Alex Wind

This week was the first week of the program. I was excited to get started, meet my team, and see exactly what we’d be doing for the next six weeks. For me personally, the objectives of the summer reminded me of y very first medical experience, the thing that got me interested in medical school in the first place.

In the summer of 2013, I spent several weeks shadowing in the urology department at NorthShore University Health System Evanston Hospital. Our objective was simple — observe and innovate. Sounds easy right? For a physics major who had just completed his first year with no medical background, it was actually pretty tough. I really enjoyed myself shadowing in the OR — enjoyed enough that I went on to pursue a career in medicine — but with very little engineering or medical knowledge I didn’t feel that there was much I could contribute. This time, I knew it would be different.

Armed with a Master’s degree and a full year of medical school under my belt, I entered the hospital and the clinic with my team excited to see how I could apply my knowledge. One reason I wanted to be involved with Pulmonary Critical Care this summer is because of the numerous settings we’d get to shadow in. We spent the first week moving around from the ICU, the pulmonary clinic, the pulmonary hypertension-specific clinic, the sleep clinic, and the pulmonary function test lab. In these different places, we saw examples of both good and bad design.

Good design: In many ways, the ICU runs like a well-oiled machine. The stakes are incredibly high and every member of the care team from doctors and nurses to respiratory therapists and pharmacists, have to be operating at 100% efficiency. Watching the way the different teams weaved in and around each other in the ICU was mesmerizing, one team rounding on patients while a critical care nurse tended to a patient all while a group of pharmacy students starts rounding in the opposite direction. While not a device or technical innovation, the way all these teams work together is, in my opinion, an example of good design. It’s no accident that literally dozens of people, each with a different role, are able to flow around each other in the relatively cramped space of the UI Health ICU, all accomplishing their respective tasks without getting in the way of anyone else. This type of efficiency requires careful precise design to be effective.

Bad Design: The ICU is impressive, but it is not without flaws. One example of bad design that I saw is the way that the medical team rounds. The medical team consists of about 10 people with roles ranging from medical student to senior attending physician. This large group walks around the ward from patient to patient, stopping outside each room to discuss each patient in detail. At these stops, each patient is presented to the attending physician by either a medical student, a resident, or a fellow. The physician takes time during these presentations to ask questions to the group, quizzing them on relevant details and keeping everyone sharp. The bad design here comes simply from the size of the group, which is so large that it takes up a lot of space, and also is very hard to hear. Additionally, the group pushes around two large computer workstations, dubbed “WOWs” or “Workstations on Wheels” which allow the team to view the chart and any relevant imaging studies right outside the room. In addition to the WOWs, each member of the team carries around a thick leaflet of paper containing general information, medication lists, and lab values for each patient. The system works, but I can see a lot of areas for optimization and improvement.

This week, we focused on storyboarding our experiences in clinic. The idea behind a storyboarding is to break a task down into its most fundamental components, isolating each action into a separate step. By considering a task from this perspective, it’s easiest to see possible hang-ups or redundancies.

For my storyboard this week, I decided to examine the workflow of seeing a patient in pulmonary fellow outpatient clinic from the perspective of the attending physician. Fellows clinic serves a dual purpose — it’s primary function is to make clinic hours available to patients but it’s secondary function is to allow the pulmonary fellows to see patients in clinic under the supervision and instruction of an attending physician, The attending’s time in clinic is limited and valuable and structuring the workflow such that the maximum value is extracted from this time would be beneficial to both the physicians and the patient’s trying to get an appointment in clinic.

1. The patient is checked in at the front desk
2. The patient is brought to a room by a medical assistant
3. The patient has vitals checked and recorded by a medical assistant
4. One of the pulmonary fellows goes in to see the patient. This is the first real time the attending is made aware that the patient is being seen. Before this step, the attending just sees that the patient is on the schedule and whether or not they have arrived
5. The attending has time while the fellow is in with the patient to review the patient’s chart or imaging. Often, if a different fellow has just finished seeing a different patient this time is used to discuss that patient (see step 6)
6. The fellow, who has now seen the patient, comes back to discuss the history, physical, assessment, and plan with the attending in the back office. This is the major teaching-time for the fellow, with the attending simply confirming or expanding the fellow’s action and plan.
7. This step is variable. Often, the patients need to be educated about a new medication they’re taking both in terms of what the medication is and how to actually take the medication. There are many different kinds of inhalers, all with different mechanisms, and all containing different combinations of drugs. At some point during the patient visit, one of the PharmD or PharmD students goes in with the patient to discuss what their prescribed medication(s) is(are) and how to use it(them). This may happen while the fellow and attending are meeting, and may happen afterward.
8. Finally, the attending goes in to see the patient. This final step is interesting, and seems mostly designed for patient comfort more than serving any real purpose. The attending may ask a few additional questions, do a cursory physical exam, and answer any questions the patient may have, but at this point the patient has already been seen by the fellow and a plan has been made.
9. The attending returns to the back office to await another patient

This workflow is functional, but there are a few places where it could be optimized. While the attending’s presence is required to teach and train the fellows, a lot of his or her time is spent doing nothing in the back office. I’m interested to see how steps could be combined or rearranged to make the attending’s use of time more efficient.

This week, our objective was to begin crafting “needs statements”. Needs statements are an important part of the development process for any innovation. It basically serves as the bridge between a problem and its potential solutions. In this way, a well-thought-out needs statement serves a dual purpose: it both succinctly and specifically summarizes a problem, and provides the context for beginning to think of ways to solve that problem.

A good needs statement has three components:

1. Problem
2. Population
3. Outcome

In crafting my needs statements this week, I tried to iterate so that my statements contained all three components. This wasn’t always easy — pulmonary critical care isn’t a procedure-heavy specialty, and most of the needs that my team identified were either structural or administrative. That is to say, they didn’t immediately should “engineering solution” at us. Regardless, I did my best to craft needs statements that both addressed a real problem and lent themselves to achievable solutions. While we worked on many needs and many needs statements this week, I’ll include one below as an example, showing each iteration to illustrate the process of crafting one of these statements.

1. A method to improve ICU communication
   1. This statement starts to scratch the surface of the problem we identified (i.e. ICU rounds serves a dual purpose as both a chance for physicians to consult each other regarding the care of a patient, and as a roaming classroom giving younger doctors and doctors-in-training a chance to learn from more senior physicians. The ICU is loud, however, and this “roaming classroom” can often feel more like sitting in the back of a lecture hall listening to a professor speak without a microphone. While this statement identifies the problem, it’s much too vague and doesn’t suggest a solution
2. A method to improve ICU communication during crowded ICU rounds
   1. Again, this more specifically describes the problem, but it doesn’t contain any info about who this problem affects, or what direction possible solutions could take
3. A method to improve the presently insufficient team communication between team members for health professionals during crowded ICU rounds
   1. This is the final needs statement I landed on this week — it contains a problem, a population, and an outcome. Notably, a needs solution is never necessarily done and I plan on improving and iterating this further (if it’s the need we choose to work on) over the next several weeks.

This week, our objective was to settle on a specific need, and begin the brainstorming process for developing a solution. When I heard we were supposed to spend this entire week brainstorming, I was initially very skeptical. Brainstorming seemed like a very intuitive process, something that I felt we’d sort of been doing in the background the entire time. I soon learned that despite my training as an engineer, I’d never had any experience doing the sort of structured, regimented brainstorming that we learned about this week.

During class on Monday, we learned several techniques to stimulate creativity and draw out our best ideas for solutions. My friend and teammate Zafar said several times throughout the week, “the first few ideas we think of are probably going to be the least creative — that’s why they’re coming out first. We have to draw deeper and think harder to get at the truly unique solutions.” After spending a week trying to think of every possible solution we could think of to our problem — namely, that CPAP has extremely low patient compliance — I came to agree with Zafar’s analysis.

The low CPAP patient compliance rate problem is so interesting because there are so many different avenues a possible solution could take. Could we make the mask more comfortable? Sure. Forget the mask, can we provide positive pressure some other way? Why not. As a matter of fact, forget positive pressure, can we keep patient’s airways patent without using positive pressure at all? We sure can if we think hard enough about it. This week was challenging, but in many ways it was the most fun week of the program so far for me. Flexing your creative muscles to see how far you can push yourself towards a creative solution can be an incredibly rewarding experience. Here are some of my ideas from this week:

• Electrical muscle stimulation to keep airway from collapsing
• Reclining bed that raises during sleep to keep airway open
• Warm air mask that lets you breathe warmed air which stimulates the airways to stay open
• Pressurized “tent” that coverers your entire head and neck which works like a CPAP

Obviously, these solutions are all over the place in terms of concept. We did want any solution we came up with this week to meet certain design criteria though. Our only rules for solutions were that they meet these criteria — past that anything, no matter how crazy, is far game. Here were our design criteria for the week:

• The solution needs to be comfortable and should not contribute to patient irritability
• The solution needs to work throughout the entire sleep cycle→ no systematic errors or temporary shutdowns, needs to administer continuous treatment
• The solution needs to improve sleep quality→ ensuring full progression of 90-minute sleep cycles without disruptions
• The solution needs to be customizable for each patient→ compatible with facial/bodily proportions
• The solution needs to function at the patient’s home→ or where the patient currently resides
• The solution needs to be safe to use

For our final week, we narrowed our options for a final project to focus on down to our final choice. After much deliberation, weighing potential benefits versus feasibility, and at least one physics argument, we finally settled on developing a system to improve the dismal CPAP compliance rates for patients with sleep apnea. Our system consisted of two parts:

• A system which uses metrics measured from a wearable device to determine how asleep a patient is
• A CPAP machine and special pillow which read the information from a wearable and use that to both ramp up the pressure and change the elevation of the patient’s head based on how asleep they are

The goal of this system is not exactly to treat sleep apnea, but increase compliance with a treatment that’s already proven to work namely CPAP.

Once some time is taken to explain it, most people understand the motivation and mechanics of our system. It was great to have a simple method for conveying the exact information we need in order to explain the device without overloading someone with miscellaneous info. One way to do this is through the help of a concept card.

A concept card is a tool for explaining a device or innovation to an investor or anyone that’s looking to understand your idea. It includes several key pieces of information like the needs statement and some quick specs, and then a drawing of the device or solution that’s being proposed. It’s perfect for when you need to convey the most important aspects of your idea to someone (e.g. to a busy physician so that he or she can tell you if your idea makes sense or not). We utilized these kinds of quick drawings and explanations to get feedback on our final system, and we actually used that feedback to make some changes to our design.