RSNA News - December 2004

Underwater Medical Mission Uses Radiology Telementoring

We want to be able to deliver the highest quality diagnostic and surgical care to remote areas of the world as well as in space.
—Julian Dobranowski, M.D.

Recently, a Canadian radiologist successfully drained a patient's abscess. Sound routine? Maybe, but in this case, the patient was hundreds of miles away lying 19 meters beneath the surface of the waters off Key Largo, Fla.

It was all in a days work for Julian Dobranowski, M.D., and the crew of NEEMO 7, otherwise known as the National Aeronautics and Space Administration (NASA) Extreme Environment Mission Operation.

The goal of this joint venture by NASA, the Canadian Space Agency (CSA) and the Centre for Minimal Access Surgery (CMAS), a surgical center affiliated with McMaster University that develops techniques to be used in remote medical care, was to test and evaluate the latest in remote medical diagnostic and therapeutic technologies.

"We want to be able to deliver the highest quality diagnostic and surgical care to remote areas of the world as well as in space," says Dr. Dobranowski, chief of the Department of Diagnostic Imaging and medical director of the Imaging Research Centre at St. Joseph's Healthcare in Hamilton, Ontario.

Julian Dobranowski, M.D., in the telerobotics lab at St. Joseph's Healthcare in Hamilton, Ontario.

Photo courtesy of NEEMO 7

More photos

The Crew

The crew for the 10-day October mission was split into two teams—a land-based team and the underwater team.

St. Joseph's Healthcare was the base for the land crew. The team comprised a number of experts including Dr. Dobranowski, NASA astronaut Bill Todd, who was the mission director, and Mehran Anvari, M.D., CMAS founder and director. Dr. Anvari is world renowned for having performed the very first hospital-to-hospital remote surgery in 2003.

The underwater crew included mission commander and CSA astronaut Bob Thirsk, M.D., NASA astronauts Mike Barratt, M.D., and Cady Coleman, Canadian surgeon Craig McKinley, M.D., and habitat technicians James Talacek and Billy Cooksey. The underwater team conducted their work from the Aquarius Undersea Laboratory in the Florida Keys Marine Sanctuary. The steel cylinder Aquarius habitat is similar in size to that of the service module for the International Space Station.

"The extreme conditions of a long underwater mission are similar to those of space. The NEEMO 7 mission afforded aquanauts, astronauts and medical professionals an unprecedented opportunity to test state-of-the-art remote medical techniques in real-time and real-life situations. Someday, these techniques could be used in long-duration, manned space flights to the Moon and Mars," says Dave Williams, M.D., CSA astronaut/aquanaut and trauma physician, who was slated to be mission commander of the Aquarius before a last-minute surgery prevented him from making the trip.

Mission Objectives

The mission had two diagnostic imaging objectives. The first objective was to experiment with telementoring by having Dr. Dobranowski and his team guide medical and non-medical personnel aboard the Aquarius through an evaluation of the abdomen and neck using a portable ultrasound unit.

The second objective was telementoring of a percutaneous drainage of a simulated abscess under ultrasound guidance. Other mission objectives included telementoring the crew through various procedures including intubation, suturing of a nerve and artery, and laparoscopic cholo-appendectomy or nephroscopy.

The mission was successful and proved that medical and non-medical personnel could successfully locate key organs and perform accurate and reproducible ultrasound-guided tasks. It also showed that educational manuals designed to help non-medical personnel use the ultrasound machine and identify key organs in an emergency situation were effective and valuable.

Mission Complications

In the past, signal delay has been an area of concern for remote surgical applications. However, Dr. Anvari's research has shown a delay of up to three-quarters of a second is tolerable during surgical procedures as long as it's constant. But, with the signal delay to the International Space Station estimated at one second and the delay to the Moon thought to be about three seconds, how long is too long?

"In many ways we are trying to push the edge of the envelope and take technology to its limits to find out where it begins to fail and break down so that we can learn how to develop the next generation of technology," says Dr. Williams. "We truly believe that we are changing the face of how we deliver healthcare. In so doing, we are reducing or eliminating the geographic disparity in healthcare."

From radiology's perspective, signal delay has not been as much of an issue. "We didn't find that the delay impeded our mission objectives whatsoever. It was all quite fluid and went very smoothly," says Dr. Dobranowski.

The only real complication for the mission arose when St. Joseph's temporarily lost real-time visual contact and was unable to see into the Aquarius. "At that point we communicated instructions to the astronauts using our cell phones and they were able to perform their duties successfully even in that scenario," says Dr. Dobranowski.

In the end, the team successfully completed all surgical and radiologic objectives.

What's Next?

As telecommunications and robotic technologies continue to improve and expand, so to will telehealth capabilities.

For now, Dr. Dobranowski feels that a logical next step might be pursuing research with other imaging techniques. "We're very limited with ultrasound as a modality," he says. "Experimentation with digital radiography in these types of extreme environments and at the space station would be an important step."

With the NEEMO 7 mission firmly under their belts, the crew is satisfied that the information collected will help to further refine medical technique, equipment and resources needed for the delivery of medical care in remote locations now and in the future.

A NEEMO 9 mission to further explore telehealth is tentatively scheduled for next fall.

The first journal manuscript submitted from the International Space Station is now available on Radiology Online (rsna.org/radiologyjnl). See "Radiology In Public Focus" for more information.