Joseph F. Clark, Ph.D.

The 2009 NATA conference for me was a big success and well worth the trip. Unfortunately because of family commitments I needed to miss all of Saturday, but my goals for Thursday and Friday were met and exceeded on all fronts.

By way of a background over the past several years I make the conference about every two or three years to stay current, scout technology and ensure CEUs for the BOC. I’m a Professor of Neurology and no longer work directly with athletes, but rather do research related to head injury, traumatic brain injury and related neurologic diseases. As it turns out technologies that are applied in the sports medicine setting have many applications to the primary, secondary and tertiary care arenas. So much of what I get from the conference is newer methods and technologies that might have applications to other clinical settings. Therefore, I attend presentations, poster sessions and the exhibits to get a feel for what is being done for and to athletes.

In my main work we are trying to develop ways to diagnose and treat patients with concussion, traumatic brain injury and stroke. These patients are similar to athletes in that they are seeking care, treatment and rehabilitation to return to their lives, much like athletes are seeking care and rehab to return to play. A difference is that the stroke patient’s goal is often to be able to do the simple things in life; like walking and getting dressed in the morning. Whereas the athletes are more willing and able to try new things in an effort to gain a competitive edge, the stroke patient will need to depend upon their care givers to apply FDA approved modalities to improve their situation. So in a way, the trainers and athletes are giving me an opportunity to see what we can put to the FDA for helping TBI, stroke and head injured patients.

Over the past few years there have been hot new things at the convention which have eventually faded and disappeared and some things move into mainstream. I like to think that I am part of that process of mainstreaming technologies. A concern that I have about the relatively rapid nature with which new technologies can come and go in the sports medicine arena is that sometimes the background research and safety may be lacking. Of particular concern I have and have had is untested, unfounded and misleading nutritional supplements marketed to the athletes. For example, a few years ago I was emailed a supplement’s info that someone wanted me to look at and according to the ingredients it had toxic heavy metals in it as well as one radioactive nuclide. Yes, a compound whose most common isotope was radioactive. Needless to say that supplement was not long lived.

Recent FDA activity has also called into question the safety of dietary supplements targeted to athletes. http://www.cnn.com/2009/HEALTH/07/28/body.building.steroids/index.html

I therefore have a bit of a habit of looking at the ingredients of the nutritional supplements and quizzing the vendors on their claims. Most are inflated and with the vaguest of background research support but rarely do you see toxic and radioactive compounds in them. That is until this year. I was looking at the ingredients list for an ergogenic aid and dietary supplement mixture from a company I have chosen to keep nameless. In the ingredients list was guanidinopropionic acid also known as GPA. The most common form of GPA is the beta form, where the guanidine group is attached to the third carbon of the propionate. This molecule, GPA is an analogue of creatine. It can be phosphorylated by creatine kinase in muscle to produce GPA-phosphate. However it is not as good a buffer of ATP, compared to phosphocreatine and GPA is an inhibitor of creatine transport. A proprietary form of creatine was also on the ingredients list. So, GPA’s presence will inhibit the putative benefits from creatine in the formulation.

The above information about GPA is a cause for concern in and of itself, because GPA might be decreasing the beneficial effects of creatine and impeding the creatine kinase and creatine transporter systems. What makes this supplement of particular concern is that GPA has been known since the 1980s and 1990s to cause heart failure. It is actually given to animals to cause experimental heart failure. It is highly toxic especially if given the chance to accumulate in the body, which is what the company suggests for its supplemention regimen. GPA accumulates as GPA-phosphate to much larger concentrations than phosphocreatine and will deprive the muscle of ATP. Heart failure is thought to occur because of damage to the mitochondria and contractile proteins of the muscle.

This is obviously a case of caveat emptor, let the buyer beware. But the informed athletic trainer also needs to beware of what, if any, science is behind the technologies being peddled by the exhibitors. As stated in the beginning of this piece, there are a lot of cutting edge technologies available to the sports medicine community and I’m proud to play a part in getting technologies to other patient populations, which means your athletes are the guinea pigs for my stroke and head injury patients. However, I would hate for you the ATC and your teams to have to learn lessons of toxicity in some supplements, when the information is already out there. The counter to Caveat emptor is Lux Et Veritas, Light and Knowledge.

This is a re-post of a letter to the editor of the NATA News which appeared in the July 2009 Issue. Reprinted with permission.

Ok, so I had my second book signing and as usual I learned a thing or two. Not a bad thing for a college professor talking about ambulance education. Never too old to learn and continue learning. The book signing was at the Firehouse Exposition in Baltimore Maryland. I was doing the signing at the exhibition booth of the bookseller Firehouse books. I did however take some time to walk around the exhibits in an effort to see what some of the latest technologies are. This proved to be quite educational.

I learned how the profession of EMS is more and more about putting disposable plastic stuff into and onto people. As one example, I liked the concept of a plastic template for placing an endotracheal tube into the patient without the need for a stylette or visualization of the vocal cords. This will, according to the sales woman, “work perfectly every time,” for the right sized patient without abnormal anatomy.

The exception is a concern for me. If all the easy intubations on non-swollen, non-hemorrhaging and normal body type patients are done with the idiot proof device will that make the intubation skill set of the paramedic get stale? My concern is that when he or she needs to do a hard intubation the lack of repetition on the easy ones will magnify the difficulty of a challenging intubation.

There are emergency rooms where the policy is to have anesthesiology intubate patients as opposed to the emergency room physicians or ACLS certified nurses. There is some justification for this type of protocol because the ER has a staff to back up each other. The paramedic does not have this luxury of a quick back up. I talked about this concept briefly in my book, My Ambulance Education’ in chapter 16 entitled Along for the Ride. So if you can’t ‘tube’ the patient the patient dies. Therefore, keep up those skills and try to not be too dependent on fair weather technology.

So while I love the technology and I support faster and better EMS concepts, I firmly believe that the practice of emergency medicine needs hands on practice. I am neither for nor against the company or intubation technology. I just wish to emphasize that those skills need practiced and proficient hands and eyes.

Learned thing number two. Every time I tell EMS people about my current research to develop diagnostic technologies for the neuro patient including stroke and head injury, they nod vigorously. They bemoan the fact that over 85% of the time an EMT or paramedic can diagnose a stroke but not treat that stoke patient because it is not yet possible to diagnose the subtypes of stroke, which need different treatments. They are equally concerned with the “dead man walking” patient where a patient with a mild concussion is bleeding in the brain and in a lethal condition. This is what most paramedical personnel fear and may be what happened to Natasha Richardson. So the community seems open to diagnostics in the ambulance and anxious to adopt new things. With limited space on the ambulance, we need to be very careful what is developed and how it is packaged. But changes and improvements are coming.

The NIH needs to solicit and fund a massive effort to reduce, refine and replace the use of antibiotics. This is desperately needed because of the growing problem of drug resistance. Microbes become resistant to antibiotics via a kind of natural selection when the genes of the bacteria mutate and become resistant to our attempts to kill them. Thus if a person has an infection and is given antibiotics, the bacteria causing the infection might become resistant spontaneously via mutation and become the so called superbug. Thus the use of antibiotics leads to the formation of superbugs.

I am not at all suggesting that people who need antibiotics be refused antibiotics. I am suggesting ways to avoid the abuse and misuse of antibiotics.

In the USA 40,000 people die annually from antibiotic resistant bacteria and that number is rising. The numbers of patients affected by such infections and the costs for taking care of these people becomes staggering totaling in the billions annually. The signs indicate that the incidence and impact of superbugs is growing, so we need to mobilize now to head off a potentially devastating health crisis.

The best way to prevent superbugs from being produced is to not give them an opportunity to be formed. That is done by avoiding the misuse of antibiotics. The ways to avoid using antibiotics can be: prescribe only when needed, prescribe only what is needed, and prescribe alternates. While this sounds simple on the surface, to do these things will require research and education. Educating physicians and patients because they will need to modify the behavior of people who have come to depend upon antibiotics because of the outdated thought, “they cannot hurt” the patient. Well, the patient may not be directly hurt by the antibiotics except that the use of that antibiotic may be giving a bacterium a chance to be gain resistance. Further, that patient may become dependent upon using antibiotics and not train their immune system to respond when needed.

One example that is an unfortunately common scenario is the patient suspected of meningitis. If a patient sees a physician for a suspected meningitis infection the physician will do the usual diagnostics including culturing spinal fluid. But the culture can take days to bring back a result. In the interim the physician will prescribe poly-potent antibiotics to prophylacticly treat the meningitis. When the results of the cell culture come back if negative the antibiotics were not needed. If the result is an infection the physician can focus the antibiotic to treat that infectious agent. This sequence of events is absolutely good clinical practice for the patient but devastatingly risky with regard to causing the formation of a superbug.

What would be more prudent would be to be able to focus the antibiotic treatment from the first day to treat the specific bacterium causing the meningitis. That would require identifying the bacteria in minutes to hours, as opposed to days and the state of technology is not able to provide an answer that quickly. A quick diagnosis will be possible only if the NIH decides to fund research focused on providing fast answers and ways to reduce, refine and replace the use of antibiotics, which is the theme of this discussion. Again, I plead with the NIH and others in the medical and research communities to begin an initiative to stem the tide of capricious use of antibiotics.

Why do most research universities in the USA lose money on research?

That is a question that comes up in numerous college, university and teaching hospital conference rooms. Deans, Department Chairs and essentially all administrators are asking that question. It is not because of the economy although the economy contributes to the very bad situation that we have right now. This issue is not unique to where I work either. I can assure you that many scientists around the country will have a similar story to tell.

As an academic researcher I can tell you very simply why my research is losing money for the University. “We are not allowed to make money.” My academic research is not allowed to make a profit is the reason research is not profitable. The best I can hope for is to break even. If for one second I do not break even and lose money, I am never allowed to recover that loss. Those are the rules. Said rules came about when colleges, universities and hospitals funded research because it was needed to educate the next generation of scientists. But with years of huge state and federal budget cuts funding for research has dried up. Therefore all researchers need to have grants to cover every penny of their research. This demand to cover all expenses is referred to as being more “business like” with research.

I fully agree and embrace the concept that the business of research is business. If you want me to run my lab that way, then let me run it like a business and let me control my funds, make personnel decisions and make a profit. But with the current rules, I cannot run my research like a business, so do not make me try. These rules are not my decision, so someone in the higher levels of academia needs to make a policy change. Research is either part of the University remit along with education, or it is a business. You cannot have it both ways. I cannot make my lab do both academic research supporting students and make a profit. Just choose and tell me what the rules are. Then it is up to me to sink or swim.

Let me give some simple examples of the confusion that occurs for researchers. If the federal government awards me with a grant and writes a $100,000 check to support one year’s worth of research, the University will take $46,000 of that check and keep it leaving me with $54,000. The University claims that the $46,000 is used to support facilities such as the library and pay electric bills. I have never been to the University’s library, but still have to pay those fees. The remaining $54,000 the University holds for me as I spend it to get the work done. The money is paid up front, so I spend it out of university held accounts. However, it does not earn interest for my research. If after the end of the grant I have spent $50,000 and completed the work proposed, I cannot (normally) keep the rest of the money. It needs to be spent. The extra $4000 cannot be banked and cannot be held for a rainy day. The philosophy is; use it or lose it. So I have to be revenue neutral; get a grant, spend it all and repeat.

Anyone who works in business will see that the problem is there is no profit margin and a waste of capital equity. If I were a business, I would put the initial funds in an interest earning bank account and re-invest the extra $4000 for the future or as cash reserves for a future short fall. In today’s system, that is not allowed. Yet, the leaders of many universities want me to run my research enterprise like a business but with rules where the business model is untenable.

Another way that the profitability of the University’s research enterprise is limited and thus not business like is that researchers are not allowed to work on their research if it is likely to make money. That is considered a conflict of interest. Again let me explain with a simple example. If I were to discover a drug that could treat patients with cancer and cure them of that disease I would have to stop all research on that drug the second it looked like that drug might work. As soon as a company starts considering doing drug trials to treat patients I would be forced to stop doing work on that drug because it might be perceived as a conflict of interest. Even if I spent my entire life and career trying to find such a drug as soon as I might be the least bit successful on that subject the University will say that I am conflicted and not allow me to work on that subject.

The result is a profitable funding opportunity is gone. I will have lost a revenue stream and again my research will no longer be generating money. This is absolutely unconscionable, but true. Therefore, many scientists do not want to commercialize their research or make products that could be useful because once a company sees that the research might be profitable that research opportunity is taken away.

As said above, someone in a position of power needs to make a decision as to if academic researchers should be business researchers or educational researchers. Tell me which one you want me to be and set the ground rules clearly. What is happening now is a slow disaster where the best and brightest are being prevented from being successful. The result is the best and brightest minds are leaving science and new people are not entering science.

I have spent innumerable hours in meetings and do what ever I can to avoid talking and leading meetings. People know that the best way to get my opinion is to ask and people tend to listen if I am forced to participate. I tell people I am a voracious note taker and bring my laboratory notebook to meetings as part of my work product and document history. Thus I can ‘focus’ on the notes and synthesize data later. Now unfortunately I am *forced* to lead meetings and will need to call future meetings and resolve issues as well as making decisions. That said, I guess I am pretty institutionalized and desensitized to meetings, agendas and the drudgery of academia replete with endless hours of meeting minutia.

That experience does not however preclude me from being impressed by the skill of others who have truly mastered the art of verbal mysticism in the setting of a meeting. I was once privileged to be involved in a highly technical and confidential meeting concerning finances and drug development involving a large pharmaceutical company and some academic researchers who might work with the company’s drugs.

Obviously I cannot disclose the company or the drugs, so forgive me for being cryptic. In the meeting a very poignant question was asked of the drug company executive. The question was one that would normally make company executives squirm because a complete answer would require disclosing company plans and expenses, which they will not wish to provide. In such a case the typical strategy for responding would be; to answer a different question, state that some things are confidential, deny having the authority to disclose, deny having knowledge of the subject etc. If you watch politicians on TV they will do that for many questions. Watch for phrases like, “The issue is not what you asked but rather … this other issue.” And they answer that question.

Well after years of meetings I thought I had seen it all, but in this meeting I learned another method to avoid answering a direct question. This skillful administrator spoke randomly and provided various facts and complimented the questioner and the university on our skills and expertise. He waxed lyrical on our international standing on such subjects and paid numerous compliments interspersed with unrelated facts. Without exaggeration he gave a 10 minute monologue and made absolutely no effort to answer the original question. He concluded his soliloquy by posing another question to another member of our team. Someone always anxious to provide an opinion and she instantly and efficiently answered his question, while the group seemed to have left the original issue well behind.

In my note book I wrote something along the lines of; “BS.. No info. more BS… Yawn. Wow this guy is good!!!”

I was impressed, but I doubt I’ll emulate his performance.

BTW, the deal discussed in that meeting did not go through so the above lesson is the only benifit from that meeting.

I was asked an interesting question a while ago that deserved thought before responding. Here is the question and response.

It seems that all of our politicians are lawyers. There are a few medical doctors in congresses but why are there no Scientists?

Good question. The answer is, “I have no idea why there are no scientists in Congress.” But given that answer I am happy to speculate. By way of review, I have been educated as a scientist and actively participate in the education system for physicians. So, I feel I see how those intelligent people are trained and educated. I have never been through law school, but my brother went, so I got some ideas from him.

I think that the reason that scientists tend not to be politicians is they are educated and think completely different than politicians and lawyers. Lawyers are trained to work against and adversary. They fight other lawyers and judges and defendants etc in the name of justice for their client. Also, when lawyers are preparing contracts or documents two lawyers battle against each other.

Physicians are often educated in highly competitive and cutthroat systems to get into medical school, or into residency etc. They are taught to make one decision, that their decision is right and defend it. Their adversary is other students in school and lawyers to prevent malpractice law suits.

Scientists are taught to try to see multiple sides of a story, get outside opinions and to work with different disciplines to answer a question. A scientist will encourage others to verify if they are right or wrong and adjust their hypothesis if new information comes in. Openness and collaboration between scientists is encouraged and trained from an early educational stage. Scientists are very effectively trained to work with and as part of a team.

With that brief summary of the education and mind set of those disciplines the odd one out is the scientist. Physicians who need to out-compete classmates for coveted spots in medical school are well suited to elected office because the election is like competing for a spot. Lawyers are used to disparaging comments of adversaries so criticizing the opposing party is a natural thing to do. Scientists however are not trained to work or think in those terms and just do not make it to national offices such as congress. Is that correct? Who knows, it is just my opinion. But nonetheless, it is sad that more scientists (any) are not in congress.

If you want to know how or why scientists would be good to have in congress, watch this space.

A colleague asked me about the partners I had when working on the ambulance. She specifically wanted to know what female partners I had and if I had any female partners.

Yes, I did indeed have several female partners. However, they were not as visible in My Ambulance Education as some of the other partners simply because the memorable and colorful calls with the female partners seemed to have not stuck with me. That does not mean that the memories of those partners did not stick with me.

Speaking of drivers’, an ambulance driver is a special kind of skill. The ambulance is bigger than a cop-car but is expected to navigate through the streets like a smaller and nimble police car. It does not have the visibility or presence of a firetruck so it sometimes is not given the respect that a 2.5 tone vehicle should get. Therefore an ambulance driver needs to have the skill of a police officer at speed but handle a heavy weight vehicle sometimes more like a firetruck. This is a unique skill.

Drivers tend to treat their ambulances like a person staking out personal space. We all have personal space where if someone stands too close too us we feel uncomfortable and will tend to move away to a comfortable distance. Drivers do the same thing. We form an invisible bubble around the ambulance where it is safe for other cars or pedestrians to be in it before we feel uncomfortable and try to evade them. Part of the comfort bubble is dictated by special awareness of the driver. Spatial awareness is knowing where the vehicle starts and stops on all sides.

So let’s say that I’m a driver and my comfort bubble is 12 inches on the driver’s side, 24 inches on the passenger side and three feet in front of and behind the ambulance. This might be typical. So I can drive along and parked cars will be about two feet away from the passenger side door. I would stop and have three feet in front of the ambulance and the car in front of me. Most on duty ambulance drivers will also stop at red lights with about 5 or 6 feet between them and the stopped care in front of and in the fast lane such that it is easy to pull into oncoming traffic to turn around or get through the intersection if called to an emergency while waiting at the red light.

One particular partner I distinctly remember working with was a woman by the name of Lucy Krupp. Lucy was without exception the best driver I every worked with. The analytical person in me wants to say that she had the shortest and smallest comfort bubble I had ever seen and this is explained below.

Like an Indianapolis 500 race car driver she would fly into turns or intersections and break at the last minute seemingly too late to stop, but be able to stop in time. She would use the whole turn and intersection to get through stop lights safely and at speed while accelerating out of a turn, long before it seemed like we were done turning. It was an emotional and wild ride when Lucy was driving lights and sirens.

With her very short distances in the comfort bubble we would be passing parked cars with just an inch between us. I would literally be jumping out of my seat and into her lap, figuratively, for fear of crashing on my side of the ambulance. But we never hit anything. Lucy would chuckle knowing what she was doing to me as she calmly made her way through the city streets. I’m leaning away from the door wide eyed, but not wanting to look. I’m also trying to take the radio call and sound somewhat calm despite being scared witless as we race through traffic.

At one intersection, when we were between calls, Lucy was driving and we were stopped at a red light. Lucy pulled in the passing lane and the front bumper must have been about two feet from the car in front of us. I knew better than to comment that if we got a call we were stuck until the light changed because the odds are against that and it was not too big a deal. Well as these things go, we did get a call and needed to turn around, but I thought we were stuck until the light changed. Immediately, Lucy cut the wheel hard and slammed on the gas. In one maximal G force turn I’m slammed against the window of the passenger door as we make a hard U turn. I am amazed we miss the car in front of us and even more shocked to miss the parked cars on the other side of the street. While I’m speechless and breathless, I got on the radio and gave an eta for our arrival on the scene of our next call. All Lucy did was chuckle at my white knuckled posture as I grip the mike of the radio and stutter our response to the call.

To some, Lucy might seem to sound like a bad but lucky driver. She was skilled and if you looked at her when driving she was calm and having fun. Maybe she had fun tormenting her partners or maybe she enjoyed pushing the ambulance. I’m not sure which. But she was quite a person to ride with. Perhaps I was in shock after she drove to calls such that none of her calls were memorable enough to make it into My Ambulance Education, but driving with Lucy was an education nonetheless.

HIPAA; Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act was supposed to protect patient’s privacy from being abused by insurance companies. So a lot of confidentiality issues were addressed in the act. The result has done almost anything but help patients. What is has done is made research and communication between physicians impossible by making transfer of information illegal. One result has been to force patients to be custodians of their records and referral procedure.
Some physicians and doctors offices will no longer transfer files, records or make referrals for fear of running afoul of HIPAA rules. My father wanted another doctor to look at his X-rays and his physician’s office would not send them to another physician. They would only give the copies of his medical records personally to my father and no one else. While being very ill, unable to walk without assistance, we had to walk my father into his doctor’s office to obtain his records to get a second opinion. My father, the patient, suffered in this example because it caused delays and physical stress to have to be a currier in this case.
I am a scientist with unique skills in the diagnosis and understanding of some types of stroke and stroke complications. Prior to HIPAA I was frequently consulted by physicians as to their patients. Now many physicians are afraid to talk about their patients with me because of HIPAA compliance fears. These physicians may be impeded by not being able to obtain important cutting edge knowledge for their patients. Who suffers; the patient?
The goal of HIPAA may have been to help the patients but the patients are suffering horrendously. There are many things wrong with the American Health Care system and HIPAA is one of them.

I had a chance to spend the day in an emergency room this past week. Fortunately it was not because of an emergency for myself or loved one. Rather I was shadowing a physician to evaluate technologies used in the emergency room and to help identify areas of technological improvement. This was an interesting assignment because my prism for emergency medicine is based on my working as an EMT on an ambulance and in the emergency room over 20 years ago. The last time I was working in an ER was around 1989 and my EMT expired in 1992.

I can tell you in great detail some of the huge scientific and technological breakthroughs that have occurred in research technologies in that time and I needed to evaluate what the state of the art is in ERs. The ER physician and I arrived at 7:00 AM and went through report and transfer of patients. This is a process whereby the status and disposition of the patients in the ER are given to the incoming physicians and nurses. The personnel are briefed and introduce themselves to their new patients. This time honored tradition was executed with efficiency and clarity in much the same way it was over 20 years ago and likely remains unchanged for many decades.

The patients from the overnight shift were unremarkable. While those patients were not in life threatening conditions, they were emotionally wrapped up with their situations. For most of the patients the physicians were waiting on some kind of information; X-rays, lab reports, pregnancy tests, expert consultations etc. There was a lot going on, a lot that needed to be done, but nothing that could be done right then. So, we waited.

One patient who came in was a person with visual dysfunction for about 5 days. A possible ischemic or hemorrhagic stroke is possible or direct problem of the eyes could be the problem. X-rays, blood tests, and CT scans were ordered. This means the physician orders the tests, the tests are transferred to a coordinating person, the orders were distributed to the lab and radiology and we waited. The next patient is best described as failure to thrive; someone with multiple medical, substance abuse and psychological problems. Again a series of tests are ordered and we wait. Another patient arrived from a nursing home and went into a room for serious patients. He was non-responsive, poor oxygenation and a person who showed signs of age and medical dysfunction of multiple organs. The problem is to figure out what is the most serious problem and keep that person alive. He could have ischemia, toxic build up, organ failure or myriad other issues. Again, multiple tests are ordered and we wait.

We get word that 2 or 3 gunshot wound patients are in route from a gunfight down town. It is only 10:30 AM and the knife and gun club has opened for business. With a three minute ETA the ER physician rushes around the ER to try to clear other patients from their rooms. He is still waiting for multiple tests on multiple patients and does what he can before the GSWs arrive. In the mean time the main trauma rooms are cleared and prepared for the GSWs. The surgical trauma team arrives to handle the most serious patient(s) and the operating rooms are prepared.

The first GSW victim arrives and he was shot in the arm as an innocent bystander of a shooting on a bus. He put his hand up defensively and the bullet went through his forearm. A second ambulance brought in the more seriously injured person, there were only 2 victims, and the second person was shot in the abdomen with a through and through wound. The patient was x-rayed in the stretcher and to demarcate the bullet holes the surgeon taped on unfolded paperclips to point to the holes. That is NOT high technology but it works for the x-rays. The patient was calm and stoic, possibly in shock, but coherent. Impressively the patient was transferred to the operating room within minutes of arrival to the ER. Speed was needed to save his life and that is what happened.

The rest of the day was uneventful with chronic medical problems that caused someone to come to the ER. Sometimes poor perfusion to the legs, rule out heart attack, pain of unknown origin and etc. The scenario for the ER physician was also pretty constant, of evaluate the patient, order some tests and wait for results. He would sometimes walk in complete circles to deliver orders to get a patient admitted or get an x-ray. Occasionally asking to see if an x-ray was done and needing to wait longer. Then checking on some results to find out they were back a while ago, but he did not get the info.

From a technology perspective the monitors that I saw in the ER are very similar to what I saw 20 years ago. Monitoring of blood pressure, heart rate and respirations is pretty much the same. Real time blood oxygenation is new, but as with most of the monitoring devices the alarms are pretty much turned off and ignored. So what is the use of that technology?

X-rays are better in their resolution but the problem is the time it takes for the information to be conveyed from point to point. Some of the benefits of the x-ray resolution may be lost however, because they are now viewed on computer screens and shrunk, so size perspective is easily lost.

In the technology business there is a saying for people doing research and development of, Cheaper, Better or Faster: pick any two. That means that if you are doing R&D you should improve two of those three metrics. Well in ER technology as far as I can see Faster is not a priority because there was too much waiting for tests to get back. Better is subjective because I’m NOT convinced what I saw after 20 years of technology movement represented an improvement. We all know that medicine is not cheaper than it was 20 years ago, so where did the technology go when it hit the Emergency room? While this is a 21st century emergency room I remain to be convinced that the technology improvements are real improvements. Different is not better.

With regard to different, there are things that are different. Drug dispensing is more organized and inventory can be better monitored. Kits for suturing, catheters, IVs etc are all prepackaged and disposable. So technology has taken us from ala carte choices to prepackaged fast-food presentation of medical devices. As far as I’m concerned, this is good news for what I want to do with regard to developing technologies for ER and EMS situations. There are a huge number of clinical and technological opportunities where advances can be made and I hope we will be at the forefront of making those strides forward in improved patient care.

An interesting paradox has arisen. An email came through my website that commented on “My Ambulance Education” and referred to it as my first professional writing. That comment, while kind in its intention, gave me pause for thought. I actually do consider myself a professional writer and did so before this. My job as a university professor requires me to write papers, grants and reports. I’m not complaining about the comment, but I acknowledge that my ‘professional’ publications are not that widely read. For example, a grant application that gets funded for a few million dollars is likely only read by about five or six people to get that funding. The research papers are read by a few more people and I know that the book, “Creatine and Creatine Phosphate” sold about 2000 copies. There are a lot of great writers who toil tirelessly to convey very complicated scientific concepts and these people are professional authors. I considered myself amongst the ranks of these professional writers. I also teach students to write scientifically and it is a learned skill required for the academic community.

I am honored to have a publication in the popular press and really do not think that the skill of science writing and writing “My Ambulance Education” is that different. The common denominators are to know the reader, know your audience and have a clear goal of what you want to say. If I write a grant, I put myself in the shoes of the grant reviewer. When writing “My Ambulance Education”, I put myself in the shoes of the active ambulance personnel. If I felt they could relate and like what they heard, I would keep writing. I love my job, I love to write and I loved writing “My Ambulance Education”.