Hospitals that care solely for children have unique challenges compared to regular or adult-only hospitals. Children are smaller and so need to be surgical tools and orthopedic devices designed for them. Children grow rapidly, so implants need to be replaced often.
“Just from a population/numbers standpoint, there are fewer kids than adults, and fewer kids going inside hospitals than adults,” said Justin Ryan, director of the Helen and Will Webster Foundation 3D Innovations Lab at Rady Children’s Hospital, San Diego. This alone impacts cost. Providers of surgical tools and devices, like any manufacturer, rely on mass production to bring costs down to make it financially feasible. “Usually at children’s hospitals, we get the scaled-down version, or a version used only on adults, and we’re left trying to figure out how to best apply it for a pediatric application.”
Enter 3D printing, with its ability to make anything a child, or a children’s hospital, might need.
The challenge for Ryan when he came to Rady Children’s in 2018 was establishing such a facility, a 3D print factory, and streamlining its operations for the needs of the medical staff and their patients. First came surgical modeling, but the capabilities expanded beyond that. Rady Children’s itself is unique, since it is a regional provider whose geographic scope extends to remote Pacific islands. “We believe that 3D modeling, 3D printing, and extended reality intersect with the goal of helping as many kids as possible,” he said. “If we can plan for a surgery better than we could with these emerging technologies, we’re going to do that.”
Surgical modeling (often referred to as anatomical modeling) was the first and most obvious use-case of 3D printing for Rady. The basic concept, becoming more prevalent throughout surgical medicine, is to model the organ and sometimes its surrounding body structure in an anatomically accurate piece that surgeons can handle and touch.
Such modeling starts by scanning the patient thoroughly with radiology devices such as CT and MRI scans, and convert scan data into 3D CAD models through the talents of segmentation specialists. These digital models are then used to 3D print the models a surgeon can handle, and a patient’s family can see. “We enable our surgeons and our interventionists to look at anatomy before they actually operate on a patient. They get to see the traditionally unseen, which is very exciting to be part of,” said Ryan. Via a 3D model, parents may fully understand for the first time the problem their child is dealing with and how a surgeon is going to fix it.
A surgeon’s reaction is just as important. Looking at a model for the first time can be surprising. Sometimes, the model is made of a material that mimics tissue and bone, so the surgeon has a chance to practice challenging procedures before touching living flesh. “Sometimes [surgeons] recognize that [the anatomy they intended to operate on] has a different problem or challenge” than the one they had initially thought, he said.
The complexity of a cardiac or trauma case can be overwhelming. “A majority of what I do are models for very, very young kids, under the age of three,” explained Ryan. “Not only is it challenging to educate the child about their diagnoses, but educating the family [is a challenge] as well. These models are an incredible tool. The average family doesn’t have a medical background; in fact, a significant part of our patient-family population lack advanced education or access to resources to do their own education. How do we convey complex medical diagnosis and information to these families that are already stretched emotionally and significantly stressed by their child’s diagnosis and pending surgery? These models provide a tool for that.”
With a 3D model they can hold in their hands, surgeons can show what part of their child is going to be operated on, where cuts are to be made, what veins, arteries or ligaments are to be moved, and even what the post-surgical results might look like. From Ryan’s perspective, the specialty services, such as cardiothoracic, pulmonary, orthopedic, and ear-nose-throat, find surgical modeling particularly helpful. “I’ve seen adoption of the technology being surgeon-specific. One surgeon will love the technology immediately and want to request it more. Others might be a bit lukewarm to start, but usually we win them over as they start to see some of the more advanced models,” said Ryan.
At Rady Children’s, 3D printing is used for more than just patient-specific modeling. Specialty devices can be used in both clinical and lab practice, and for unique equipment around the hospital. “A nurse might have an idea for something that’s going to improve her or his workflow, say a connector for an existing device. Or, pharmacy may want to create a solution that helps them track outgoing medicine a bit better,” explained Ryan. So, his 3D Innovations Lab will create the fixture, part, connector or what-have-you to increase efficiency of the staff and operations.
Similar to how 3D printing might be used in a manufacturing plant, ideas are evaluated, a CAD model is created and a first prototype rapidly printed.
“These technologies help us go through an ideation process for solutions that aren’t commercially available or sometimes commercially viable (we may only need a few),” explained Ryan. “We’ve done that a few times now, and it’s starting to gain a lot more acceptance, due in large part to COVID-19.” For example, a staff member had an idea for a simple fixture that could hold clinical samples. The commercially available solution, Ryan noted, was not working as needed. “We 3D printed a specific solution for our needs. If a hospital only needs three or four of those, a commercial company is not going to make those. There is not enough incentive.”
On the flip side, he also said there are exciting ideas that the staff at Rady Children’s are also inventing that have “immense potential for commercialization,” he said. “And so, 3D printing not only provides this tool for delivering a quality improvement tool for our staff, but also the potential for revenue to come back to the institution.”
Like many other aspects of our economy in general and manufacturing in particular, the COVID pandemic has created a unique spotlight on 3D printing inside hospitals. “COVID has really increased the awareness of this technology,” said Ryan. “More nurses, more staff are reaching out about things that they want created that help them in their daily activities.”
For example, because of COVID there are more teleconferences between surgeons and families to reduce the risk of in-person exposure. “Before, a surgeon could draw on piece of paper what they were going to do, but over a video conference, communication is more challenging,” he said. “I get conferenced in on these video calls, and I’ll show a 3D structure on the screen. The surgeon will draw on the screen what’s going to happen.” By showing, even drawing, on a 3D model the procedure the surgeon will perform on the patient, the technology helps maintain a high level of communication, even in these challenging times. It is easy to make the leap that, if proven effective, these types of processes may continue post-COVID-19, especially if a family is located far from a specialist and travel leading up to a surgery is a burden.
One of the most interesting foundations of the Helen and Will Webster Foundation 3D Innovations Lab at Rady Children’s Hospital is Justin Ryan himself, who started his academic career studying art, not the engineering of 3D printing. “I attended Arizona State University, where I was mentored by professor and artist Dan Collins, PhD, in the field of intermedia, a form of art whereby collaboration between different disciplines of art is encouraged. Then I was mentored by Biomedical Engineering Professor David Frakes, PhD. My colleagues and I forged new art-inspired methods of creating anatomical models with the intent of enabling and informing engineering projects,” said Ryan in a post to the Rady Children’s website. Drawn into helping people, Ryan first earned a degree in art, then went on to get a PhD in biomedical engineering.
The lab itself is equipped with devices from Formlabs, including a Form 2 and a Form 3B printer. “The Form 3B will allow us to offer sterilizable 3D prints in the near future.” Other devices include a 660 ProJet from 3D Systems and an HP MJF 580 for full-color, nylon prints. “These prints [from the MJF 580] can be autoclaved [sterilized], which had significant implications in our COVID projects,” he said. Finally, the lab has a Stratasys F370 and the Stratasys J750 Digital Anatomy Printer. “[The J750] enables us to do complex models with material properties intended to be similar to different types of tissues. So we have flexible models that we can cut and suture. We’ve got rigid models that replicate bone that we can cut into and place in implants.”
He also noted that the lab owns an Artec Eva 3D scanner to create models of scans. “It is important to recognize that 3D printing doesn’t necessarily need to happen in a bubble,” he said. This means using extended reality technologies such as virtual reality (VR) and augmented reality (AR) that he said more hospitals are starting to leverage. “We’re doing a little bit of VR here. I’m more interested in some AR applications, but I think we still have a ways to go to really leverage those unique capabilities.”
Other directions for the future? “One of the exciting things we did last year is hire Parham Gholami, a programmer with video game experience, to extend our augmented and virtual reality applications,” said Ryan. He stresses that video-game-inspired technology is in addition to 3D printing. “We want to look at building 3D tools for surgery that leverage the resources and intuitiveness that video games deliver,” he said.
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