(lines whooshing) (light upbeat music) - Welcome to "At Issue."

I'm H. Wayne Wilson.

And thank you as always for joining us on the program.

It's no surprise to know that there have been many, many medical advances over recent years.

It's a constant move forward.

And especially here in central Illinois, where, with the Jump Trading Center, the Jump Trading Innovation and Simulation Center, a lot of innovation coming out of that organization.

Today, we're going to look at three improvements in medical care.

That's just the tip of the iceberg, but we're going to look at three of them to give you an idea of the progress we're making in providing services to patients.

And we're going to hear from Debbie Trau.

Debbie is OSF Saint Francis Medical Center emergency services nursing director.

Thank you for being with us.

- Thank you.

- Also with us is Tate Ralph.

Tate is the OSF Innovation Simulation engineer, One of several, I think.

- Right.

- And also with us Dr. William Bond.

Dr.

Bond is the University of Illinois College of Medicine at Peoria professor of clinical emergency medicine and a staff physician at OSF HealthCare.

- Thank you for having me.

- And let's start with you, Debbie.

I think most people are familiar with an IV drip, syringes, methods of getting fluid into a body.

That's useful in most cases.

However, when someone has very low blood pressure, is in shock, they need fluids more quickly.

And in conjunction with an organization called 410 Medical, OSF has piloted a new method.

Could you explain verbally, we're going to see this in just a moment, but could you explain verbally what this is?

- Absolutely, it resembles much like a small squirt gun that you had when you were a child.

The trigger on that allows us to administer fluids so rapidly that in contrast to, by gravity, I can take this gun and start squeezing it and administer up to a liter of fluid into a patient in less than five minutes.

That's about 10 times faster than any pump can do currently.

It's quick.

It's easy to use.

It is one-handed.

It started with our patients, particularly in the pediatric area.

Those patients can get sick very quickly and need some volume.

And the IV access, the size of the catheter, which I'll show you in a bit, can be very small.

And the ability to give fluids through that is constricted just by the diameter of the tubing.

So in order to give fluids, we have to have some pressure behind it.

And that is what this is able to provide to our patients.

Here's an example.

So which of these straws do you feel like it would be easiest to drink from?

of course, the one on the right, the white, right?

- The white one.

- The IVs that we put in are much smaller than the red one to give you an idea of concept.

So if I can get some pressure behind the fluids that I'm administering, I can get fluid and volume to the tissues.

Tissues need perfusion and they need to have volume to get perfused.

So that helps prevent any organ damage, or at least quicker reversal of any progression of the lack of tissue perfusion that's occurred.

- And explain tissue perfusion for all of us.

- So the blood carries oxygen to our tissues, and when I'm in shock or have low blood pressure, my volume, or our circulatory system basically collapses, that's why it's difficult to get an IV in or administer fluids.

By giving those fluids in a rapid fashion, I'm opening up the circulatory system by which blood can travel to those organs and give the oxygen rich nutrients to that tissue.

- So the theory is that you can save organs from failure?

- Yes, yes.

It's really vital when a patient presents, when we get IV access, to be able to administer that quickly.

Whether it's a pediatric patient, an adult patient, an obstetric patient, it's really important that we give that fluid.

So our initial pilot was with IV fluids in pediatric patients.

We then advanced it to adult patient situations or scenarios, and then worked with 410 Medical to look at blood product administration.

It has been spread across our entire ministry as a tool to be used in the emergency departments for pediatric and adult patients, as well as for crisis teams responding to patients that are critical in the hospital.

Just recently, we've expanded that to our EMS agencies in a pilot.

Because when we think about our pre-hospital EMTs, they're getting to our patients.

Whether they're in shock because of lack of volume, dehydration that's so severe, or sepsis, it's really important that they're able to administer that volume.

And this LifeFlow tool has a trigger that I can use one hand to do that and use another hand to hold pressure on maybe a site that's bleeding.

But it really does administer fast the fluids that I need to resuscitate the patient.

- So an EMT coming in with a patient in an ambulance could be using this in the future, which would be critical in getting those fluids into the body prior to arrival at the emergency room.

- Correct, the administration of fluids would enable us to take a patient who maybe has a very small bore IV and increase the size once I've gotten some volume back into that patient.

And that allows us, again, to further resuscitate that patient.

- Is this the usual procedure where you work?

Because 410 Medical is not part of the OSF system, but you have invested in it.

- Correct, through OSF Ventures.

It was a company that we felt had benefits to our patients.

And really, at OSF HealthCare, every decision is based on putting the patient at the center of our decisions.

And that was evident.

We saw what they had to offer.

We worked side by side with the vendor to improve it and to look at ways that we could expand that.

And we believe in it so much that it was invested by OSF Ventures.

It brings so much value as a nurse.

I've had almost 40 years at the bedside, and to be able to speak to the vendor and tell 'em what I need a product to do and have them listen and adapt so that I can improve patient care, that's rewarding because all of us are here to help save that patient.

- And bottom line, what results have you seen?

I mean, you've had this for a short period of time.

- Correct.

We started just pre-pandemic, so November and December of 2019.

And we have seen the ability to administer blood and fluids in a very rapid fashion and resuscitation occurring in some of those patients.

Without a doubt, we know we volume resuscitated the patients.

There may be medical reasons that we cannot save their lives, but we know without a doubt that we've gotten the fluids in that they need.

- You talked about the ability to work with 410 Medical.

I wanna transfer that over to a discussion with Tate Ralph, because, before the taping, we were talking about the importance of working together.

In this particular case, it's at the Jump Trading Simulation and Education Center where the process that we're going to talk about is not new.

The training is new.

Before we get into the video and before we talk about what the training is, what is this process for certain types of cancers to be taken care of?

- Sure, so I think a good way to think about it, with radiation therapy.

And so, traditionally, when you hear of radiation therapy, you're likely talking about external radiation where they're irradiating certain tissues from a source outside of the body.

Brachytherapy or brachytherapy, depending on who you're talking to, is a way of doing that internally.

So instead of going through tissues, we're going right to the source of the problem and then putting radiation there and controlling it very tightly.

The problem with that is it requires some complex surgical skills.

And whether people are doing it currently in hospitals and can train other people isn't always a given.

And so the idea of kind of what we're going for is creating a device to train those skills that doesn't require an actual patient to work on and can be repeated and shipped somewhere else so that you can work on something like that without necessarily having the infrastructure in place.

- Before we see the video, explain to me, and we're gonna see Dr. James McGee, but explain to me how you worked together to make sure that this model that you put together actually represents the human body so that the physician can train before ever performing brachytherapy.

- So I'm lucky to have gotten into a field where a lot of these tissues have been characterized already, right?

The human body is pretty well known.

We can take tissues like silicone rubbers, ballistic gels, and we know their characteristics too, so it's just a matter of matching them together.

So my process is talking with the physicians, going through a design kind of structuring, developing what exactly I'm gonna do.

And then we put together a model, a prototype, and then we take it to that physician, let them work with it.

And we go through kind of a talking about what's good, what's bad, a feedback process.

And then we iterate on the design and make a new one.

I've got a whole shelf full of old designs that we tried and failed, and now we have the good one.

- Well, let's look at the good one.

Dr. James McGee of OSF HealthCare will demonstrate the training of brachytherapy.

- And in preparation for their treatment, we've created models that represent their normal anatomy and the anatomy of their cancer.

Usually, this is after initial treatment with chemotherapy and radiation, probably for about five weeks.

But then we have to essentially double the dose that's already been given.

And at that point we've largely used up the normal tissue tolerances of structures like bladder and rectum and small bowel.

So a very sophisticated analysis then is able to be done to treat the area that, on this model, we've indicated in the cervix with some graphite pigment.

And the reason we use that pigment and that graphite is that the only way we're gonna see this anatomy as a clinician in the operating room is with transrectal ultrasound.

So we've developed trainers which are able to be used with transrectal ultrasound probes that are placed in the corresponding location on this model in order to deliver applicators through the vagina and the surrounding perineal tissues to really give a perfect dose distribution into this area.

We're helped by many different types of applicators that are available to us.

And we're also going to use a lot of this technology to start to develop applicators that are custom-made for the individual patient.

This applicator, this trainer was made by 3D printing.

So we took the patient's MRI scan and created a 3D model, and then, using different materials, printed a representation of the patient's anatomy, which we have in this Lucite box.

That is really helpful when you're going to the operating room.

And remember, you can't see anything except what you see with transrectal ultrasound when you're actually there.

You can do a vaginal examination, you can do a rectal examination.

You can palpate this cancer up here in the cervix, but you can't see it, at least only down in the vagina.

So with transrectal ultrasound, we get a good representation, but you can imagine why people feel uncomfortable if they're not experienced in doing this.

You know, first of all, you're often working with a complex set of devices to try to get things just in the right area for that patient.

And then the radiation source has to travel in there.

You have to figure out how to have that source move.

That source can go, for example, through a needle.

And it would be hooked up, come on a three-foot long connecting cable from a machine that houses one single, very radioactive source of iridium, 192-iridium, four millimeters in length, one millimeter in diameter, small enough to fit down in the needle.

And that source then would travel in the cable down into the end of the needle.

And then it could work its way back at five millimeter steps spending varying amounts of time as it went along.

So at the end of the needle, you might wanna push dose out a little bit to the cover the top of the cervix.

Well, it can stay there for, let's say 10.8 seconds.

And then it might move down and get close to a critical structure and just skip that, move on down.

But it might be going 10.8, 6.1, 4.2, varying times with a granularity of tenths of seconds to essentially work with any other applicators that we're putting in, which I'll demonstrate in a minute, to deliver a radiation dose in an ideal setting, in an ideal fashion, to the cancer as it's defined from MRI scans and represented here in a 3D model.

So when you think about the complexity of doing all that, it gets to be very daunting for a lot of people who haven't had the opportunity to do fellowships and so forth in just brachytherapy.

So typically, one example would be this type of an applicator, which has a cylinder in the vagina that has channels for the needles to pass in here in combination with a template on the perineum that has the ability to have needles passed into each of those little holes with a Foley catheter in the center.

And so the idea clinically is to create a situation where we're able to have the doctor emulate placing that applicator up against the cervix with the perineal template.

You might wanna put some needles into the walls of that cylinder.

And that would give a good approach then to the cervix.

In certain instances, we might have all of those needles around the applicator giving dose, and in other situations that may not be by itself quite enough.

And so we may have another, what we call a tandem that goes in the center.

And a lot of times, these can go up into the uterus itself.

And in addition, if there's cancer, as often happens with cervical cancer, growing off the side, then we can take advantage of these holes on the side.

Pass that needle, and then that can go outside of the cervix and go up into the other tissues alongside of it.

And here you can kind of see on the side, you can perhaps can see this needle as it's outside the vagina.

And we can emulate putting that up against the cervix.

So it's a very complex system.

Sometimes multiple, multiple needles are used in concert with this.

And again, the only thing we can see is with a transrectal ultrasound in the rectum.

But at the end of the procedure, the goal is to have needles, intracavitary applicators, cylinders in the vagina in order to provide access for that one radiation source to be able to move to all parts of this cancer, and under our direction, so to speak, spend varying tens of seconds at all those locations it can reach in order to create an ideal dose pattern that does not give much dose to the rectum, does not give much dose to the bladder, eliminates dose to the small bowel, and doubles the dose effect over what has been already given with external beam radiation.

- See the importance of the procedure brachytherapy, but we want the physicians to be trained properly before they ever perform brachytherapy.

As you develop this, this is used at OSF HealthCare's medical centers, is the intention to share this with other medical systems?

- Yes, eventually, we wanna prove that it's effective and valid for the procedure.

And we have research in place set up to go through that process.

But, eventually, the goal is to share it with other centers so that we can share the ability to do this procedure with other places as well.

- And are you working on models for other types of cancer where you would have brachytherapy?

- Yes, absolutely.

So cervical cancer is obviously important.

There are other gynecological cancers, but this can be extended to the prostate cancers, to skin cancers, and pretty much anywhere where you would want to have very controlled radiation dosage and spare some tissues.

- So more work in front of you for designing the training models.

Let me turn to Dr. William Bond.

Dr.

Bond has been working on, dare I say, artificial intelligence.

(both laughing) And I don't want people to say, "He's doing what?"

Explain to me and to our viewers the process of a student at a medical school is presented with a simulated patient.

They write notes.

Sometimes it takes a long time for the faculty member to get to those notes.

Your goal is to shorten that timeframe.

How are you doing that?

- Right, so as part of the learning process in becoming a physician or a nurse practitioner, we have to learn to write notes about the patient encounter.

So it's a very important thing, because I need to document what happened in our visit today.

And that documentation might help another specialist understand what happened at that visit.

And nowadays, it also leads to information for the patient as well.

But to learn that, we have to give them feedback.

And right now, the process is they would come to the Simulation Center, interact with a patient actor, take a history, do a physical, describe their differential diagnosis, the list of diagnostic possibilities in their note, and justifications for why they think that's the diagnosis.

Now, it may take the faculty weeks to grade that information in a written note.

And so, as you can imagine, do I remember a case that I saw two weeks ago, the details of what the case was about, and did I do this or ask that, you know, perform that physical examination maneuver?

We may not remember.

And so any feedback that's delayed in that nature is not near as good as feedback that could be given the same day.

And so our goal is to really have them click Submit and have their note go into an automated system that will give them more immediate feedback.

- So this is a form of artificial intelligence where a machine is actually interpreting the student's notes to make it easier for the faculty member to give feedback?

- Right, so what remains to be seen, for now, the faculty are teaching the machine how to grade the note.

And I anticipate there will always need to be some of that, that the faculty will have to train it to see some of the subtleties by grading a few notes as a training process.

So we're looking at data sets of other notes that help train the machine on how to grade.

And that combined with the faculty grading lets the machine know, "Aha, I see that the learner asked about how long the chest pain lasted and they documented that in their note and I can say, yes, they asked that question."

- So this gives a faculty member more insight into the thoroughness of the student's notes.

And if there was a deficiency in keeping the notes, like you said, the immediate feedback will improve that.

- Right, right.

So it basically does speak to their thoroughness and history gathering and doing a physical examination.

So it gives them feedback on things we saw in the note and did not see in the note.

The evolution of expertise is a tricky thing.

And so as you become more expert in clinical medicine, you may ask fewer questions and get to the right answer.

That's part of becoming a seasoned clinician.

And so we hope to someday see the evolution where we might be able to tell the difference between, "Aha, the machine says that's a resident note, that's a student note, that's an attending note."

It may be able to see the maturity and see that.

For now, it's at a much more basic level.

- So patient care is the bottom line here.

- Correct, so in the evolution of note writing, they get very little feedback.

So if we're in the clinic with patients, we're very rushed and we don't have a lot of time to give feedback to the students.

Or in the ER where I work, not much time to give feedback on their notes.

And in the simulated environment, we have a delayed problem where the feedback is delayed.

So this gives them more and more specific feedback and more timely feedback.

And that's really the important thing in the development of them as clinicians.

And again, the open notes happened very quietly during the pandemic that patients now have access to the notes.

Like as we were talking about earlier, I can pull up my phone and see my recent wellness visit with my nurse practitioner and I can see what happened at that visit.

And so, more and more, the communication to the patient on, "Oh, what was my shared decision making?

What is my plan of care?"

they're gonna be able to access their note and see that.

And so it's helpful for us to be able to write that in a way that is patient friendly.

And so we hope to, at some point, give feedback on the patient friendliness of the note.

- Much as Tate discussed working with various individuals in various departments in order to develop the training module, you have been working with other organizations as well to develop this.

- Yes, thank you for mentioning that.

I have to thank my lead co-investigator, Professor Suma Bhat at the University of Illinois Urbana-Champaign.

She and I were connected through a Jump ARCHES grant.

So that was the initial funding source that began the engineer, Suma, and myself as a clinician, that collaborative relationship.

She had some wonderfully talented grad students at UIUC.

We're also now collaborating through a similar fund grant of the National Board of Medical Examiners with the University of Illinois College of Medicine at Chicago with Dr. Rachel Yudkowsky taking the lead up there.

And so our hope is to spread this innovation beyond the University of Illinois College of Medicine at Peoria where our patients are now some of the first in the country to pilot test this feedback.

- And if it pans out the way you think, across the country?

- That's our hope, yes.

Over the long term, absolutely.

- And hope is a critical word for all three of the advances in medicine.

And we wanna say thank you to Tate Ralph.

Tate is, he's a simulation engineer at Jump Trading Simulation Education Center.

And thank you to Dr. William Bond- - Thank you.

- And to Debbie Trau- - Thank you.

- For sharing the advancements in medicine.

- Thank you very much.

- And we'll be back next time with more discussion on the very next "At Issue."

Thank you so much for joining us.

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