Eight-year-old Trent McGee is paralyzed from his neck down. Trent was riding in the back of his family's station wagon when the car was hit by a suspect fleeing the police.
"He was a very active child who loved sports," said Charles McGee of his son. "For months he just laid on a pillow. All he had was breathing treatments and suctioning to remove the mucus from his throat and lungs."
As the little boy comprehended the seriousness and permanence of his condition, he showed signs of severe depression.
Quality of life has become a topic of increasing importance and effort in healthcare in recent years. It has become one of the most challenging aspects of patient care, especially for a person who is paralyzed. How does a quadriplegic patient--one who is paralyzed from the neck down, a person who is dependent on someone else for almost everything--attain any quality of life? And how do healthcare workers and an institution whose motto is "To Make Man Whole" relate to a patient who cannot be made whole?
By human-computer interface technologies . . . interventional informatics . . . perceptual psychophysics . . . biocybernetics . . . and virtual reality.
Virtual reality was first used by the military applying interactive computer technology to stage mock battles and to train pilots. Then the entertainment industry saw its potential, leading to applications such as computer games and adventure rides.
Further application of this powerful technology was developed at Loma Linda University Medical Center and Loma Linda University Children's Hospital to help sick children and severely handicapped people attain quality of life. For example, by using only the muscles of the face, physically challenged people will be able not only to control their environment but also to make a contribution to society and to enjoy feelings of accomplishment made possible by such contributions.
By using human-computer interface technologies--including electronic sensors to measure the movement of the eyes and the activation of facial muscles--a severely handicapped person can move a cursor on a computer terminal by moving the eyes and can ask the computer to initiate commands by clenching the jaw, smiling, or raising the eyebrows.
With this emerging technology, such a person will be able to access on-line services such as Google, eBay, America Online, and Yahoo! Such capabilities will give these patients access to the world of research, travel, entertainment, and possibly to the development of international relationships. They will become citizens of the Information Culture. Many handicapped people no longer will have to be institutionalized. With advanced human-computer interfaces, including the use of computers with voice recognition to control CD-ROM (Compact Disk--Read Only Memory), such a person could conceivably become an attorney or--by the use of Computer Aided Drafting--an architect.
David Warner, M.D., Ph.D., known as Dave by the children he serves and admires, is a 1995 graduate of the School of Medicine. He entered medical school with a wealth of knowledge about computers and a valuable network of contacts with people in aerospace, the military, and entertainment. Warner now is matching existing computer technologies with healthcare in ways never before conceived. A participant in Loma Linda's M.D./Ph.D. program, Warner is now focusing on the physiological basis of information processing. Applications of his research have enabled his team of researchers to develop procedures, using off-the-shelf technologies, to help severely handicapped patients achieve goals never before thought possible. This is technology transfer with a heart. Warner has studied the neurological system as an information processing network, a link between the mind and the outside world.
Warner first transferred technology from a NASA subcontractor to healthcare with the VPL DataGlove. The DataGlove has fiber optics in the fingers. When the fingers are bent, movement is sensed by the fiber optics and translated to numerical values by a computer. He first used the DataGlove in medical applications to measure the frequency, duration, and intensity of Parkinson's tremors. It provided objective, quantifiable measurements and comparisons for neurologists to use in determining a Parkinsons patient's response to therapy and time.
Then Warner applied this technology to help patients who could no longer talk turn hand gestures into speech. By using sign language, a patient using the DataGlove could generate a computer-synthesized English-speaking "voice" to communicate with his caregivers. If the patient's loss of speech was sudden, resulting from a stroke, for example, Warner programmed the computer to "talk" from simple hand gestures, such as holding up one to five fingers for five different computer-synthesized voice messages ("I'm thirsty." "I need to go to the bathroom." "I'm having trouble breathing," etc.).
The DataGlove was then used to permit rehabilitation patients wearing it to move virtual objects around on a computer terminal. They could pull virtual levers, turn virtual wheels, and move virtual boxes around on the monitor screen, developing hand/eye coordination and fine motor skills with very little strength.
Recovery from injury often depends on a set of repetitive exercises. The rigors of rehabilitation can be difficult, especially for children. Interactive interface technology, such as virtual reality, fosters motivation because patients are having fun.
"Without exception we find that this technology engages the mind to interact. And that's a great thing," says Warner. "In rehabilitation the problem a lot of times is not that we can't rehabilitate them physiologically. It's the psychological capacity that blocks them. They don't want to do it. They're depressed. They've lost function. But now we give them something fun to do. They think they're having fun--we know they're rehabilitating."
Warner set up a research laboratory, dubbed "The Center for Really Neat Research," and later, the Human Performance Institute--all while completing medical school. His work has been mostly unfunded, out-of-pocket, low-cost efforts, using his own computers and self-designed software, or computers and software he has borrowed from sympathetic sources, including volunteer programmers. This software converts electrical impulses and other inputs into computer commands.
For example, the software can read the electrical activity created by movement in a patient's muscle. Fast-changing voltages are received by digital signal processors and determine how much energy is being expended in relation to time. When the computer detects a change in voltage, specially designed software converts those changes into computer commands. The harder the muscle works, the greater the differences in the voltages.
During each session the patient gets wired up for a variety of activities so that different muscle groups get a chance to work out. The system provides a mechanism for the patient's improvement to be monitored objectively and documented. Mike Fredholm, one of Warner's adult patients, acknowledged that the technology could increase the amount of time he would spend exercising his muscles.
However, Warner and those who see this technology's potential feel frustrated.
"It's not sanctioned, supported, or refundable by insurance," says Warner. "We're able to make a difference, but unable to use it routinely."
But that doesn't stop him. Warner is on a mission to do the most possible good with any available resources--leading by example. He is leading the effort to alter patient outcome and outlook whenever possible by using interactive information technologies.
Crystal Was a Pioneer
The first quadriplegic patient to benefit from Warner's creative mind was a baby girl named Crystal Earwood. Crystal was only 12 months old when she was paralyzed from the neck down in a terrible automobile accident. When Warner saw the baby for the first time six months later, her condition touched him deeply. She was a conscious, bright baby, just lying there, unable to move. Warner was motivated to design a computer system for Crystal. By using a bioelectric sensory band around her head, above her eyes, Crystal was able to move a Happy Face around on the screen of a computer terminal. In short, her eyes became her hands. It was the first time little Crystal had been able to do anything by herself since the accident. But it was a major achievement. One small step for Crystal--one giant step for the profoundly disabled.
Warner had obtained the bioelectric sensory band from graduate students at Stanford University. He figured if he could make it work with an 18-month-old, he could make it work with anybody. His next patient was an adult, a man also injured in an automobile accident. The electrical signals from his muscles were converted to music.
"This is the first time I have been able to do something since the accident," the man replied. The technology had a great psychological benefit. It lifted the patient's depression.
Word of Warner's achievements has spread internationally by print and broadcast media. His work has been covered by the news media in Austria, Norway, Slovenia, Italy, Germany, France, Japan, Australia, the Netherlands, Canada, and across the United States. It has been featured in the New York Times and the Los Angeles Times, and in such magazines as Scientific American, Stern (Germany), and Virtual (Italy). Warner's work has been featured on a number of television programs, such as "World News Tonight with Peter Jennings," "Beyond 2000," "Future Quest," "Quantum," "Life Choices," "America's Talking," "Nightline," and "CNN World News."
Warner has made presentations at virtual reality conferences across the United States and around the world--35 during his senior year in medical school. His keynote speech at a conference in Monaco was translated into five languages. He has made presentations at Los Alamos, Lawrence Livermore, and Sandia National Laboratories, where his topics included "Prosocial Uses of Technology Developed for the Military." In 1993 Warner made a presentation, "Human-Computer Interface Technologies in Rehabilitation," to the California Medical Association. Inquiries about Warner's work have come from rehabilitation institutes and even from the Encyclopaedia Britannica.
A special production featuring Warner, "Frontiers in Science and Technology," a laser disc produced for junior high and high school students, was designed to give children an example of a person who has done good things with sophisticated technology, to motivate them to enter science and help make the world a better place.
The First Cybernaut
Ashley Hughes, 7, of Claremont, California, paralyzed since birth, is the world's first "cybernaut." Ashley had never been in a swimming pool. However, with the help of a young man Ashley enthusiastically calls "Dave," she went "swimming." Warner built Cindy Cyberspace, a mannequin head with two small TV cameras for eyes and two microphones for ears. When Warner carried Cindy into the swimming pool, Ashley, wearing 3-D glasses and stereo headphones, was able to watch and hear everything and squealed with delight.
"I feel like I'm really in the water," said Ashley. Seeing through the "eyes" of Cindy Cyberspace, Ashley was able to look over her backyard fence for the first time and climb a tree. Warner's team has developed a computer interface system for Ashley. By using her well-disciplined cheeks, a mischievous wink, or her expressive eyebrows, Ashley can operate computer games, drive a remote control vehicle, and navigate through virtual reality. Ashley's story was featured on the front page of the San Gabriel Tribune (August 15, 1994).
To Warner, this application of virtual realty is a quality of life issue.
"She's going to be the princess of the Internet," said Warner. "She's going to teach the others how to surf the Internet.
Warner and his team of researchers recently cracked the mouse barrier. The next technological step was to devise a system that allows facial sensors to activate a computer mouse/pointer. A mouse-driver, activated by electronic sensors on Ashley's face, makes it possible for Ashley to easily communicate with people around the world. Ashley is a cybernaut in training.
"Computers will be her way of life," said Jerry Hughes, Ashley's grandfather. "For Ashley, virtual reality is reality."
"Virtual reality is a very powerful training tool for the disabled," said Harry Murphy, director of the Center on Disabilities at California State University at Northridge. "This will take us places we haven't been before, in ways we haven't been before," he said.
When asked by Ken Kashiwahara on "World News Tonight With Peter Jennings," why she liked using the new technology, Ashley responded, "ÔCause I get to fly."
Trent McGee's Outlook Brightens
A story on the front page of California's Orange County Register (October 25, 1994) told of Warner's work with Trent McGee, the 8-year-old boy who had been paralyzed from the neck down while riding in the back of his family's station wagon. His reality had caused severe depression. But once Trent got involved with virtual technology he experienced a significant change in perspective.
Warner attached sensors to the muscles of Trent's face and taught him how to operate the BioCar. A remote-controlled car from Radio Shack was modified so that it could be controlled from the parallel port of a standard computer. Trent could operate the BioCar by simply manipulating the muscles in his face. A smile moved the car forward. Raising his eyebrows moved it backward. Flexing his left cheek turned the car to the left. Flexing his right cheek turned it to the right. Television glasses received signals from a small TV camera on the front of the little car and made it possible for Trent to chase his brother and sister around the house and to "see" inside his bedroom for the first time since the accident. (The same system that allowed Trent to control the BioCar could be adapted easily to control his wheel chair and to empower him to become a functional member of society.)
An amazing thing happened. Not only did the boy come out of his depression, but he used his facial muscles so much, that he was overriding his respirator.
At the end of the sessions the expensive prototype equipment was taken back to the laboratory.
"In a few years the cost will be much less," Warner says. "But how do you tell a kid to wait until then?"
Make-A-Wish Foundation has since given Trent his own computer system and toy car.
Others have been inspired by Warner's work. During a nationwide broadcast, live from the Loma Linda University Children's Hospital, technicians contacted by CNBC's "America's Talking" volunteered to get involved by offering the use of electronic servos, devices that are used in animatronics and robotics, to help Warner multiply his efforts on behalf of severely handicapped patients.
Warner has worked with more than 100 spinal cord and brain trauma patients from throughout Southern California. "CNN World News" recorded Warner expressing his feelings about his efforts: "When one of those kids looks up and you see the smile on their face when you've given them a new capability...that is so incredible...so motivating."
Dr. Carolyn West, on the Australian Broadcasting Corporation's "Beyond 2000," summarized Warner's efforts: "Technology can help those impaired by circumstance to control their environment and so improves their quality of life. And the fact that this direct biological interface can do that while it's helping them restore their motor function, makes it a game with a lot of winners."
Warner enjoys working with children. "They start laughing," he says. "...kids who haven't laughed in a week. They start moving around in a higher degree of mobility...because they're excited about something. They've had a positive experience."
People who are knowledgeable about virtual reality usually associate it with a futuristic-looking headset that puts the participant into different computer-generated virtual environments. Using the headset, Warner has been able to help cancer patients in the Children's Hospital, some who have lost their hair from cancer therapy, to "net" big fish in a giant "aquarium," "fly" like a helicopter around the Medical Center, and explore a "house" with different rooms.
Virtual reality has shown promise in patient education and psychiatry. A real-time performance animation system was used to encode facial expressions of an actor and then to generate a 3-D talking head with realistic facial expressions that could interact with hospitalized children. The computer-generated cartoon teacher taught several classes in anatomy to a group of children assembled in a classroom and then made individual bedside appearances to children in isolation over the Children's Hospital television system. The potential for this system is profound. It can educate children about the hospital environment, interview children to assess their concerns, and augment the quality of life of a hospital-bound child.
While this chapter of LEGACY was being written, Warner helped a young man communicate by grunting--yes, grunting. The adult patient had experienced traumatic brain injury and could only make primitive sounds with his mouth. He was capable of making a variety of different sounds, but his "speech" was unintelligible. Using an off-the-shelf computer with sound card voice recognition capabilities, Warner was able to link the patient's verbal efforts with messages Warner and his team had recorded in their own voices on the memory of the computer. The patient would vocalize. The computer would "hear" his primitive sounds, recognize them, and translate them into the various messages. With off-the-shelf technology costing less than $1,000 and five minutes of instruction, the young man was able to communicate with clarity--by grunting.
Stay tuned for further adventures. This is just the beginning. Future achievements will be limited only by lack of funding. Even though Warner and his team are taking just baby steps, they are leading the world in human-computer interface technology and its relationship to physically challenged people of all ages. These patients are now capable of significant achievements and of enjoying improved quality of life.