- Robotic medicine may be the weapon the world needs to combat the coronavirus.
- The COVID-19 viral outbreak, which began in Wuhan, China, is now spreading to many countries, including South Korea, Iran and Italy, and CDC officials warned Tuesday that an outbreak in the U.S. is likely.
- Telemedicine is playing a key role. Robotic devices and camera technology from companies such as InTouch Health and Zoom Video Communications are being used with coronavirus patients and in broader communication during the crisis.
With top government health officials warning it is only a matter of time before there is a COVID-19 outbreak in the U.S., it’s not likely that specialized masks and respirators, or canned goods and Clorox, will be sufficient to fight a global pandemic. Viral outbreaks like COVID-19 highlight the growing role new medical technology — in particular, ideas from the field of robotics — can play in fighting the spread of novel infectious diseases. But medical experts say it will be a mistake if innovation rolls out only when the world is on edge.
“Extreme cases make us rethink how we do things,” says Dr. Robin Murphy, Raytheon professor of computer science & engineering at Texas A&M University. The 2014 Ebola outbreak in Texas, the first in the U.S., led to years of study by Murphy and others on emergency response and the integration of robotics with medicine to help limit pathways for a highly contagious disease to spread. “A hospital lost a whole wing temporarily. Two ambulances were infected,” she recalled.
Still, she says, not enough has changed. Wild ideas from the world of robotics capture attention, but health-care experts like Murphy are focused on more basic automated solutions, like seeing robots perform routine medical work for contagious patients, without replacing or eliminating health-care workers, to free up medical staff so they can spend more time on direct care, as well as reduce risk of their exposure.
For starters, the robots don’t look like people.
“There are lots of start-ups based on humanoid robots. No, no, no,” Murphy said.
Making extreme medicine routine
Think robots capable of helping to change IV bags or take patient samples, which require fine manipulation that is harder to perform in heavy and hot protective gear.
“There’s an exposure risk just to change an IV bag,” Murphy said. “Some things are so routine we take them for granted. How many times have you been in a hospital with loved ones and you hear that beep, beep, beep. … Why aren’t we automating it?”
Hospital beds that can be automated to cycle through a series of positions (e.g., elevate head for X amount of time, then lower and elevate Y) can perform work that is difficult to do for health-care professionals while they are wearing protective gear and focused on higher-priority items. “The medical professionals said they were always behind,” according to Murphy, but this was one task that Ebola workers found did provide patient benefits.
Robots designed for handling biohazardous waste and decontaminating rooms and ambulances are also ideas born out of an era of increasing experience with pandemic risks.
“Why waste a person carrying the trash? Why send a nurse in to change a position on the bed. Now we’re not thinking of the robots as things that look like a dog or humanoids — think of the bed itself as being a robot,” Murphy said.
Dr. Edward Damrose, chief of medical staff at Stanford Health Care, said that to some extent the robots are already present and playing a role in our health-care system though many people are not aware of it. At Stanford, diagnosis and recommendations can come from telemedicine, and in the hospital, robots are bringing supplies and linens to the ward.
Stanford Medical Center IV bags are wirelessly connected to a network and can be remotely programmed — an IV bag Internet of Things — though the system does not include the robotic changing of bags that Murphy envisions. Sensors from Leaf Healthcare are used in the Stanford hospital to prompt nursing staff to turn or ambulate patients. UV sanitizing robots from Xenex are used in highly contagious infection rooms where virulent organisms are present. “I have a feeling in time that may become standard,” Damrose said. “Look at the antibiotic crisis and how these organisms are adapting to disinfectants and antibiotics. It doesn’t make sense to hand clean a room. Rooms of the future could all have UV cleaning robots.”
But Damrose said much manual labor that nurses still often perform because physicians don’t have the time, and residents in training have other priorities, are obvious places to look for robotic alternatives. Humans in a protective covering will always be available and required for lifesaving or critical care, but simple interactions can be handled by robots and reduce the “mundane risks of virus,” Damrose said.
Transmission risks from spillover events are occurring with more frequency, said Dr. Jason Moats, associate division director with the Texas A&M Engineering Extension Service’s Emergency Services Training Institute (TEEX), one of the largest training providers for first responders, emergency managers, and local government officials. It trained over 200,000 people last year from more than 100 countries.
“Robotics for menial tasks does not mean unimportant tasks,” Moats said. “Moving patients around, radiology … intake of patients. It could be a little robot the size of a Roomba that hooks into a bed,” said Moats, who has been preparing the nation’s first responders and emergency managers to respond to disasters, including infectious diseases, for more than two decades, and more specifically on enhance response technology since the 2014–15 Ebola outbreak.
“We bring out specialized equipment for these novel events, but if we’re going to have specialized equipment it better be integrated into everyday operations. Then it becomes institutionalized and adopted,” he said. “If we can teach a robot to aim a weapon, we can teach it to aim a bottle of disinfectant.”
Dr. Laurel Riek, a professor of computer science and engineering, and emergency medicine at UC San Diego, said during the recent Ebola outbreaks health-care workers could sometimes spend over an hour getting into protective gear. While that helped improve safety, it was time intensive and took them away from treating patients. Even with strict protocols, a number of health-care workers were infected and died, and that is repeating itself in the COVID-19 outbreak, with many health-care workers infected and some fatalities.
Riek said systems that enable clinicians to control mobile manipulators — such as mobile robots with the ability to grasp and manipulate objects — are getting closer to the point of becoming affordable. “It’s possible well-designed robots could help reduce the risks to health-care workers, who are already at a high risk of workplace injury,” said Riek, who also serves as director of UC San Diego’s Healthcare Robotics Lab. Robots can be used to take vital signs, provide comfort care, perform minor procedures and perform some delivery and cleaning tasks.
But don’t think that anytime soon a “robot injects needles into veins like a phlebotomist does,” Murphy said.
Learning at the epicenter of Ebola
How to incorporate robotic technology into infectious-disease care is an issue that Doctors Without Borders (Médecins Sans Frontières), which is on the front lines of many viral outbreaks around the globe, has been weighing.
“We routinely miss opportunities to innovate during outbreaks because it is a difficult time to do so. … Robot development is just another form of this,” said Armand Sprecher, public health specialist at Doctors Without Borders who worked on the West Africa outbreak of Ebola. “Maintaining momentum (and funding) between outbreaks can be a challenge.”
Doctors Without Borders does use drones for some transport, but it does not yet use robotic technology on the ground, though it is interested in the potential, Sprecher said. One reason: Needs outstripped the organization’s capacity as the past Ebola outbreak grew.
“The unaddressed suffering was distressing and a challenge,” he said. “The value of robots appeared to be that they were not at risk of infection and not limited by heat stress.” (Protective garments can be difficult for humans to wear for extended periods of time.)Robots may also provide a way to bring safer specimen processing and diagnostic procedures with no risk of infections to remote areas which are not up to the technological level of modern laboratory settings. “Humans are a significant source of laboratory error, so removing them where possible is often a good idea. Diagnostics requires precision, attention to detail and patience enough to do things the same way every time. Robots are good at this. People, less so,” Sprecher said.
But there is a particular set of risks associated with automating too many medical tasks for Doctors without Borders, which employs a lot of local staff as part of building community trust in remote locations around the world. “If we exclude them and favor robots, we take away some of their self-efficacy and an important way for the community to know what is going on by being involved,” he said.
“Outbreaks of new pathogens that lead to outsiders showing up in strange clothing coincident with lots of people dying gives rise to a host of rumors, many about what the evil people in the funny clothing are really up to. It is a tricky time to introduce novelty and innovative gadgets. This is not to say that it cannot be done, but one would have to do so with caution, transparency and communication of what one was up to,” Sprecher said.
Telemedicine and infectious disease
At Providence Regional Medical Center in Everett, Washington, a telemedical robot called Vici from InTouch Health, a company currently in the process of being acquired by Teladoc Health, was used with the first U.S. COVID-19 case. The simple-looking, lanky metal cart — with a keyboard navel, tablet for a chest, and camera for a forehead — allowed doctors to communicate with the patient in isolation.
“You don’t want to make more people potential vectors,” said Todd Czartoski, chief medical technology officer at Providence St. Joseph Health, which runs 51 hospitals including Everett, as well as more than 90 clinical programs across a total of 120 hospitals in eight states.
Three primary-care providers used the telemedical robot on a daily basis with the COVID-19 patient. “Mainly, it was communication, talking to the patient and listening to the heart and lungs, and also communicating with nursing staff in the room,” Czartoski said. “It just helps to keep people from having to go in and out of the room. We still had to have a nurse gowned up with the appropriate equipment, but the robot made it easier to listen to the heart and lungs with a digital stethoscope and talk to patients without having to get suited up multiple times a day.”Virtual medical visits are growing fast
Czartoski, a neurologist by training, initially began using telemedicine in work with stroke patients, one of the best early use cases for telemedicine. “If I am seeing someone with stroke symptoms I can examine them with a camera fairly quickly and tell if there is left side weakness and trouble speaking, and I can look at a CT scan and labs, and make a decision with the ER physician.”
Virtual visits are booming at Providence. The nonprofit health-care system completed roughly 100,000 virtual visits in 2019. In 2012, Providence performed a few hundred telemedical visits a year, and it has been growing at a rapid pace — from 12,000 in 2016 to 41,000 visits in 2018 to over 100,000 last year. That number does not include the use of telemedicine in ICU specifically.