Thursday, May 22, 2014

Google Glass in the OR: Not ready for prime time



The Royal London Hospital and the Barts and The London School of Medicine and Dentistry presented the first live-streamed surgical procedure in the UK. The operation was an extended right hemicolectomy with resection of a metastatic liver lesion.

I was able to view the entire broadcast portion of the surgery live, and you can see it if you click  [6/3/14 Addendum: The link to the video is now here.]

Here is what I thought about the event.

The case started about 30 minutes late, which is similar to what would have happened in any operating room in the United States with a case scheduled for 2 o'clock in the afternoon.

I noticed some curious things. Many of the staff, including the anesthesiologist, weren't wearing masks in the operating room. There is no Joint Commission in the UK.

When the surgeon changed his glove, he opened the inner portion of the package with his bare hand, and the scrub nurse then touched the same area with her gloved hand.

The surgeon did not know what the patient's preoperative hemoglobin level was and had to ask the anesthesiologist.

The colon procedure was done in under an hour which was impressive considering the patient was somewhat obese, but I thought the surgeon hurried a bit. He could have been more careful. For example, he applied staplers without seeming to double check their position.

In a previous post, I listed many reasons why I felt live broadcast surgery was a bad idea.

Among them was the problem of distractions and there were many during the case.

The surgeon talked about how many people in different countries were watching.
He said that a number of text messages were coming up on his Google Glass screen.
At 21 minutes into the case, he stopped for a 5 minute interview with a TV crew.
He chatted with a colleague who came into the room for a few seconds.
He said hello to a medical student from Australia who had spent some time with him.
He asked questions of the audience and answered them himself.
Several times, he asked his technical crew how things were going.

Several other issues detracted from the educational value of the operation.

The glare from the operating room lights was constant and markedly impaired visibility.
Most of the time the Glass camera was aimed too high and too far to the right so much of the operative field was not in view. The surgeon pointed out anatomic structures that the audience could not see.
He moved his head frequently causing the picture to jiggle.
A stationary television camera with the ability to zoom in would've been much more effective.
The sound quality was poor and often unintelligible.
The liver portion of the case was not shown because the Glass's battery had to be recharged after 70 minutes.

What this demonstration showed me is that Google Glass has a long way to go before it is useful for education.

22 comments:

Anonymous said...

About masks in the OR, I think most non-US OR's don't insist on them for non-operative personnel. Unless you are physically leaning over the operative site. I don't see how it can make a difference.

Anonymous said...

OT:

To the posters here, on average how many tries does it take to get thru the captchas ?

Maybe I am stupid or have a leaion in my viaual cortex, but it takes me 3 tries for the captchaa with one real word and one gibberish, and 10 tries for the ones with 2 gibberish strings of distorted fields. Seriously, most of the latter are unintepretable.

Skeptical Scalpel said...

Anon, you and I know that if you are far from the operative field it probably doesn't matter if you wear a mask, but that's not the way the Joint Commission and the state health dept people see it. There's also the issue of people walking past the back table and what if someone sneezes.

I don't know what to say about the captchas. I receive a heavy load of spam even with them. I shudder to think what would happen without them. I moderate all comments myself. I wouldn't have time to do anything.

andrewswright said...

Having used the Google Glass in the OR I would echo some of your comments. The focal point is too high, but that can be fixed by using some tape on the earpiece to point the lens downwards. The battery life is short - so I use an external battery connected via a micro-usb cord threaded down the back of my gown like a light cord. The bigger issue is the lighting - OR lights wash out the picture so much that it is difficult to make out the target tissue.

Issues of distraction, interviews, text messages, etc. are real and not limited to Google Glass. You have to be very careful and thoughtful if recording or broadcasting a case.

Skeptical Scalpel said...

Andrew, I appreciate your comments. How do you correct for the lighting problem? it's easy with any decent video camera, but apparently not with the Glass camera.

This article (http://www.telegraph.co.uk/health/10851599/Surgeon-uses-Google-Glass-during-cancer-operation.html) in the UK newspaper The Telegraph said of the text messages "The questions appear to the side of the Google Glass so it does not restrict the surgeon's view." But didn't discuss how distracting they might be.

The article also said 90% of those who watched liked the idea. From the texts which were streaming alongside of the video, it looked like most of the questions were from non-medical people. I think the audience would get bored watching cases like this on a regular basis.

Anonymous said...

I can't seem to find whether the event was recorded or not. The provided link takes us to the comment section. Is there a link to the recorded operation to review? Thank you.

Skeptical Scalpel said...

The link's contents have changed since yesterday. I was able to watch the recording yesterday because I wanted to check some things like the timing of the interview during the case. I no longer see it.

I went to the hospital's site but I can't find a link ti the video there either. I'm sorry the Live Stream site took it down. I will try looking for the video later. If I find it, I will post it here and change the link in the post above. Meanwhile I will remove the link in the post since it no longer goes to the video.

NewHampster said...

I use a 3D printed shade over my Google Glass prism. Needed in brights sunlight as well. It is just a 3 sided, slip-on that covers all but the user side. Distractions can and should be disabled via the myGlass app on the phone. Just turn off Google Now, Messages etc

Rafael Grossmann said...

Very nice review of that event in the UK. Thanks for posting it.
I have to agree with you in that GoogleGlass is not ready for prime time quiet yet, but not completely for the reasons you posted. Glass is a first edition product still, but I think it s completely usable in this setting, and it represents already a fantastic tool for medical education and especially procedural learning.
As a Glass explorer and the first surgeons who ever used it in the OR ( Glass in the OR http://t.co/W0EJQy9U8s 
&MedEd http://t.co/0vYPZcrzKk ), I have been experimenting with it for almost a year. I really believe that the fact that the device can not just record, but also stream live video ( that feature has been temporarily removed but it is coming back with improvements), from the "point of view of the user (the surgeon, in this case), makes it an amazing tool for showing the right perspective to someone looking to learn from among other things, a visual angle.
When I streamed my procedure (a quick Perc End Gastrostomy), the view that the students had was basically the same I did, just as if they were inside my head. The ability to interact live is certainly a positive aspect of this platform for the teaching setting, but just as it happens during any operation, there's a time for everything, and the level of distraction should always be controlled by the surgeon, with or without Google Glass on.
The logistics, "choreography", lighting, angle of view, mindfulness of the head's movement, battery charge, etc., are all aspects that can be controlled 100%, and are all dependent on the user's experience.Obviously in his case, he did not have control over many of these details.
I'm glad that this surgeon tried this in the UK, but I'm less than pleased by the result of his production.
When I started watching the video, I really thought for several minutes that it was all a joke of some kind. Since I saw no masks or eye protection ( not the routine in the USA - nor in UK, I believe), I thought that he was maybe working on an animal model ( even then, I would mask and eye cover, for my own safety).
These are links to some of the other Glass-Healthcare and MedEd events and encounters I've had. Happy to keep the conversation and again, thanks for bringing this interesting theme to your, by the way, amazing blog ( It is one that I routinely recommend to my third and fourth year med students from UVM and UNECON during their surgery rotation with us in Maine.
Twitter: @ZGJR
Blog: www.Rgrosssz.com

TEDx on wearable #GoogleGlass #mHealth “OK Glass: I need a surgeon" http://youtu.be/fo3RsealvGI
"OK Glass":Disrupt Healthcare Now
http://youtu.be/DVzkw7y4_u4
Natural Evolution Up to GoogleGlass
http://youtu.be/Psq-T2O0LDs


#GoogleGlass vs. #Healthcare http://t.co/V46j9XTCQc via @ZGJR A new post w my VISION for Healthcare Equation #MedEd as well
Technologies that r changing #education #MedEd including #GoogleGlass http://www.theguardian.com/education/gallery/2014/feb/05/technology-shake-up-education?index=1

Shafi Ahmed said...

Hi Skeptical surgeon and others. Thanks for your interest in the live stream on Thursday and also the comments which have been very helpful

I do take your points raised as there has been far more experience in the US with this sort of streaming from the theatre with google glass and there is much to learn at our end.

Overall the technology worked reasonably well but we do need to tighten up some of the issues.

1. Control the amount of students and insist on unique and individual password so that we will use to purely for training. I will do this for the next feed but this won't be available to the public at large.

2. Moderate the messaging so that it is only appropriate

3. We don't need to wear masks in the UK - they have been shown in many studies to have no influence on infection and actually only to protect the surgeon rather than the patient. The UK do not have a policy on wearing masks and a lot of open and laparoscopic surgeons never wear masks. This is different in the US.

4. The operation wasn't hurried at all and I actually went slower as I was talking and teaching at the same time!

5. I agree that we need to be careful of the theatre etiquette when streaming and this is will be easily resolved.

6. I had no complaints about the sound as we had the students listening in to my feed on a headset. We checked the sound levels many times with or without mask and we were happy before proceeding

7. I have used stapling devices for 20 years and checked the position and it was fine.

8. Actually I received many comments that I kept my head deliberately still and there was less movement than most streams which I knew would be a problem for a live feed as some can feel seasick when watching live operations . But this can be a problem I agree.

I am happy to take take any advice of course and work with all of you to get this right. I personally think that this will better and the students get a better learning experience. I am. It sure abut the US but our students sometimes do not come to the OR as they find it a poor learning experience as over the whole day of theatre do not get to see much of the operation.

Best regards

Shafi Ahmed

Shafi Ahmed said...

Rafael

It would be great to hear of all your experiences in this field at some point as I am sure we could learn a lot. Will you be coming to the UK at some point?

BW

Shafi

Skeptical Scalpel said...

Dr. Grossman, I was aware of your pioneering work with glass. Thanks for commenting and posting the links.

Dr. Ahmed, thank you for commenting and for being a good sport about my nitpicking of your procedure. I admire your courage in doing the case in front of such a large audience.

Dr. Wright, who commented above, has someone else narrate and answer questions when he live broadcasts a case. You might want to consider that because it cuts down on the distractions for the operating surgeon.

Is the video of Thursday's case available online? If so, can you post the link? Also, please let me know when you you do another live streaming case.

Shafi Ahmed said...

Skeptical surgeon

Thanks. I actually thought your comments were the most useful and the only one that I have responded to thus far.

We are editing the video at present and will post online. I have yet to decide on putting the whole video back on livestream.

I am planning on the next case and will keep you informed.

#GlassSurgery

Shafi

Rafael Grossmann said...

Thanks Shafi. I'm on my way to Paris soon to talk about Glass in Health.
Have two potential invites to Bin and UK. Would love to connect there. I'll let u know. @ZGJR

Emily said...

I'm just a patient and have zero power over what goes on in the operating room, but I'm trying to picture myself as that patient on the operating table with the surgeon and others bent over me without a mask. The surgeon is speaking to the nurse or whoever and there's no chance saliva or whatever might escape from his mouth into my open abdomen? And if it does, no big deal? Really? I don't buy it. To me it's suggests OR team comfort and lazy infection precautions trump patient safety.

Shafi Ahmed said...

Emily

The evidence is very unclear despite many systematic reviews and remains part of surgical dogma and tradition.
However for the next live case I will wear a mask for the whole operation.
You may want to look at the latest review.
intervention Review
You have full text access to this content
Disposable surgical face masks for preventing surgical wound infection in clean surgery
Allyson Lipp1,*, Peggy Edwards2
Editorial Group: Cochrane Wounds Group

Published Online: 17 FEB 2014

Assessed as up-to-date: 29 OCT 2013

DOI: 10.1002/14651858.CD002929.pub2

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Database Title
The Cochrane Library
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002929.pub2/full

Shafi Ahmed said...

Rafael

Let me know if you do come to uk email shafi.ahmed@bartshealth.nhs.uk

BW

Shafi

Emily said...

Thank you for responding, Dr. Ahmed. Being a lay person with no scientific background, I suppose I have to concede to this study even though my "common sense" tells me otherwise. But I'm curious why this study was even done in the first place since whatever the conclusion of masks or no masks, there would have been no added benefit to the patient.

Skeptical Scalpel said...

Emily and Shafi, to be clear, that Cochrane review does not say face masks are unnecessary. What it says is "This review of trials found no clear evidence that wearing disposable face masks increases or reduces the number of surgical wound infections in clean surgery. More research is needed."

It was also involving only clean surgery, not colon resections.

Shafi Ahmed said...

Dear Skeptical surgeon

I am performing a second live stream tomorrow and have made quite a few changes from last week. It is at 0930 GMT and the operation is a closure of ileostomy .

The audience will be students and trainees only with password access and moderation for questions.

I would be happy for you to access the stream as the patient has given full consent for anyone to observe but I will test how the system works for our students before doing another big event. Please free to comment.

The access is via our new website as we are trying to make this the portal and have control http://glassmedics.org/ileostomy/

Also the previous video is on the website but also can be found on this link on YouTube

http://youtu.be/WkxD8Frdjq8


Skeptical Scalpel said...

Shafi, thanks for the information about your next live stream and the link to the previous video.

As much as I would like to see tomorrow's case live, I will probably miss it because 9:30 GMT is 4:30 am here on the East Coast of the US.

Good luck with it. Let us know when the video of tomorrow's case can be seen.

Shafi Ahmed said...

Dear Skeptical surgeon

The 2nd live stream went well with 822 students across 37 countries. We made many changes from the first transmission which went well and made for better viewing and interaction . We are getting there! Will
post feed online soon

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