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.