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Pioneers Use Cisco IP Network to Test Limits of Medicine

Space program NEEMO 7 relies on Cisco MPLS technology to run tele-mentoring and tele-robotics experiments for bringing advanced medical help to astronauts and others in isolated locations

November 18, 2004

By Charles Waltner, News@Cisco

Cisco Systems is helping prominent Canadian and United States research organizations find radical new ways for doctors to make house calls.

This October the NASA Extreme Environment Mission Operations 7 (NEEMO 7) used Cisco's state-of-the-art Internet Protocol (IP) networking technologies to test some of the most advanced approaches for delivering remote medical assistance ever attempted.

"We were trying to see if we could use technology to do surgery and diagnosis by proxy, so to speak, by allowing lay people to act as doctors and surgeons with the aid of telecommunications," said Dr. Mehran Anvari, who directed the medical experiments.

For the NEEMO 7 mission, a crew of three astronauts, one scientist and two habitat technicians lived for 11 days in Aquarius, a 9 foot by 42 foot capsule 50 feet under the ocean, seven miles off the coast from Key Largo, Fl. Aquarius simulates the isolation and confinement of a space ship. Due to the pressure change in the habitat, the astronauts required 17 hours decompression before they could safely ascend to the surface. As with astronauts in space, the NEEMO 7 crew's contact with the outside world was mainly through a communications link.

The crew explored tele-mentoring and tele-robotics as ways to provide advanced medical assistance to people in isolated environments. While this project specifically examined how such techniques can help bring emergency medical aide to ailing astronauts in space, the work has wide-ranging implications for delivering advanced medical assistance to remote or isolated locations, as well as rural communities throughout the world.

Tele-mentoring is a process in which an experienced surgeon or specialist uses a two-way video conferencing link to guide a lay person or doctor at a remote location through an operation or procedure. Tele-robotics uses virtual-reality technology and robotics to allow a surgeon to remotely operate on a patient from hundreds or thousands of miles away. In both cases, a highly reliable and high-performance network is crucial for conveying the life-saving information and dependably operating sensitive robotic surgical equipment.

With the aide of Drs. Mehran Anvari, Julian Dobranowski and Anil Kapoor, the crew on Aquarius practiced ultrasound examinations for such conditions as kidney stones, performed mock laparoscopic surgery, and trialed life-saving vascular suture repair techniques, among other procedures.

The main participants in the project included the Centre for Minimal Access Surgery (CMAS) at St. Joseph's Healthcare affiliated with McMaster University, in Hamilton, Ontario, the Canadian Space Agency (CSA), and the National Aeronautics and Space Administration (NASA), as well as Cisco and Bell Canada who donated their expertise and equipment.

Dr. Anvari, who founded the CMAS and is a pioneer in tele-robotic surgery, said the success of the crew's medical experiments depended on the quality and robustness of the communications link.

"The mission hinged in large part on the network," Dr. Anvari said. "Many of the experiments were about communications and the network needed to work at a very high level. Without Cisco's vision, we would not have been able to do what we did."

The 1,500 mile telecommunications link from Aquarius to Dr. Anvari at CMAS headquarters at St. Joseph's, relied on Cisco's industry-leading technology for the high quality and high performance broadband IP connection. The IP network used Cisco's advanced Multi-Protocol Label Switching (MPLS) and virtual private networking (VPN) technology. MPLS brings a new level of intelligence and flexibility to IP networks, making such medical-grade communications possible. The signal traveled over the IP backbone run by Bell Canada to Key Largo. From there, it was relayed via a microwave transmitter to a buoy above the Aquarius. An "umbilical" communications line ran from the buoy down to Aquarius.

On board the Aquarius, the crew used a Cisco 2950 switch and a Cisco 2955 switch to manage the communication network within the capsule. The switches had to withstand pressure over two times greater than earth's atmosphere, high humidity and lots of jostling in the cramped quarters. Despite such unusual conditions and rigorous demands on the network and its equipment, Dr. Anvari says the entire communications infrastructure performed flawlessly.

During a phone conversation from inside Aquarius with News@Cisco, Dr. Robert Thirsk, commander of the NEEMO 7 mission, and crew member Dr. Craig McKinley, reported that the high quality video and audio feeds into the underwater chamber were playing a pivotal role in the success of the tele-mentoring experiments.

"The broadband video and audio make it seem like the consulting surgeon is in the capsule with us," McKinley said.

The astronauts noted that only with the advent of high-quality broadband networks are such remote medical procedures even possible. "Any snafus on a network can greatly undermine the effectiveness of these types of efforts," Thirsk said.

The NEEMO 7 crew also evaluated highly experimental tele-haptic software. Tele-haptics conveys the sense of touch to the surgical controls operated by a remote surgeon. The technology would allow doctors such as Dr. Anvari to perform much more advanced surgery by providing the feeling of texture and tension over a broadband network. Time delays in a network can greatly undermine the effectiveness of tele-haptic software, but the Cisco MPLS IP communications link proved up to the task, Dr. Anvari said.

While the tele-mentoring experiments worked well and the tele-haptics tests provided important insights, the tele-robotics experiments were curtailed, the astronauts reported. The crew quickly discovered that existing tele-robotic equipment is not small, nimble, or rugged enough for use in a setting such as Aquarius. The NEEMO 7 organizations will be developing and testing new robotic designs for use on Aquarius next year.

Though the tele-robotics experiments on Aquarius were limited by equipment issues, Dr. McKinley knows that this new technology offers great potential for medical aid in space and in any location far from sophisticated hospital resources. He was the attending physician in North Bay, Ontario, where Dr. Anvari performed the world's first hospital-based tele-robotic operation on February 28, 2003. That surgery was also performed over a Cisco network run by Bell Canada using MPLS technology, connecting Dr. Anvari in Hamilton, Ontario to the robot in the operating room in North Bay over 200 miles away. Since then, Dr. Anvari has performed 22 similar operations. "We learned that tele-robotics can give outside doctors a physical presence regardless of where they are," McKinley says.

Dr. Anvari says the experiments on Aquarius only hint at the potential of tele-medicine as advances in telecommunications and robotics combine to bring new capabilities to doctors. He expects tele-robotic operations to greatly increase over the next five years, in the process transforming the care provided to patients far removed from advanced medical services.

"These procedures will become an important use of telecommunications networks," Dr. Anvari says. "There's growing interest in these technologies to bring medical services to areas from the Arctic Circle to the mountains of Bhutan to the remote towns of Canada, so the implications of NEEMO 7 go far beyond space travel. They address the very basic need of how to save lives."

NOTE: Aquarius is owned by NOAA, the National Oceanic and Atmospheric Administration, and is operated by the NOAA National Undersea Research Program Center at the University of North Carolina at Wilmington. Because of similarities between undersea and space habitation and exploration, NOAA and NASA have a cooperative project in which NASA trains astronauts in Aquarius and researches crew behavior, habitability, and space analog life sciences.

NOAA's Aquarius--the world's only underwater ocean laboratory dedicated to marine science and education--is located in the Florida Keys National Marine Sanctuary. The laboratory is deployed three and half miles offshore, at a depth of 60 feet, next to spectacular coral reefs. Scientists live in Aquarius during ten-day missions using saturation diving to study and explore our coastal ocean. For more about the Aquarius habitat, please visit: http://www.uncw.edu/aquarius/

Charles Waltner is a freelance journalist in Oakland, Calif.

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