Pac-Man Invades the World of Medicine

“There’s nothing good that will come from playing video games.”

That’s what I heard some older folks say when I was still young. Well, I beg to disagree. If you’re a parent who don’t like your kids to play video games, please don’t hate me for this.

My first exposure to video games was in the early 1980’s when Game and Watch, a handheld electronic game, was introduced by Nintendo. I played games like, Octopus, Chef, and Donkey Kong. I did not own a Game and Watch as my parents would not splurge on these. But near our school was a store where one can rent Game and Watch. They were chained to a wall, and for 25 centavos, I can play for 10 minutes.

Later on I occasionally played video games in the mall arcades, like the classic Space Invaders and Pac-Man.

classic Pac-Man (photo from the web)

classic Pac-Man (photo from the web)

For home video console back in those days, there was Atari. Again we don’t own one, I just played in my friend’s house. I remember one instance when I was still in College, my friends and I spent one night playing video game till the wee hours of the morning.

The next generation handheld video games had more advanced graphics. Game Boy launched a handheld version of Tetris which was a huge success in the early 90’s.

One time after I finished Medical School, I joined a Medical Mission trip to Batangas. I sat beside a girl whom I recently met at that time, and she played Tetris the entire trip that she barely talked to me. But at least she let me borrow it for a few minutes.

Nowadays, I still play Wii, once in a while, with my kids, and I have a few games in my iPhone as well, that I play when I am bored. Though I don’t consider myself a serious gamer, nor do I wish to play some of the newer games today, as they are far too violent than Super Mario beating up fungus and turtles.

Last week I attended a seminar in Minneapolis to learn a new way of doing bronchoscopy (scope to look inside the lungs). This method borrowed technology from video games and thus it turns bronchoscopy into something like playing one. It is called Electromagnetic Navigational Bronchoscopy (ENB).



By the way, I have known the term “electromagnetic” since I was in grade school. Yes, you read it right, since grade school. I learned it from watching super robot anime, Voltes V. One of its weapons was the “Ultra-electromagnetic Top.”

Back to Navigational Bronchoscopy, the procedure involves placing an electromagnetic locator board underneath the patient. With a special software it transforms the patient’s CT scan images into a virtual map that can lead you to any specific point you want. With this modality, it improves the yield and accuracy of biopsy results.

Let’s say there’s an 8 mm nodule in the patient’s lungs seen on CT scan. I can program this as my “target,” on the software. Then using the specialized scope, I will follow the virtual image on the screen, that will help me navigate turn by turn into the different bronchial passageways until I reach the target for biopsy. It is like doing bronchoscopy with a GPS.

This technology evolved less than 10 years ago and is becoming mainstream in the past few years. Even though I have performed more than a thousand conventional bronchoscopies since I finished my Pulmonary Fellowship training in 1999, I want to stay current with the changing times. So I went to train for this new technique.


our training facility

Meet Jackson, my trainer. He is not an expert bronchoscopist. He is a pig. No, I’m not calling people names. He is really a pig! Sacrificed for the sake of science. Here is Jackson’s lungs where I practiced and tried to sharpen my skills in Navigational Bronchoscopy.



Who said you cannot teach an old dog a new trick?

This morning, with the assistance of one of my junior partners, I performed a Navigational Bronchoscopy on a real patient. Even though the location of the target was quite difficult to reach, the ability that required hand-eye coordination came out naturally for me – honed from years of playing video games.  And guess what? It was fun too. Just like a video game.

Who said nothing good will come from playing a video game?


PS. The girl whom I sat with who played Tetris for hours, years ago? She’s now my wife.



Sound Technology

Two weeks ago, I went to Boston to learn a new technology and acquire more skills regarding this state-of-the-art practice in my subspecialty. The technology is something about the use of ultrasound.

Ultrasound, which uses sound waves for imaging, is not by any means a new technology. Man is not the only creature to use sound waves to detect objects either. Whales, dolphins, and bats use sonar to echolocate and navigate their way. The term ultrasound applies to sound waves that is beyond the audible range of human hearing which is 20,000 Herts. The frequencies used in medical diagnostic ultrasonography is 2 to 18 mega Hertz (2,000,000 to 18,000,000 Hertz). These sound waves are really beyond what we can hear, even for bat ears, which can hear up to 120,000 Hertz.

When we think of ultrasound or ultrasonography, we usually think of the technology of imaging babies. This imaging using sound waves is invaluable in assessing the developing fetus as it does not use potentially harmful x-rays. Another popular medical use of this technology is imaging of the beating heart, which is called 2-dimensional echocardiography. But with the advancing technology, the ultrasound probes are getting smaller and smaller that they are now mounted on flexible scopes, and can be inserted to almost anywhere in the body. Yes, anywhere you can think of.

The course that I attended is about bronchoscopic use of ultrasound or Endobronchial Ultrasound (EBUS). The ultrasound probe, which is as small as a pencil eraser, is mounted at the tip of a bronchoscope. There are many other applications of ultrasound in my  field of specialty, especially its use in the Intensive Care, but that was a separate course that I took about two years ago.

Bronchoscopy is the procedure that uses a bronchoscope, a flexible fiber-optic tubular instrument, with a video camera and light on its tip, which is 2 feet long and half as thin as your pinkie finger, to visualize and examine directly the inside of the air passages and lungs without surgical incision. It is through this that we can also biopsy the lungs, or a lung mass,or a lymph node inside the chest cavity. This scope is inserted through the nose or mouth and is advanced down the throat (larynx) and into the air passages (trachea and bronchi) of the lungs. Of course the patient is sedated for this. We are not that sadistic.

With EBUS added to the bronchoscope, aside from viewing directly the inside of the lungs, we can also obtain ultrasound images to locate tumors (not babies!) and lymph nodes, and accurately biopsy them. It is really a neat technology.

bronchoscopy (photo credit from University of Iowa website)

Even though I am trained and already skilled with bronchoscopy, EBUS was not even developed or was in its infancy stage when I was doing my training in Pulmonary more than 12 years ago. However in the past five to seven years, this technology is getting used more and more, and is becoming mainstream practice in taking biopsy of lymph nodes or tumors that cannot be reached before, except through surgery by a thoracic surgeon. Therefore I want to learn this skill to be updated, competent and competitive in my field of practice. Who says “you can’t teach an old dog new tricks?”

When doing bronchoscopy and EBUS, we insert the fiber-optic scope with the ultrasound probe into the patient while we look into the video monitor. It requires a good hand-eye coordination, just like when you are playing a video game. I guess playing those video games when I was younger  have helped me with this skill. And they say that there’s nothing good that comes from video games? Just don’t let my son know this, or else he will use this against me when we tell him he is spending too much time playing.

I don’t know what other technology will be developed in the future that will affect and change the practice of medicine. Maybe they will develop an instrument that is handheld that is as big as the old Texas scientific calculator, that you can wave over the patient’s body and make an instant diagnosis. Just like the “tricorder” used in Star Trek. Yes, just like in Star Trek.

“Change is the essential process of all existence.” – Spock, Star Trek

Teach? Just Let Me Sleep!

I was on-call a few nights ago and I received a message from “Call-Transfer” at such an unholy hour of the night. I fumbled to reach for the phone in the dark and tried to shake myself off from sleep. It was a little past 1:00 AM.

“Call-Transfer” is our health-system call center (similar to the call centers that studded Manila) that handle all requests from other outlying hospitals and physicians to transfer their patients that they believe are so complicated to handle in their local institutions. These kind of patients they believed are better served in our tertiary, level-one trauma center, and academic hospital.

Most of the time, when I received these kind of calls they would like to transfer some kind of a “train-wreck,” a term we use for very sick patient with not just one but multiple problems. Usually they are intubated and on ventilator, or in critical cardiac failure, or in shock.

Frequently these patients will be fetched by our air-ambulance (helicopter), and would arrive after 30 to 45 minutes after I approved to accept them. Though almost 100 % of the time we consent for these transfers, except if there are no more available beds in our ICU. If the weather is too dangerous for the helicopter to fly, then they would be transferred by land ambulance and would arrive in our institution after about an hour to two hours depending on how far they are. Sometimes, we would receive a patient from more than 100 miles away.

I returned the call to the Call-Transfer and was soon connected to the Emergency Room (ER) of the outlying hospital. The ER doctor started to give me the history over the phone of the patient they are treating – a young volunteer firefighter who was fighting a brush fire for a few hours, and was brought to their hospital due to exhaustion, difficulty breathing and headache. My dreamy mind started to paint several different scenarios in my thoughts on why they would want to transfer this patient……..

Maybe the patient succumbed to smoke inhalation and was in respiratory failure and was intubated and required ventilator. Maybe he had airway thermal burns that requires me to do bronchoscopy (a procedure where a long flexible scope is inserted into the nose or mouth and down into the throat thru the vocal cords, and into the trachea and bronchial tubes, to directly visualize the upper and lower airways) to determine how extensive is the burn. Maybe he had significant smoke inhalation and suffered carbon monoxide poisoning and needed to be treated in our hyperbaric chamber (a pressurized chamber where patient is placed and subjected to 2-3 atmospheric pressure with 100% oxygen, like diving in a submarine, to eliminate the carbon monoxide in the body rapidly to prevent long-term neurologic sequelae). Maybe……

hyperbaric chamber

As the ER physician gave me more details of the history of the patient, it was nothing of the different scenarios I imagined. The patient was awake, alert and is not in severe respiratory compromise. In fact, he was even feeling better after several minutes in the emergency room with the application of supplemental oxygen by mask. His carboxyhemoglobin (carbon monoxide level in blood) is less than 10 %. A 20-25% or higher is dangerous and definitely need intervention, but less than 10% is usually insignificant.

I told them then, that I don’t think the patient needs to be transferred, and I don’t even think he needs to be admitted in the hospital. He just needed to be on supplemental oxygen for an hour or so and then can be released.

I was glad that I can go back to sleep and that I don’t need to leave home and drive back to the hospital. But before I can hang-up the phone, the ED physician told me that he was a senior resident, a doctor-in-training, who was moonlighting in that emergency room. He asked me what were the “teaching points” in this case.

“Are you kidding me? Do you have any idea what time of day it is?!!” Maybe that was my first thought, but that was not what I said. For I obliged, and was able to muster a few teaching points about carbon monoxide poisoning to this young physician even in my half-awake brain.

I know I was in that situation before. And I am thankful for all the teachers and instructors that gave their time and effort to teach and guide me. If it was not for them, I would not be where I am now. Now it is my turn to do the same. That is one reason I practice in a teaching hospital.

I laid awake for more than an hour afterwards and cannot get back to sleep after I hung-up the phone. Darn! So much for teaching points.

(*image from here)