Last month I was in Vancouver to attend the e-Health 2018 Conference. This annual conference and tradeshow brought together 1,250 digital health professionals from diverse backgrounds and across Canada. It was a good opportunity to network, share ideas and learn from each other.
I participated in a plenary session at the conference. Sonny Kholi (physician and entrepreneur, Cloud DX), Isabelle Tremblay (director, Canadian Space Agency) and I were panelists discussing the topic of space medicine. Bob McDonald (host of CBC’s Quirks & Quarks) served as our moderator.
Our panel explored what is on the horizon of human spaceflight for the next 20 years and shared insights about the medical care needs of future astronauts. There seemed to be great interest in the topic.
Prior to the panel, Dr. Trevor Jamieson interviewed me to get my thoughts on deep space exploration and healthcare innovation. Trevor works at the Women’s College Hospital Institute for Health Solutions and Virtual Care (WIHV) in Toronto as the lead for Virtual Care. These are the questions that Trevor asked:
Trevor Jamieson (TJ): Welcome, and thank you for sitting down with me today.
I wanted to start by giving you an opportunity to give an overview of what you’ll be discussing today in the plenary session.
Robert Thirsk (RT): Changes are now occurring in the Canadian healthcare sector such that medical practice is becoming less institutional-based and more patient-centric. We also pursue an objective of ‘aging in place’ in which we strive to keep geriatric patients healthy and happy at home and out of acute care hospitals, unless absolutely necessary. Several of these new healthcare delivery models being introduced into society are also applicable to helping astronauts survive and thrive in space.
I had the opportunity to fly in space twice, but on both missions, I wasn’t more than 400 km from Earth when I flew. Mission Control was able to oversee many crew operations. For instance, whenever my crew encountered a significant medical problem, we consulted with the flight surgeon on the ground for aid with diagnosis and treatment. In the unlikely event that a really serious medical problem arose, it would’ve been possible to transport an ailing crew member to a tertiary care centre on the ground within 12 hours or so. However, the next forays in human space exploration will take astronauts deeper into our solar system – far away from Earth-based healthcare delivery.
Deep space exploration missions are now being planned by NASA and its international partners, including Canada. Exciting stuff! Humanity is heading back to the moon within 10 years. Within two decades, I expect the first human expedition to land on Mars.
The moon by travel time is 3 days away from Earth with a 3 second ‘latency’ (i.e. communication delay). For instance, if you on the ground said “Good Morning” to me on the moon, it would take 3 seconds for me to hear your greeting and respond. This voice and data latency precludes certain types of medical interventions such as remote surgery or ground-based oversight in urgent situations like cardio-pulmonary resuscitation. When astronauts venture even further to Mars, we’re talking about 6 months of travel time with up to 20 minutes one-way time lag in communications. Therefore, future healthcare delivery models for deep space missions will need to be more autonomous and patient-centered with less reliance on the ground for monitoring, diagnosis and therapy.
My dream is that Canadian clinicians, engineers, industrialists, researchers and institutions will partner together to develop and implement a new model of astronaut healthcare delivery for deep space. We have the necessary expertise in Canada to play a leadership role. For example, digital health is a national core competency – three of the world’s most innovative and esteemed AI ecosystems are located in Canada. The Council of Canadian Academies recently reported that clinical medicine and ICT are two of Canada’s six research strengths. Furthermore, Canada is a highly regarded international leader in medical simulation, medical robotics, minimally-invasive surgery and in the training of medical practitioners.
During today’s e-Health plenary panel, my colleagues and I will discuss the challenges of living and working in space. We’ll describe how we currently treat medical maladies in space, and envision some of the healthcare technologies that must be developed in order to support deep space exploration.
TJ: You’re actually touching on a number of things I was planning to ask you about. As you alluded to, you were on the International Space Station for 6 months, and you’d gone to space once before that. Were you present on the missions primarily as an MD or did you have a different role?
RT: Following recruitment, every astronaut is trained to become a generalist.
Whether you enter the astronaut corps as a medical doctor, engineer, physicist or pilot, you will receive training to expand on your original skills. For instance, I received additional training in robotics, space-walking, assembly, maintenance, repair, rendezvous and docking. However, since I was also an experienced physician, I served as one of two designated “CMOs”, crew medical officers, aboard both of my missions. When a crewmate experienced a minor medical problem such as a cold, a laceration, or back pain, I was able to manage that. If a more serious situation arose, as I previously mentioned, I would consult the flight surgeon on the ground who was available 24 hours a day.
TJ: In terms of the types of things that you could deal with in a self-contained capacity on the ship itself, what sort of equipment do you have and what would be the most advance type of issue that you could deal with independently?
RT: A spacecraft has limited medical facilities and capability. Due to constraints of power, mass and volume, it would be impossible to include an MRI for example, aboard a spacecraft. Our medical capability in space would be akin to that of a small village medical clinic.
For example, we have the equipment and pharmaceutics that a family physician would need to perform a periodic health exam and to treat minor ailments. We have cardio-pulmonary resuscitation equipment including oxygen ventilation and countershock, and an airlock that could function as a hyperbaric chamber. The only onboard imaging modality we have is ultrasound.
TJ: One of the jobs I have is to work at a research institute in Toronto called WIHV, and the V in WIHV stands for virtual care. We’ve been doing a lot of work on “apps”, and wearables, and patient-focused tools. Obviously, by necessity, the space program has had to do a lot of virtual care for some time. When you return from space, are there things that stand out as elements of virtualization that we could translate into our healthcare system?
RT: The first thing that jumps to my mind is machine learning. You’ve probably seen the movie 2001: A Space Odyssey. The AI entity in that movie was named HAL 9000.The responsibilities of HAL included the monitoring of the spaceship’s various technical systems as well as the ongoing health of the crew members, some of who were still in deep hibernation.
When future astronauts will voyage far from Earth, I envision that sensors and AI will play a role monitoring and accumulating physiological data on the crew. If the embedded machine learning system detects aberrant data, then the system can report it to the crew and recommend a course of action.
I also envision AI-guided tele-mentoring. When I flew aboard the Space Station, a crewmate and I experienced some atypical visual problems. We were asked by our flight surgeon to perform ultrasound imaging and electronic fundoscopy of our eyes. We had never trained on those procedures. However, a technician on the ground successfully tele-mentored us through the procedures. We obtained high quality imagery that aided the flight surgeon on the ground to make the diagnosis – moderate papilledema.
As we venture further into space or perform new operations, we can be sure that additional medical problems will arise. We can’t predict and train for every medical eventuality. I therefore envision that AI-guided tele-mentoring will play a significant future role by helping the crew perform diagnostic and therapeutic procedures.
TJ: Some of the things you’ve described are pretty advanced; some of the things like communication, while not easy to do from a space station, at a conceptual level is a pretty basic thing. What do you think is preventing some of the things that the space program has been doing for a long time from getting into conventional day-to-day healthcare in Canada?
RT: The Canada Health Act stipulates that every Canadian will have reasonable access to health care facilities and entitlement to the same quality of health care. Those principles have not been fulfilled for citizens who live in remote or northern communities nor for vulnerable populations who live elsewhere in Canada.
The specific answer to your question requires a governmental response, so I am not qualified to answer. But what I can say is that some of the models, technologies and protocols that we will need to develop to maintain the health, wellbeing and performance of astronauts in deep space could have similar application and benefit in northern Canada.
For example, if you are treating a female patient with pelvic pain in a small community in Nunavut, your differential diagnosis might include ectopic pregnancy. If you are uncertain about the diagnosis, you may transport her to a tertiary care centre in southern Canada at great cost for definitive diagnosis and treatment. If small communities in Nunavut had medical resources similar to a deep space vehicle, and if the northern healthcare practitioners had astronaut-like training and were linked virtually to tertiary care centers, like the Women’s College Hospital for Virtual Care, we could potentially improve access to health care and lower its costs.
But let me add that the direction of spin-off innovation is not entirely from space-to-Earth. Some of the developmental work already being done in virtual care institutes like WIHV, MaRS and W21C will eventually enable space-based health care of the future. I envision a two-way translation of knowledge.
TJ: Wrapping things up, I wanted to ask you a little bit about innovation. Everyone at eHealth2018 is talking about innovation, but at the same time it’s not always clear that everyone knows how to make innovation really happen in healthcare. The space program has obviously been innovating and incorporating new technology for quite some time. Are there any things that healthcare could take from the space agencies as models for innovation?
RT: If you had asked me before I launched to space, “What is the best thing about the International Space Station?”, I probably would have responded that the Station is a world-class facility for doing research that cannot be performed on Earth.
After having flown with crew mates who represented four other countries, I now say that the best thing about the International Space Station is that it is international. The Station’s international partnership will become the program’s greatest legacy. Formerly adversarial countries have come together to pursue a common vision; to do something incredible in the areas of discovery, creativity and innovation; and to inspire society to pursue audacious dreams.
I read the 2015 Naylor report on healthcare innovation. Besides stifling policy and regulatory practices, I got the impression that one of the biggest roadblocks to healthcare innovation in Canada is interprovincial barriers. We’ve got incredible research that is being performed at many centers in Canada. But the Ministries of Health are structured like silos. Work is not being coordinated and enhanced across provincial borders. We keep reinventing the wheel. I dream that a national deep space healthcare initiative could become an exemplar – a role model – for cross-Canada health innovation.
Wouldn’t it be terrific if all levels of healthcare innovation – provincial, indigenous, space, military, commercial, academic, primary and specialist care – could get engaged in a moon/Mars initiative? We could showcase the innovation potential of cross-Canada collaboration. We could set the international standard for health care delivery to remote communities – on Earth or in space.
TJ: That’s a vision many of us could certainly buy in to.
Thank you for sitting down with me. This has personally been a very valuable discussion. Enjoy the rest of the conference.
RT: Thank you for the opportunity.