistance
and I would imagine it would be easy to feel the resistance
of something really hard, but to feel something like tissue
which has so many kinds of resistance, I mean it's soft, it
gets a little tougher, and then you push your way through
and you feel yourself going through, you feel that release.
That's a subtle difference, and I could feel all those changes
ALAN ALDA (NARRATION) This feedback from the instruments is critical
to the system's effectiveness.
BOWERSOX The most common cause of abdominal injury in combat
is from shrapnel, which results from mines, like what's happening
in Bosnia or from grenade injuries; it puts a lot of small
fragments of metal in someone's abdomen. It's important to
try to get as much as you can out of the body. Here's a good
ALAN ALDA One of the things we used to do on Mash all the time
was run the intestine, I always took that to mean that we
would feel along the intestine or the bowel for fragments
or holes. Was I right about that? You would use your fingers?
BOWERSOX You're right. That's one of the most important parts
of trauma surgery is to take a look at the entire 12 feet
of small intestine to make sure you haven't missed a piece
of shrapnel or a hole in the intestine that could go on to
cause an infection. And that could be readily done by telepresence.
But the most common cause of death after trauma on the battlefield
is bleeding to death. Right now we are going to simulate bleeding
from an arterial wound such as would be encountered by a combat
ALAN ALDA Okay, wait a second. I am going to watch this from the
battlefield. Don't start.
ALAN ALDA (NARRATION) The demonstration ended with a theatrical flourish.
But if this were a real wound, having the experience and skills
of a trauma surgeon right there on the battlefield could have
saved a life. The major funding for telepresence surgery comes
from the military, where it's the key part of an ambitious program
to use communication technology to locate, diagnose and begin
treating casualties within minutes. It would all have made Hawkeye
and the gang from the 4077th green with envy.
ALAN ALDA So, that scene we used to have where the helicopters
would come in where everybody would be laid out on stretchers,
and we would be bending over them figuring out for the first
time what we had, what the injuries are, who gets to go first,
and that kind of thing. That all would be done already, it
would be in the computer as the people were arriving? We would
know exactly what kind of procedure you were headed for?
SATAVA Exactly. You can allocate resources before they come.
If you need expertise, the command and control know what's
going on as well, and they can provide expertise that you
would need. So it's the flow of information and even telesurgery
is information flow. I move my hand, bits and bites travel
down and the knife cuts. And that's why we say we have to
thing of medicine in a different term. It's no longer blood
and guts, but it's bits and bites.
ALAN ALDA Well, I've got a great idea. If you reach the point 50
or 100 years from now, where you don't need a real person
there at all, then don't send a real person out there to get
SATAVA I'm sure they're working on that in other programs.
That is for sure.
ALAN ALDA Well, mention my name.
SATAVA Well, okay great.
ALAN ALDA (NARRATION) Three years ago, we visited Dan Kemp at his
home in suburban Detroit. Six years earlier, he'd been in a
jeep rollover accident. His spinal cord was damaged, leaving
him with no control of his legs, and limited strength in his
upper body. Dan Kemp became involved in an experimental program
aimed at eventually restoring to people with injuries like his
the ability to move their limbs - perhaps even to walk. It was
a remarkable glimpse of 21st century medicine. Dan Kemp was
helped by his daughter Kendra... and his wife and biggest fan,
KEMP We got married after the accident, so that can tell you
a lot about her moral character. She bought the whole package,
not just the outside wrapping. The first thing that I'd like
to do when I finally do stand, would be to stand up, look
in the eyes, and give her a big hug.
MARSOLAIS What I'm trying to get is his gluteus maximus muscle.
ALAN ALDA (NARRATION) Helping him reach that goal is Dr. Byron Marsolais.
ALAN ALDA Now, what you're inserting into the muscle, that's not
the electrode itself?
MARSOLAIS No, no, this is just a little probe.
ALAN ALDA Right
MARSOLAIS A very tiny probe.
ALAN ALDA And the reason you're doing this is to see if you can
get the muscle to react, to give its greatest response?
MARSOLAIS Exactly, and I want just the right muscle, that's
the muscle we want, it goes right down here into the femur.
ALAN ALDA Yeah
MARSOLAIS Exactly, and I want just the right muscle, that's
the muscle we want, it goes right down here into the femur.
ALAN ALDA Yeah
MARSOLAIS Which is the big leg bone, and you see how it's
beginning to jump there, it's beginning to do what we want.
I think I can do better, and in order to do better I have
to get it right beside the nerve.
ALAN ALDA (NARRATION) There's nothing wrong with Dan Kemp's muscles
- it's the nerve-brain connection that's the problem. That's
why he feels no pain during the procedure. Normally fifty muscles
are involved in leg movement. In Dan Kemp's case, sixteen will
be controlled by eight implanted electrodes. If all goes well
he'll get back limited use of his legs.
KEMP If you don't use it, you lose it and you know, it stands
to reason the more I can use, the healthier I'll stay healthy.
ALAN ALDA Now, I think Dr. Marsolais looks like he's found the
ALAN ALDA (NARRATION) Now the permanent electrode, attached to a
wire as thin as a hair, can be implanted. The electrode's not
much bigger than a pin, and it's at the tip of this tube, which
will be removed once the electrode has been placed right at
the point of maximum muscle stimulation.
MARSOLAIS Measure. Now we bring this down to exactly the position
that we were before.
ALAN ALDA (NARRATION) This is an experimental program - so a question
occurred to me...
ALAN ALDA How do you feel when you're going through this? Do you
feel a little bit like a guinea pig?
KEMP Yeah, I do, but it's well worth it. You know, and down
the road, people will be able to look back, and say if it
wasn't for people like me, that they wouldn't have gotten
as far as they've gotten in the new procedures. So it goes
down the line.
ALAN ALDA Yeah.
KEMP Everybody helps everybody else, whether they realize
it or not. Okay.
KEMP Okay. Hit the "G" button.
ALAN ALDA (NARRATION) Back home, Dan and Kendra began his daily routine,
using a computer to control the impulses which stimulate his
KEMP Okay. You ready?
KEMP Go! Here they go.
Here they go.
KEMP Thank you very much.
ALAN ALDA (NARRATION) An essential part of the system being developed
by Dr. Marsolais and his team is exercise - and that's what's
happening here. Right now the control box is automatically working
Dan's quad muscle group, at the front of the thigh. It's fortunate
they've been able to turn it into a game, because Dan has to
do this for a minimum of an hour every day. Once a week, Dan
returns to the Cleveland VA Hospital, where the research is
based, for a session with the team's physical therapist, Paul
Miller. Eventually, the control box will transmit its signals
directly through the skin. So these external connectors - difficult
to maintain and keep clean - won't be necessary. The joystick
controller is designed to be used by patients with very limited
strength. Here Paul selects an exercise program, then records
the muscle power and endurance. Five months earlier Dan could
do this for just seconds at a time - now he can keep going for
an hour or more. He's almost at the point where he can attempt
a real task, like standing up.
MILLER When you're stimulating a muscle or contracting a muscle
that hasn't been used in five, ten years, it's like starting
all over again, like a little baby. So, we have to build the
strength so that they have enough strength to do a functional
KEMP Sitting around after six years of not doing anything
and seeing your legs start moving, and feeling the fatigue
after a while, it gets you back into a normal pattern of life.
It's a great feeling, it really is.
ALAN ALDA (NARRATION) We'll come back to Dan in a moment. First,
meet Eric Bellamy. A motorcycle accident five years ago left
him paralyzed from the waist down. He's one of six people using
the largest implant system, with over 50 electrodes now in place.
Eric's a kind of pioneer.
BELLAMY You can't count life out 'til you go out there and
try it. And swimming is something to try, all sports is something
to try, anything that gets you in better shape physically
and mentally. Life's still out there.
ALAN ALDA (NARRATION) Life is still out there - but the problem is
getting at it. Access has improved in recent years, but for
Eric a small increase in mobility would make all the difference.
BELLAMY I see being in a chair always, but I see being able
to go up steps, and knock on the front door, and say, hey,
you know, I'm down here. Instead of running around the house,
and screaming you know telling the guy, hey I'm here, I'm
here. I see, even convenience stores, one step you know. So
being able to get up and go through this narrow door to get
into the bathroom. Just for them answers. If they can come
up with that right there, just, your life's in a chair, but
being able to overcome difficulties would be a tremendous
step. And that's what we're working on right now.
ALAN ALDA (NARRATION) On the outside, Eric's system looks like Dan's.
But on the inside it's much more complicated - both within the
control box, which right now is programmed to handle 41 of the
fifty implanted electrodes, and within Eric's body, where a
network of wires runs under the skin from above the waist to
below the knees. Why so complicated? Because Eric's system is
designed for walking. The first thing to do: Eric selects "stand"
and "walk" from the controller's menu of programs. Then he'll
hit the "go" button.
MILLER Okay. go ahead and stand up.
ALAN ALDA (NARRATION) The controller goes into its pre-programmed
walking cycle, putting out about a hundred muscle commands for
every pair of steps. Remember, Eric has no natural lower body
control at all. This is completely synthetic movement. But he
is using his upper body strength to balance - and as with all
these research patients, his muscles have to work immensely
MILLER They're using tremendous amounts of muscle mass. Their
quadriceps are on 100%, their gluteal muscles are on 100%,
their hamstring muscles are on 100%, their back muscles, everything
is just blasted.
BELLAMY Whenever they do something, their using 100% of all
their strength. Whether it's one step, two steps, they're
using everything they got. Like when you stand, everything
goes right into it. 100% bam! Total exertion, you know. Everything
ALAN ALDA (NARRATION) Now for the other key function - stairs. Today
will be the first time Eric has faced a commonly found design.
Eric can maneuver past the lips on the steps only by using his
tremendous upper body strength. It's an example of the biggest
challenge facing the research team - the control system has
to be able to adapt to a changing world. The aim is to add sensors
to the feet and legs which can feed information back to the
control box. Then part of the enormous burden of concentration
and effort, which so far falls on the user, can be transferred
to the computer control.
DRIVER You guys ready to go?
ALAN ALDA (NARRATION) Eric has a personal challenge: to reach these
seats unaided. Today, he's going to try for this simple goal
- for the first time. Success will bring the world at large
a few crucial steps closer - to Eric and the others who'll eventually
benefit from this research. Things don't look good. For some
reason, Eric's left knee is not locking up. Eric and Rudi Kovetic,
who programs the computer controllers, run through the muscle
BELLAMY Up left?
KOVETIC Looks like he's got enough power in that left leg,
but it doesn't seem to bring him up.
BELLAMY Could be fatigue.
KOVETIC Yeah, but it looks like you have a lot of strength
in that left leg.
ALAN ALDA (NARRATION) They decide to try again. This time it works.
They don't know why, but artificially stimulated muscles often
seem to change in strength. Now, it's back to the "walk" program.
MILLER You have to pivot back a little bit more.
BELLAMY I said I'm going to sit down Rudi.
MILLER Good job Eric.
ALAN ALDA (NARRATION) We're back with Dan Kemp, and today's the day
he'll face his personal challenge - to stand... and to hug his
MILLER You ready?
KEMP I'm ready
MILLER Okay. One...Two...Three... Alright! How's it feel Dan
KEMP Oh, it feels vertical
KOVETIC You getting dizzy?
KEMP C'mere. No I'm fine.
Are you sure?
KEMP C'mere. Gimme a hug. It's great!
Long time since I've seen you that tall.
ALAN ALDA (NARRATION) Dan, like Eric, was a pioneer - of a technology
that in the 21st century could change the lives of thousands.
KEMP That's the best feeling I've had in a long time.
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