Transcriber: Marine Gallois Reviewer: Elisabeth Buffard
I should start the talk by basically saying straight up
that I'm no professional in this field.
Most people will also say that
they're no professional in the same field.
I have no MD, I have no PhD.
I'm here solely as someone who has done some work
for a few years in a pretty exciting area,
and I want to talk to you about a few of the things that I've come up with,
that has sort of touched me as something that's very interesting,
and as something that could take off and be something wonderful.
So what I'll present here are a few assertions,
and then I'll go at the end and ask you a question.
These assertions aren't fact.
Few people who will say things that are all encompassing like this
are really trying to tell you fact, those who say they are are wrong.
But instead, they'll make you think. You'll agree, you'll disagree.
In reality, that's what makes great research,
and that's what makes great medicine.
My first assertion is that our ability to cure or manage disease,
is purely limited by our ability to diagnose it.
What that means is, you can't fix what you don't know is wrong.
I could drive my car down the street today,
and I can have a hole in my muffler.
If I'm able to drive down the street, it doesn't make a weird noise,
it doesn't do anything wrong,
then as far as I'm concerned, my car is fine
and therefore there's no hole.
But in reality, come a few weeks down the line,
the hole's going to get big enough
that I'm going to start hearing a weird sound,
and pay a lot more than I would have had I gotten it fixed earlier.
So therefore, my position is that if we are able to diagnose disease,
and diagnose disease early in its progression,
we are therefore more effectively able to cure it.
So what's diagnosis ?
This thing should be pretty much recognizable to everyone.
In 2016, it's going to have its 200th birthday,
and that's rather exciting I think.
This is a stethoscope. This is a means of diagnosis.
You put it on your own heart, and you say :
"Ha ha, I can heart that, that's pretty cool !"
You put it on someone else's heart, and you may get a bit worried
about what you're hearing, because if it's not like yours,
then you start wondering what's going on.
But that's going on, and it's still used everyday
just like it had been 200 years ago.
This is an ECG.
Same type of idea, leads put on your heart.
This is used in every type of diagnostic exam for cardiac.
It is part of our ACLS protocol,
that states that we must know what your rhythm looks like before we can handle it.
It is used pretty much in every field in internal medicine and surgery,
as a means of either a preoperative workup or a continuing followup.
Pulse oxymeter. Every EMT in the room should know how to use this at this point,
and that tells us something important,
because not every patient who is breathing in a way that we notice it,
is necessarily breathing well.
Therefore it's important to know what exactly is going through their blood.
Finally here are just our basic lab test tubes,
a means of diagnosis no different really than a stethoscope,
it's just a bit of a different way of taking it.
And this is where we're going to : the age of personalized medicine.
The notion that now, we are going to be able to take
what's been a generic form of diagnosis, like the stethoscope,
and personalize it to your individual genetics, your individual DNA.
This is both exciting and scary to a lot of people,
because if we can personalize your diagnosis,
personalize your management medicine,
what does that mean ? Now I can personalize my kids ?
I like blue eyes, I want blue eyes for my kids.
So, what are we going up to now ?
For all of you who are giant nerds in the audience like me,
I was a big trekkie, and I love this idea.
This is the Qualcomm X Prize, announced in 2012.
The idea that if you are able to create a Star Trek Tricorder,
something that can diagnose 13 different diseases in 3 different patients,
then you're able to do that in a non-invasive fashion,
then you get 10 million dollars.
There are institutions, San Diego State, major companies...
there are huge grants going around
purely to try to get the money from this Prize.
I think that's really exciting, and there're some people saying
that in the next year, we're going to see something cool.
Here's my second assertion.
Now that we've talked about our first one, I've tried to make my case.
I'm going to make a second one.
And that's purely within the field of surgery :
our outcomes are based upon the detection of blood flow.
Not just our outcomes, but our complications.
They don't just depend on blood flow, they depend most on blood flow.
What do I mean by that ?
It's a pretty bold statement to make.
If we are to look at blood flow, look at this type of patient.
This is a burn. This is not just a burn like when you touch a hot stove
and get a blister for a couple of days.
This is a deep deep burn.
This is another burn.
It's a guy who has his face pretty badly scarred up by an injury.
This is what a burned patient can look like weeks later
if not properly diagnosed and managed.
Burns are notoriously difficult to manage in the emergency department.
That's mostly because of two major issues that you're faced with.
First, there are a lot of burned patients.
And burns don't all come in the same shape and size.
I can show you two burned patients with the exact same burned area,
and their mode of management is phenomenally different.
But also because we are not worried about management of the initial burn injury.
In fact, the FDA isn't even really worried about
the management of the initial burn injury.
They're worried about what happens afterwards : our scarring.
We get a scar on our hand, you know,
"I got a bad paper cut and I got a tiny little scar."
We say : "Ok, that's okay. This guy's face is going to look like that forever."
You're an employer, a parent, a child, someone walking past you in the street,
you are never seen in the same way again, hired in the same way again,
managed in any way, in the same way because of your scar.
So I'm going to tell you about a few facts.
First of all, the number one leading cause of time missed from work
is and has been burns for since we've been alive.
450,000 burn injuries this year.
26,000 admissions to 125 burn units in the year 2011.
That's 2011 because there's a bit of delay in terms of getting data,
but this number is going up.
We have a burn unit on campus that does quite well as well.
Finally, the admissions average : 9.7 days.
Over a week in a burn unit !
In a hospital, a long stay is considered three days.
Now we're here for over a week.
They're going to cost 83,000 dollars, and that's just the average.
Patients with not as bad wounds don't usually cost this much.
Patients who will die because of their burn injuries
cost hundreds upon hundreds of thousands of dollars to manage.
So what is a burn ?
I'm talking about this pretty abstractly, let's talk about what burns are.
Your typical first degree burn, is if you go to the beach.
You have a great time at the beach, you get a little bit of a sunburn,
you turn red, you can't sleep on your right shoulder at night,
it ruins your vacation but it doesn't really ruin your life.
Second degree burn is your partial thickness burn.
The damage has gone into your dermis, below that superficial layer of skin.
That's if you ever gotten a really bad blistering sunburn.
That's your second degree burn.
Finally, a full thickness : you burn through your entire skin.
You might see bone, you might see muscle,
this is now a terrible injury.
The problem is, partial thickness, this second degree burn,
can progress to a third degree burn
if you don't treat it rapidly enough or properly enough.
That means that something that's not all that bad
- a blistering sunburn hasn't killed anyone yet,
the full thickness burn is really what you worry about more.
That's why diagnosis is so important.
I will make another assertion.
This one is grounded on basic fact :
much of the time a patient spends in a burn unit
is solely related to the decision of the surgeon
on whether to operate a full thickness burn, which needs grafting,
versus a second degree burn, which may just require a conservative therapy.
I'm not the first one to come up with the idea of using
some sort of detection apparatus to diagnose burns better.
It's been identified that 66% of burn injuries are diagnosed properly.
That means that 1 out of every 3 patients that walks through a burn unit,
is going to have either too much or too little surgery,
in both cases it equals to too much scarring.
Doctor Pape, about 10 years ago, came out with the use
of this Laser Doppler instrument.
This instrument has been around for a long time.
It looks at visible red light, reflecting off a flow in red blow cells
to give you a measurement point.
They wanted to see if you could use this on burns,
if it could tell you where to cut.
This is the Doppler machine.
It's this big bulky thing, it has a scanner up top,
hooked up to a computer, it gives you a nice wired image.
But it's a scanner, so you got to have your hand
completely stationery underneath it while looking at it.
This is the picture that you get.
Red is good profusion, blue is bad profusion.
You can tell that it usually highlights
the poor areas of the damaged areas pretty well.
Now there are some basic drawbacks to this technology though.
The first one I've already said :
you have to keep a burned patient's hand
completely stationary under the machine to get a good reading.
They've adapted to rapid acquisition devices,
and now it's really gone to depth of penetration that's a second long.
The signal for a visible red light goes barely a millimeter below your skin.
Do you think that's enough to see a burn
that's going to go many multiple millimetres down ?
Not really.
Finally, it's the pure bulk of having this apparatus in your burn unit
that makes it very difficult.
There's an expense factor, there's an operation factor,
there's a purely experience-based tactic, not much different than ultrasound.
That makes whatever readings you get from this machine, not quantitative
- and by that, I mean that your temperature is quantitative,
but qualitative - and by that, I mean :
you see red, therefore Cut, you see blue, therefore Don't.
That's simply not good enough when talking about something
that impacts a patient's life so much.
This is a device that I've been working on for a couple of years now,
and this is certainly not the only one that exists.
There've been dozens of different apparatuses produced like this.
This is based around the molecule indocyanine green.
Indocyanine green is a fluorescent marker.
It's the only one approved by the FDA.
Its only approval use is for use in coronary artery bypass grafting.
If you complete a graft and inject a dye,
it lights up and that tells you that's a good one.
But right now, we're saying :
this dye that can be injected through a basic catheter,
is no different to giving a patient IV fluids.
What else can we see with it ? How deep can it go ?
What's even more exciting about this,
is that with that dye that's coursing through your body,
we can acquire real-time with a moving apparatus instead of doing a scanning.
That means I can wave at you, and you'll get a reading from it.
I don't recommend you do that, if we actually take a scan, it's not great.
But you get the idea of what I'm trying to get across.
So what do we do to test it ?
This is a burn.
This is not a burn on a human, this is a burn on a pig.
Why do we use pigs in research ?
A lot of people say animal research is bad,
I'm not necessarily going to disagree
that there's research that is painful to animals on occasion,
but the reason why we use pigs,
is because pig skin is more similar to our own.
Therefore, if a model with a pig works,
then it is more likely to work on a human
than if we were to use another animal model.
This is a 2.5 by 2.5 centimeter wound.
That's an evaluative model. If I have that stamp,
I know exactly how deep this burn goes.
We've used both forms of energy.
We've used indocyanine green, which is on the bottom,
and we've used the Laser Doppler on the top.
What should be most exciting to you by this image
is not just that you're looking at a bunch of red and blue squares,
because I wouldn't even know what I'm looking at if I actually saw that.
But the images look exactly the same.
The pixels of the Doppler look exactly like the pixels of the ICG,
except the ICG was acquired in 30 seconds. The Doppler scan took 8 minutes.
Now we used a bit of an older Doppler, it has gone a little faster,
but 30 seconds is pretty good,
and 30 seconds has given us spectacularly stronger data
as our group has published for quite a while now,
which is very exciting for us.
So I'm going to go to assertion number 3.
Because if you think about this dye going through your body,
we've just talked about burns,
well what else can we use with this ? What else makes this so cool ?
The answer is : this is, in my mind, a game-changer in medicine.
Real-time perfusion analysis and real-time perfusion acquisition
is a change that we have not seen before,
that will change the way surgical diagnostics work,
and hopefully basic medical diagnostics in this manner or in different ones.
What do I mean ?
This is a video here of a route model.
We have included the top side, that's going to show us some stasis.
We basically knocked out the vascular outflow on one side,
and let it go free on the other.
Using this movie, we can measure what happens
when an organ loses the blood flow not into the organ
- you can tell that pretty quickly in most cases,
but out of the organ, which often takes hours to manifest.
This is in skin, this can be with any type of flap surgery,
it's a wide application in both orthopaedics and plastic surgery.
In this video, we get significant differences within 30 seconds of starting this device,
of saying : this is your inflow and outflow,
therefore if it stays high for a long time, you're probably ok.
If it starts low and then builds itself back up,
there's a problem and you need to operate.
This has been a problem that mentors of mine over at Stony Brook
would be out of the O.R., driving back home,
and they'd need to get called back in, because hours after their surgery,
something looked like it was going wrong in their surgery.
This is another one, this is a piece of skin
that we've isolated from blood flow in a rat.
This big rectangle is only getting blood flow
from the area that has red in the base.
The blue is showing where the blood flow isn't going.
What we do with this, is that it's a standardized model
not just to analyze how skin dies and whether we can measure how skin dies,
but it's also meant to test different pharmaceuticals,
in order to see whether we can salvage skin better.
This applies mostly to patients that we've looked at with breast cancer,
who need breast reconstructions.
This type of compromise of skin during the breast reconstruction
can occur in up to 40% of patients.
That is a humongous stress to a patient that's already had cancer.
That's very difficult to tell them :
"There is a bit of dying skin, we have to cut again."
And sure enough, we can measure not just with Laser Doppler on your right,
but with the SPY machine, and with the clinical analysis.
So you should ask yourself now what can we really do going forward with this,
what others things can we do,
because I've just talked about skin for the most part.
The answer is, there are multiple papers that show you can track
sentinel lymph nodes without radioactive tracers.
You don't need to use a radioactive dye anymore,
in order to find the sentinel lymph node in a breast cancer patient.
I should describe what that is : when you have a breast cancer patient,
you need to know whether the cancer is spreading.
To cut all of the nodes out of your axilla, which is where your lymph nodes are
- it's where the cancer is most likely to spread,
what happens is the arm of the patient on that side will blow up,
because there is no outflow of lymph - which is the fluid that bathes our body.
By doing this, we only cut the very first lymph node
that comes out of the breast.
By cutting that one, if there is no cancer in it,
we have very good data to show that we don't need to do it anymore.
This is widely done not just for breast cancer,
but for melanoma, gastric cancer,
testicular cancer… multiple forms are being managed in this manner.
And they're all being used with technetium-99 dye,
which is a radioactive tracer and a Geiger counter.
It's a pretty crude management, but we've gotten really good at it.
But if we can use it non-radioactively, surely that's a better solution.
We can do wound modeling.
We can no longer look straight at something and say, "Well, that looks bad."
Because, I can do that a lot, I can walk through a burn unit,
look at someone's face and say, "Well, that looks bad."
But now we can model it, and we can say quantitatively
exactly what's wrong, what we cut, how we cut.
Finally, we're going to look at skin survival within minutes of surgery,
just in the same manner as we've looked at,
but not just in the breast flaps from a reconstructive patient,
but with patients with large-scale wounds that need reconstruction,
abdominal reconstructions, any type of soft tissue compromised from fractures.
Finally, we believe that this is a way to test and validate
the use of new and novel pharmaceuticals against cancer and disease.
Because what we found and what other publishers have found,
is that you can bind antibodies to this dye.
Therefore I can make your tumor light up.
And I can make nothing but your tumor light up.
I have a final assertion, which is that we've only just begun.
We've talked about a lot of concepts and applications for this new device,
this new fluorescent dye.
This dye has been around for quite a while,
it's just new ways of using it.
And I do believe that whether it be through this methodology
or through others, we are about to enter a new diagnostic golden age.
From that diagnostic golden age, we will then enter a management golden age.
Because if my first assertion is correct : one must happen before the other.
So we've talked about these applications already,
and then we're going to keep on moving forward.
Ultimately, what's our goal ?
Better health, longer life, happier life.
(Applause)
Thank you.