Editorial Sensing Simulation

Ronald C. Merrell, MD, FATA and Charles R. Doarn, MBA, FATA Editors-in-Chief

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n December 5, 2014, NASA launched the Orion spacecraft powered by a Delta IV Heavy rocket. This spacecraft, part of NASA’s Space Launch System, may one day take the first humans to Mars or an asteroid. Pretty exciting!! This was a test flight without human occupants, a simulation. The flight attained an altitude of 3,600 miles. That is, the flight went some 15 times further from Earth than the International Space Station and well into the Van Allen Belt. The craft reentered the Earth’s atmosphere, reaching a velocity of 20,000 mph and experienced heat shield temperatures of 4,000F. Reporters and analysts repeatedly asked why Orion looked so much like Apollo from the 1970s. There are only so many ways to configure a plummeting spacecraft, just as most boats have a striking similarity in that they float, and you can tell a 1903 beach buggy is an aircraft like a modern jet because they both can fly in the atmosphere. This Orion is a habitat for four people, and its potential for life support, radiation protection, communications, and maneuvering would astound the original Apollo crews. So, what does this have to do with telemedicine? This flight of only 4½ h was a simulation, and the outcome was not a simple binary of success or failure. The simulation was captured by 1,200 sensors, measuring and capturing pressure, flow, temperature, strain, volumes, electronic circuits, and images. The test flight accumulated millions of data points that will be analyzed over the coming months to refine and improve the many years of work that have culminated in the notion that people can go to Mars. For human health and illness, we have marvels of sensing that can tell us about physiologic parameters,1 movement,2 and activity.3 We can integrate the output of tiny sensors into a local area network using Bluetooth or Zigbee. The sensors cannot be overly intrusive, out of consideration for patient comfort and the dreaded Hawthorne effect, whereby the taking of measurements has its own effect on the phenomenon in question and distorts the natural outcome. We know Hawthorne referred to the change in the behavior of the subject when the subject is aware of the observer. The same applies to the sensor and observer. The data from our human patient can be integrated far away on servers, and we can embrace that patient with all the competence and caring of direct contact in at least most ways. There seems to be no limit to gathering information about human status and performance. Yet when we come to the unknown about disease, its prevention and interventions, we arrive at the door of experimentation. When we have something new or confront a new disease, we are back to the same principles of empiric experimentation

DOI: 10.1089/tmj.2015.9998

established by Francis Bacon in the 17th century. We observe, hypothesize, and establish an experiment to test the hypothesis. We could always conduct our experiments in other life forms and extrapolate to humans through more informed experiments. However, finally we needed human experiments to approximate the truth and consequences. So much of the insightful work of Einstein was conducted through calculation and thought, and only later could experiments be designed to actually test relativity, etc. This lack of experiments never bothered Einstein, of course. Can you imagine considering a series of his thoughts and calculations where the editor summarily turned them down for publication because the ‘‘n’’ could not justify statistical analysis? Well, people are just too complex for a priori abstraction. We need the data, and most of those are realized through sensors, data analysis, and confirmatory repetition. There have been at least two major problems with human experimentation. First, how can one design a nondestructive experiment that produces reliable results? Second, how much data do you need to avoid errors of unknown parameters? Human experimentation is imperfect, and yet perhaps there are great improvements to consider. The space effort has just used again a simulation to test all that can be anticipated in order to design improved systems compatible with human survival. Could we not apply sensing to better effect in human simulation? There are at least a few sound possibilities. First, the human genome can instruct as to the pharmacological response of human disease and injury. Structural analysis of receptors and mechanisms of signal transduction can inform our design of highly specific and effective therapy. That is a form of simulation. Next, the actions of drugs in vivo and interventions by human hands can be richly investigated by sensing the effects in nonintrusive ways. Why is a particular drug deadly to some and lifesaving to others? Why is a particular cardiologist blessed with such excellent outcomes not achieved by others? Measure the forces, ergonomics, and chemical results with a broad array of sensors, and perhaps the reproducible answers are right there. Next, design human simulations that are intended for teaching skills and scenarios. Put in all the variables, run the test with students and specialists learning a new skill, and discern the best practices for rapid, efficient learning. This is a work in progress now and much welcomed by all interested in patient safety. Finally, replace large amounts of human experimentation with avatars or simulacra for the subject. Apply the variable and sense the outcomes long before people are actually subjected to the formidable unknown. Do we know enough to do this kind of sensing? Probably not! However, a beginning is a beginning. Let us seek to improve sensing

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and data analysis in the simulacrum and the training device. Refine the kind of data needed to make decisions. Incorporate new knowledge such as genomics and proteomics as it is available and continuously improved until we can make the first human intervention as safe as riding in a new vehicle out to the destiny of our species. Now, despite all our efforts in health heretofore, we remain painfully mortal. It is unlikely we can change that, but we can certainly strive to improve the comfort and function of our mortality and perhaps extend it a bit. All our best efforts in advanced engineering, avionics, and life support cannot make space travel entirely safe, of course. Space travel remains sufficiently hazardous that one could reasonably ask why not just send the sensors and forget the people. Well, people make the most amazing observations, and the analogy to human disease really does not apply. There is no alternative. We hope

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to see much research in the next years in the area of sensing simulation as we move toward better and safer experimentation, better technology transfer, better translational research, and a healthier world.

REFERENCES 1. Faria I, Gaspar C, Zamith M, das Neves RC, Rodrigues F, Barbara C. TELEMOLD Project: Oximetry and exercise telemonitoring to improve long-term oxygen therapy. Telemed J E Health 2014;20:626–632. 2. Zhu X, Chen W, Nemoto T, Kitamura K, Wei D. Long-term monitoring of heart rate, respiration rhythm, and body movement during sleep based upon a network. Telemed J E Health 2010;16:244–253. 3. Doherty ST, Oh P. A multi-sensor monitoring system of human physiology and daily activities. Telemed J E Health 2012;18:185–192.

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