Why Being an ER Doc Makes Me a Better MedTech Angel Investor with Dr. Paul Davidson
Dr. Paul Davidson is an emergency medicine physician with over 30 years of experience, ranging from Level I trauma centers, to free-standing ER’s, to Urgent Care centers, to small town facilities with very little backup. He explains living through the challenges of the pandemic, what a typical day is like, who he works for and how that’s changed over the years, and products that have had massive impact on patient care. He is also an angel investor and he shares what he looks for when investing in a company, some of the companies he is currently involved with, and past investment successes and failures.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome. We've all seen the TV shows about life in the ER. But what is it really like? Today we're going to hear from Dr. Paul Davidson, an emergency medicine physician with over 30 years of experience at all types of facility settings. He's going to explain what a day is like, who he works for, and how that's changed over the years and products that have had massive impact on patient care. He's also an angel investor, and he'll share what he looks for when investing in a company. Dr. Davidson practices at several emergency medicine and urgent care facilities and is based in Colorado. His experience ranges from level one trauma centers to freestanding ers to urgent care centers, and small town facilities with very little backup. He has been involved in teaching and credentialing faculty and residents in the emergency medicine ultrasound program at the University of Colorado, a program he spearheaded and helped develop, as well as leading the effort for adoption of hypothermia after cardiac arrest at Centura Health and throughout Colorado. He earned his medical degree at Wayne State University and completed residencies at the University of Colorado Health Sciences Center, and the Denver health residency. Here's my conversation. Dr. Davidson, we're recording this in late February 2021. What's the last year been like for you?
Paul Davidson, MD 02:07
Well, it's, it's been probably the most interesting year of my career, as you know, with COVID. So we heard about this virus potentially coming over from China. And then all of a sudden it was in Seattle, you know, ripping through a assisted living facility. And, you know, just cases stacking up. We knew it wouldn't be long before it came to Denver. And it did. It had the opposite effect on our census, believe it or not, we didn't have very a very robust flu season. We were have we saw some cases in October, November. But flu was kind of tapering down by by the time that COVID got here in March. So our numbers were actually way down. I don't think that's something that the public really appreciated. But the hospitals were empty. They cancelled a bunch of elective surgeries. And there really wasn't there was tons of room in the hospitals so that by the time we peaked in about April 5, we had very lean operations. We were furloughing physician assistants, we were cutting physician hours, there were physicians that were furloughed completely from different markets, you know, so if you had let's say three er Doc's on at one time in your er, you you probably had two or one, we never got back up to normal, we're still at about 85% of what we were seeing back in 2019, early 2020. That's, that's number one. It was not New York City. If you if you were in the ER outside of a hot zone, you were twiddling your thumbs, essentially, and not making very much money. I don't think a lot of the general public really understands that. All you saw in the night news were you know, videos of New York City and the whole place falling apart or Italy you know, or some other hotspot. The other issue early on was we did not have enough adequate PP that is completely true that we had enough gloves and we were reusing our 95 so the back of my car I had like four and 90 fives and paper bags numbered one through four that we were rotating. We really were lacking was wear gowns and tie protectors eye shields. So basically full on face shields. We didn't have any which is basically a sheet of plastic with a rubber band. I mean, it's amazing. We just didn't have the equipment that we needed. We didn't have enough pepper hoods, which are the, you know, space helmet, air circulating hoods for intubated patients, they were on backorder for 12 weeks. You know, if you're going to go intubate somebody, you just hope to have a face shield and then 95. So yeah, those days, those days, the first peek that we had it was it was troublesome because of the PP. It wasn't troublesome in terms of the quantity of patients. And then it was just a novelty of it being scared as if as you know, as a 50 year old physician on blood pressure medicine that I was going to somehow catch this and bring it home life family was a little bit terrifying and unnerving. But as time went on And I didn't get infected you realize that those things put in place like hand washing, you know, being careful how you put on your equipment being careful how you take off your equipment, which is called donning and doffing your PP equipment, you know, eliminate time in rooms where patients were known to have COVID or suspected of COVID those things, those measures really work. And so with time, you know, it became an end the availability of PP, McAfee shields, it became more evident that we were going to get through this. As a group of medical professionals, we were going to get through this, the drugs got better remdesivir came out more ventilators that were available, were ICU beds were available. And then the numbers really dropped off in May, June. And we had a chance to regroup psychologically regroup in terms of equipment in terms of drugs, so that when we were ready for the second peak in November, it wasn't as big of a deal. Plus, we're starting to get vaccine. My first vaccine was few days before Christmas. And then in early 2010, I want to get my second what's up from the standpoint right now with the numbers going down with the vaccine, vaccinations going up? It's a much better place to be then then, yeah, in February, March of 2021, versus February, March of 2020.
Patrick Kothe 06:10
What are the patients like as they're coming in? A year ago versus coming in today? There's a lot more information out there. We've passed half a million deaths right now, what a patient's feel like when they're coming in today.
Paul Davidson, MD 06:26
Just their mindset, I think they're, I mean, they're still pretty freaked out. They're they're worried they're very worried for, you know, I'm not saying they're over worried. They're just, they're concerned about their health, about the health of the other people they've exposed in their family. So I would say last March, they there was pure panic in people's eyes. Now, I think with more understanding that these that, no Look, you're probably just going to need to be admitted on oxygen for a couple days and get these other therapies like convalescent plasma remdesivir, steroids, that's all we really have to offer them at this point until these other antibody therapies. So these other immune therapies come out. And we're sending some people home on oxygen. You know, that's that's all they get. We didn't have that option back in March of 2020. That we have now is to be able to disable it. We didn't we didn't have rapid testing, we have a test that takes about 30 minutes now. It's wonderful. I mean, the tests were taking a week or 10 days at the beginning. So it's it's I think people are more at ease than they were last March. They have more information. There's more therapies, we understand the disease. We understand which risk factors are bad, like chronic lung disease, chronic heart disease, advanced age, diabetes, obesity, those are big risks, we understand who's going to probably crash and who isn't. And when they crash, it's about nine days after the diagnosis or the onset of symptoms is when people really get sick. So there is time to to do things beforehand to start some therapies. So I would say as a whole, we're in a word a better place than we were last year for sure. The patients themselves understand they're very knowledgeable about about Coronavirus.
Patrick Kothe 08:10
So I saw an article last month where emergency department volume in one area was down 30%. And you said still down 15%. You know, kind of where you are. There's been debate over the years about too many patients showing up to the emergency department that don't really belong there. Do you think that this is changed anything with how many what type of patients are coming into the emergency department in the future? Or is it going to go back to normal?
Paul Davidson, MD 08:43
I don't think it's ever going to go back to normal. I think people have discovered telemedicine for one. telemedicine with platforms like American well and teladoc have really exploded and other other smaller ones that you may not be aware of where people are having telemedicine visits with their own physicians, and I have to say is a big fan of telemedicine. We've been praying for this for a long time for this switch to get flipped on to get reimbursed for it First of all, and then for patients to embrace it and for physicians to embrace it. Because these are fantastic platforms you can do so much with a telemedicine visit that really doesn't have to be an in person visit. So I think telemedicine has taken some of our visits. Others are just directed, you know, through telemedicine to go get that ankle X ray for the sprained ankle, done as an outpatient now and just bypass the emergency department completely. platforms like like dispatch health, which are you know, basically house visits on steroids. That project and company was launched from our group by guy named Mark gray there and I was involved early on. So those kind of forces of telemedicine in person visits and just bypassing emergency department is Gonna have, I think a permanent effect on our volume, the volume of low acuity patients that will hire we are Qt we've been tracking since the dawn of COVID-19. And it's clear that the patients that do end up in the ER are sicker. That that's without question. Yeah. So we're You're right, it's melt. It's more the emergency department in from, you know, less acute sore throats and ankle sprains are just don't show up anymore.
Patrick Kothe 10:27
Early on, there was a lot made of cardiac patients or PE patients. I really needed to be coming to the IDI. We're not showing up at the end. Is that turned around
Paul Davidson, MD 10:40
now? Not yet. So we're Coronavirus causes a lot of endothelial damage to the blood vessels. So you see things like large vessel strokes in young people, which is, you know, exploding clots in the legs clots in the lungs with Coronavirus. So those patients are showing up later, people are just ignoring diseases like diabetes, and infections and dental work and things like that, that, you know, to the point where they have to come to the emergency department. It's like, Oh, my Lord, you know, this person is dropped 30 pounds from their diabetes. And you know, they're really not looking good. So we've seen a lot of that. And you touched on to the biggest things, which are strokes and heart attacks, patients not coming to the ER with chest pain and essentially just dying at home. I read in New York City during the peak of the first peak. They were declaring an average day in New York City, apparently they were declaring, like, 50 people dead on the scene from cardiac arrest. And it went up to like 500 a day. I mean, it was insane. And it's not like the these disease processes like cancer. And heart attacks stop. I mean, they never stop those diseases don't take, you know, take a nap. They don't take a rest. They don't take a vacation. It's just that the people stopped presenting with them. The cath labs were empty. I mean, they weren't doing any cases, because people were just like, well, if I go to the hospital, I'm gonna get Coronavirus, so I might as well stay home and just tough this out. And while it's just yeah, we've had some public education campaigns around that with the hospital chain I work with in Colorado in with the American College of Emergency Physicians, other people just get the word out that it's okay to come to the hospital.
Patrick Kothe 12:22
So let's shift gears a little bit from from Corona and just talk a little bit about emergency medicine. So you've been an emergency medicine physician for 30 years, and I'm sure you've, you've seen it all. But can you give me a little bit of a day in the life of an emergency medicine physician?
Paul Davidson, MD 12:42
what's
Patrick Kothe 12:43
what's a typical day like?
Paul Davidson, MD 12:46
Well, it's I you know, it's really a privilege to be able to work as an emergency physician, I think you're seeing people on their worst day, you know, with their, their broken ankle there. These are visits that they'll remember, you know, potentially the rest of their life, getting stitches, having a heart attack, having a stroke, getting admitted with sepsis. I mean, these are big events and these people's lives and their families. It varies. So mercy physician, let's say between on average about 15 to 20 shifts a month, you're working in combination of day shifts, midnight shifts and afternoon shifts, you show up for your shift you you know, log into your computer, you get your stethoscope on you now, it's a ritual of, you know, wiping down your station and getting your peepee ready to go. So there's a couple added steps before your shift. And then you go see patients and for a while it was like every other patient had Coronavirus. And now it's not that at all. I don't think I've seen a positive case for probably three or four days. So you're seeing patients that have minor injuries, lacerations, contusions, sprains, you're seeing patients, a lot of them are medical and not trauma. So you're seeing people with runny noses, ear infections, particularly children, cough, chest pain, abdominal pain is a big one. Patients with appendicitis have to fish through symptoms. You know, essentially, as a doctor, you sit down, you take a history, you do a physical exam, you order the appropriate lab and radiology studies, you make a differential diagnosis, which is like what is that where the, you know, three things, four things this patient could have. They're most likely in emergency medicine, you have to put an extra layer of caution on that what are the three or four things this patient could have that could kill them, you know, that you can't miss you absolutely cannot miss things like an aortic dissection, things like a heart attack, things like appendicitis, you simply can't miss those diagnoses. And then you sit down with a patient you're giving them pain and nausea medications. And sometimes antibiotics vary, you know, frequently and then you come up with a plan. So it's the old the old thing for the lay public is SAP it's subjective, what the patient tells you objective what you see You know, on your physical exam, the labs and assessment is a and then a plan and they, you know, to basically teach people about their stake. That's how we think.
Patrick Kothe 15:10
How many patients do you normally see on a shift?
Paul Davidson, MD 15:14
So we practice in a number of different settings that freestanding emergency departments and urgent cares. You know, it's it's all over the map with Coronavirus. I mean, I've had shifts where I've seen two patients in eight hours all the way to, you know, 22 patients in eight hours. And the freestanding ers in the hospital setting we typically see more but you have the availability of an advanced practice provider, which is the new term for a PA or a nurse practitioner isn't isn't a pp. So you'll have a a PP sidekick, in the two of you will usually go through at least 30 patients in an eight hour shift.
Patrick Kothe 15:50
So let's talk about triage a little bit. So you've got patients that are coming in or walking in or being brought in? How does the board gets set up? Who does that? And how do you triage patients.
Paul Davidson, MD 16:03
So if it's busy enough, they'll have a triage nurse. And then for the walk in patients that will assign them a category, it's called an EFI. category one through five. So one is somebody who needs you know, needs to be shocked or intubated, immediately there, those are those are called the SI one. And the SI five is somebody who's there for like a medication refill. And I ran out of my life center pro or something. So that's how the walk ins are handled, the ambulances are handled through via phone. So the paramedics call and sometimes transmit electrocardiograms or, you know, other data, they tell you what they're bringing. And typically, those patients are sicker. You know, the MS patients have probably a 20 or 25% admit rate, you know, they should read to the hospital, and the ones that walk in, it's more on the level of like, 5% event rate. Yeah, so obviously, the the ambulance patients are sicker and get assigned a room immediately, you know, they don't have to wait in the waiting room or anything like that. So that's how triage basically works.
Patrick Kothe 17:00
So if there are three physicians that are that are on on shift at that point, how is it divided? Who gets what patient?
Paul Davidson, MD 17:08
It's kind of like watching jazz, or listening to jazz? Um, yeah, you're you just kind of make it up. You know, it's like, what I'm busy doing a spinal tap, I'll just tell my partner like, Look, I'm doing a spinal tap for the next 10 minutes. I can't really see any add ons. No. Cool. Gotcha. Got Your Back, you know, so they know that. Yeah, we talked to each other. It's all good. There's not, you know, competition to see those patients because usually there's more than enough to go around.
Patrick Kothe 17:36
So let's get into a situation and tell me what you're thinking. So you've got a waiting room, that's, that's full, you've got a couple of exam rooms, that you've got patients in and you know that there's a patient, possible EMI that's coming in with the ambulance, what are you thinking, when you go into the exam room and you know, everything else that's going on,
Paul Davidson, MD 18:00
you try to put up a wall between what's going on outside of the room and what you know what what you're dealing with, you're taking a history doing a physical exam on a you know, a sick, worried patient when chaos is reigning Supreme. I mean, you have some options, you can call and help, you can just, you know, most of the time, just put your head down and get through it and just take care of the sickest patients first in terms of acuity. And that's the other thing about triage I didn't mention is that you take care of the sickest patients first. So just because, you know, somebody has a sore throat and somebody got stabbed in the chest, you know, in the sore throats, but waiting a half hour, you, you just have to let them wait a little longer. Unfortunately, you just have to, you know, take care of the chest, you know, put the chest tube in, you know, and then go deal with a sore throat later. So, yeah, you just there are other options, you can pull, you can pull hospital resources down, you can have the, you know, the nursing supervisor, the entire hospital help and start getting people who have been languishing in the ER, waiting for their bed upstairs. You can call it mass casualty, you know, there's all things you could do, you could call a surgeon to say, you know, I need you to come down and write admission orders on this guy. Now, you know, I got to clear this place out. And then the last trigger you can pull is just going on for what's called diverted diversion, to just shut off your yard from any further eminences until the chaos can be stabilized. See, there's several into disposal. You could call it an on call provider, you know, there's all kinds of things you can do.
Patrick Kothe 19:24
Are you doing your own triage to or your own management to saying Okay, I know this, this patient is going to show up in the ambulance and 15 minutes, I've got the 10 minute procedure I can do here. I've got a 15 minute procedure I can do here. Are you doing that as well?
Paul Davidson, MD 19:40
Yeah. Or go into your bladder? Yeah, yeah, it's a juggling act. Yeah. And often it's nice to get advanced warning from the paramedics that they're coming in and what they're coming in with and so you can do things like get regular therapy down, go ahead and get your intubation equipment out. Go ahead and call the car We all just, you know, go ahead and call the trauma surgeon and just get your all your ducks in a row before that patient arrives. So there's, there's some advanced planning you could do. And then yeah, you just have to figure out if I've got to, you know, go draining abscess, you can't do that when when there's an ambulance coming in, you can't. Sometimes the procedures just have to wait. Unfortunately, and you just make it up. I mean, you just from experience, you realize what you need to do next. And then after that, and then you know, your day will unfold, and just make order of the chaos.
Patrick Kothe 20:36
So you've worked your 30 years, you've worked in level one trauma centers, you've worked in community hospitals, freestanding ers and urgent care centers, what's the difference between all of those different settings,
Paul Davidson, MD 20:51
um, you know, the level one and level two, there's lots of help. And there's lots of expertise, you can tap, you know, your cardiologists or infectious disease specialists, you know, you have a lot of resources. So it's a, it's like a Big Comfy blanket, that a level two is almost as good as a level one. So you have a lot of specialists that can help you. And it's great, especially for a place like I practice a little tear Venice Hospital, where the medical staff is just just outstanding. It's a great community hospital. When you move into these other places, like I've worked in rural places, like Leadville, Colorado, I've worked in Granby, Colorado, where it's a doc in the box, and you're it. And if there's issues like whether you know, where they can't get a helicopter in and out, or the ground damages are going to be four hours, you know, you you're it, there's a little bit of unease with that. And some providers don't choose to go to those arenas, because you have to be able to intubate anybody that comes in or they're, they're dead. I mean, you have to be able to manage bleeding patients patient that needs urgent Airways, patient with a heart attack who might stay there for an hour, because there's no way to get them out. And you have to rely on, you know, a different set of rules to get those patients taken care of. I had a snowboarder come in, in Granby, you know, he's probably about 11 years old, and his forehead was angled at about 90 degrees. And we didn't really have the conscious sedation drugs. So I did something called a beer block, B, ie are not the kind of beer you drink, where you put an IV in the hand, and then you put a blood pressure cuff on. And then you inject a numbing with the same local anesthetic that used it another tooth light again, you know, where you used to soak the laceration, and you inject lidocaine in the hand and put the blood pressure cuff up, so it doesn't have a chance to escape the arm. And then you can do whatever you want to that form with the patient completely awake. So you have to rely on things like that, when you have limited resources. And similar
Patrick Kothe 22:55
type of situation at an urgent care, or I'm assuming the patients are a little bit different. You're not you're not seeing Mr. Patient walking in.
Paul Davidson, MD 23:03
Right. So I work for a hospital system called cintura. Where the rural sites and the urgent cares there's a one call system where you have access to those admitting doctors and those consultants. So it's a nice it's nice to be part of the health system. Not all people practicing in rural areas are in urgent care, you still have things like imaging, the basic lab in a called a stat lab, where the nurses or the paramedics or the even sometimes the X ray techs are helping along the labs. So you have a small lab on site, they can give you the essential things like a blood sugar, electrolytes, blood counts, pregnancy tests, strep tests, urinalysis, urine, you know what's called a urine dipstick, you don't have a microscope in urgent care. So you can't do things like spinal fluid joint fluid. You have to courier those out and hopefully get an answer, you know, within an hour or two. So that's, you know, it's a little I guess, less unnerving being in a being in a suburban Urgent Care freestanding ER where you have the resources of the mothership a few miles away than practicing in you know, in the mountains in Colorado in the middle of the winter.
Patrick Kothe 24:09
Let's Let's go to the business side of things because a lot changed with emergency medicine physicians and how they work in the last 30 years. How has How has it evolved in your career?
Paul Davidson, MD 24:23
So I was in academia until 2000. And then I joined a group, small group of emergency physicians. I was the 14th doctor that they hired. And it was really a band of brothers we staffed to suburban emergency departments, and we've since grown to four suburban emergency departments plus about five urgent cares and freestanding ers. So now we're at nine places that we staff and the way I describe it to people is like We ran a like a fraternity. For better or worse, I mean, everybody had a vote. And we had, you know, sometimes pretty raucous business meetings, but we were all friends, we were all in it together, we covered each other when we were sick or on vacation or holidays. And it was there was shared sacrifice. In 2015, we sold our group to a corporate entity, and it's run like a corporation, I think were the hardest things for me to get used to was a sort of the organizational tree, we it was just flat, everybody had a vote before, you know, for better or worse, it was run as a democratic group. Now it's run as a corporation with a with a organizational tree. So that's definitely different. There are some big other players on the scene, like teamhealth and envision Schumacher, there's other gigantic year groups. Now, for the moment, there's not a ton of growth in the field, just because COVID has really put the screws to people's wallets when it comes to mergers and acquisitions of buying other small groups that might change and get better in the near future. You know, it's just a different entity, you know, working for a very large staffing company versus, you know, a fraternity.
Patrick Kothe 26:11
So, in the early in the early days of the specialty, what emergency medicines been around since when as a specialty
Paul Davidson, MD 26:19
in the 1980s. It, you know, some of those seminal residencies were formed in the 70s, like in Cincinnati, Denver health, you know, some of the early pioneers in Detroit. And then, you know, I think the first board exam, probably around 1980 was the first American Board of physicians exam.
Patrick Kothe 26:39
At that point in time. The physicians, many of the physicians were employed by the hospitals. And now we're in a, in a staffing situation, why did that change?
Paul Davidson, MD 26:49
Some of the hospitals still employ their their own physicians, there's various models, you know, even within a big health system, like William Beaumont, in Detroit, even William Beaumont has some doctors that are hospital employed at some hospitals, and they they contract with a big company called teamhealth, this staff some of their sites, it's so variable, depending on where you are in the country. And in there are some systems that will flip their emergency physicians from one staffing company to another, because there's outcomes like quality, and there's outcomes of efficiency. And if you don't meet that, as a physician group, you know, you could be out the hospital employed, physicians is an older model, the newer models promise more in the way of quality and outcomes. And so that's, you know, the new game is value directed health care.
Patrick Kothe 27:41
Let's talk about that a little bit. What are the key metrics? Within emergency medicine? Obviously, outcomes is one, what are some of the other metrics that people are looking at to manage the department.
Paul Davidson, MD 27:56
So there's, you know, door to needle times, with thrombolytics for stroke, there are, you know, door to balloon times for for STEMI. sepsis is a big one now, just making sure you have antibiotics within an hour and the appropriate, you know, number of liters of fluid given, you know, then there's other measures that look at just not sending wasteful, lab tests, blood, blood work on people that don't need it. And then there's other measures, like, are you cat scanning too many heads, you know, for minor head trauma in children, if the kid really didn't lose consciousness or vomit, you know, and is not acting in an altered way, you know, has altered mental status, why are you getting Why are you are radiating little Johnny's head, you know, so there there are other measures that are that are grouped to look at it things like that.
Patrick Kothe 28:52
They look at room turnover, walkout range rate?
Paul Davidson, MD 28:57
Oh, for sure. The hospital administration so there's, there's various things that we get judged on. So you mentioned some things, like, people like American College of mercy physicians or the government are looking at, like, you know, door to needle times and, and, you know, outcomes with stroke and outcomes with sepsis. But yes, your hospital administrator is certainly going to be looking at things like door to doctor times and left without being seen times and things like that. Yes, for sure. So there's Yeah, there's, there's so much scrutiny on what we do, you know, in terms of going to the ER every day and working, you know, that Yeah, there's, you're being watched in several different ways. And, you know, the electronic health record, like epic is really great to, to mine those things, you know, to get the data to the providers that are looking at it.
Patrick Kothe 29:50
There's different compensation models out there with different physician things, what type of compensation models work within this staffing company. Are you involved? With insurance patience, is that anything you have patient satisfaction? Does that play into it? What's the compensation model look like?
Paul Davidson, MD 30:10
So a lot of it is just based on some some groups, you look at these things called relative value units, or RV is, the more productive you are as an emergency physician, if you're seeing, let's say, 2.5 patients that are instead of 1.5 patients an hour, you're a more productive emergency physician. So we track the number of patients seen per hour. And are you doing procedures on those, you know, we never want to do unnecessary procedures. But the more procedures you do, the more you're paid. So, you know, obviously, you need to go about your day as an ethical emergency physician and don't do procedures that are indicated. But if you can do things like document the time that you spent properly, and document an ultrasound, if you did it yourself or your document the length of a laceration properly, you know, you'll get paid what you for what you did. And so yes, we start part of our pay is what's called RVU, or relative value based. And so if you're, you know, you're cranking out patients and doing really well, you'll see a quarterly, you know, little bonus in your paycheck for based on your number of RV use, because we want, you know, we don't want a really efficient emergency physician to get paid the same as somebody who really just doesn't get off their chair to go see patients as fast. We want the patient we want doctors to be rewarded for their time and effort.
Patrick Kothe 31:29
Part of compensation is the ARV used, the other part is either an hourly or monthly
Paul Davidson, MD 31:35
data
Patrick Kothe 31:36
type hourly, hourly is is there, is there a patient satisfaction score that fits in there too?
Paul Davidson, MD 31:43
Not really, you would think it would. But it's really hard to parse that data is a facility, you will get a patient satisfaction score, that's like zero to 100. And your facility will fit into a number let's say you had 93%. Top called top box performers, where they the patients ranked you like a five, five out of five stars. And so it's really hard to parse that data per doctor, we've done it. But the software you have to get because it comes kind of blinded, you have to unblinded for provider. So you will get that satisfaction broken down. But we typically it's more for education purposes, not to penalize doctors who may not have a top box score is some of the patients are very difficult to deal with on the setting. There are some hospitals that just have a lot of meth, you know, and a lot of alcohol and a lot of psychiatric patients, that you're not going to get great satisfaction from those patients. I mean, they don't even answer the survey. So it's really tough to, you know, to penalize doctors for based on the kind of patients that they see, there's just some practice settings that are just better than others in terms of the demographics of the population, and their ability to answer a survey, you know, so it's kind of, you know, you don't want to stack the odds against the doctor and penalize them just because they're seeing, you know, a lot of urban, displaced, you know, drug addicted psychiatric alcohol patients, it's just not, it's not fair.
Patrick Kothe 33:15
Some physicians get to get to see the patient, when they walk in the door, and they follow them all the way all the way through and see a successful outcome. In many instances, you're just seeing the front end of that and not, and they may end up at surgery and somebody else's following him. How is that personally, dude? Do you? Do you wonder about what's going on? Or do you kind of, Okay, my job is done. And I'm gonna move on to the next patient.
Paul Davidson, MD 33:40
Yeah, I do follow. My patients in the advent of the electronic health record is made that so much easier because I have a list that I'll go back to often, I might have, let's say two days off between shifts, or a day off between shifts, or the next day on might be on again, and I'll I'll typically, if I've got a little bit of downtime during the shift, I'll look those patients up, it makes me a better doctor, to see those through. But in the old days, we had paper medical records, it was very difficult, you had to actually get out of your chair, go upstairs to the fourth floor, you know, go to the patient's bedside and find out, you know, read your chart and see what was going on. Because you just don't want to miss things. You know, you often wonder, did I make the right call? You know, did I? Did I make the right call and intubating that patient or assigning them this diagnosis? And how did they do? You know, because you I really do care about everybody I see want to make sure that I'm doing the right things and that you do it makes you a better doctor.
Patrick Kothe 34:32
Great point. So let's talk about technology for a second in 30 years. I'm sure you've seen some really interesting technologies that have helped you do your job better and help patients better. Are there a few technologies that have really changed the way you practice?
Paul Davidson, MD 34:49
Yes, I'm glad you asked that question. It's in it's really incremental. When you look back at 30 years of progress, you're like wow, like the way we took care of patients 30 years ago. It's crazy. clearly better now. But it's kind of sneaks up on you you'll, you'll hear a talk, you know, a lecture, you'll meet with a, let's say a drug or device rep, and start, you know, looking at these new technologies. So I could, I can name a handful of things that have changed the way we practice. One is the Arctic sun device, which is a hyperthermia vest. So imagine you've had a cardiac arrest and your doctors shock you that your heart back to life, that you're, you're in a coma. So 30 years ago, you just would have admitted that patient to the ICU and cross your fingers and hope they wake up. And their chance of waking up is about 30% and being neurologically intact after a cardiac arrest. What we discovered in the in the early 2000s, is that if you take those patients and you freeze them, so you take their body temperature from 98.6, down to 92, to 94 degrees or so and leave them in a hypothermic coma, they're all intubated none evaluator because they're in a coma. So if you freeze them for 24 hours and wake them back up, their chance of neurological recovery is now about 60%. It's at 30. So that's, that's an incredible leap forward. So we use these Basically, these vests and thigh pads that are circulating ice, ice cold water, to get their temperature correctly, you know, placed in in the low 90s. And leave them there for a day and then gradually warm them up. So that's called hypothermia after cardiac arrest, that's been a huge advance, just getting IVs and people so we're using ultrasounds to put IVs in difficult patients that don't have veins. The other thing we could do, as a last resort, is a device called the EZ IO where you basically drill an IV directly into the bone of the tibia, or sometimes in the thigh into the femur or the shoulder in the humerus. So that's, that's been a big advance, especially in the field, you know that whether paramedics can't get an IV, and suddenly they die early beats one drugs, I can talk about drugs for a minute, but drugs like adenosine to, to convert somebody that tart is going, you know, way fast, you know, there's been some great drugs that have come out. But back to devices, things like the glidescope. So in the old days, you had to use an L shaped piece of metal with a light on it to put to put a tube in somebody's throat, and you have to be able to visualize the vocal cords. Well, now there's a thing called a glide scope, which is a fiber optic, L shaped piece of plastic instead of metal. But it It allows you to intubate around the corner because you've got a camera. So you can see the vocal cords around the corner and you can intubate around the corner. So that that's been a huge advance to getting airways and the people you know, in emergency medicine, we talked about the ABCs to resuscitation is airway. So getting an airway is the most important part of that chain survival. Things like using bedside ultrasound, which was just in its infancy when I started training in emergency medicine in 1993. has advanced mightily, so we're using ultrasound, emergency physicians are using ultrasound machines, which used to be just in the purview of the radiologist. To put things in like central lines, it's so much safer, we used to just basically guess the patient's anatomy, and put needles in their neck. And sometimes you'd hit the carotid artery, sometimes you would puncture one. And you know, or just keep missing the vein. Now you can see the vein and watch the needle go into it. That's amazing. That's a huge leap for patient safety, and for efficiency, that procedure. So those things come to mind. You know, off the top of my head is devices that have changed the way we practice in the last 30 years.
Patrick Kothe 38:31
And I'm sure that there are a lot of other devices that you're using that have incremental improvements, that are advancing things but aren't quite as revolutionary.
Paul Davidson, MD 38:41
Yes, so some other things like using rubber bands to treat abscesses, we're talking about the old way of treating an abscess was to take it take a scalp numb it up, take a scalpel, open the pus out and put cotton packing and well now we're using things like vessel loops or drains to just basically sell a rubber band, you know, drain the pulse, put a rubber band in and then discharge them and have them cut their own rubber band at home instead of coming back every two days for you know, wound check. So things like that are you know, they're minor things but for the patient, it's it's a win, you know, it's clearly a win. It's a win for us. So, you know, vessel drainage of abscesses and that another example of just a minor thing that that, you know, when you stack up these minor things over 30 years, it really makes a difference here right? And
Patrick Kothe 39:25
kind of going back to the abscess thing. Very shortly you're going to have another new products that can help to treat those abscess patients even a little bit easier. So how do you learn about new products?
Paul Davidson, MD 39:38
Um, I mean, I read I look at the emergency medicine blogs, I watch you know, short videos and things on YouTube. I read the annals of emergency medicine. I talked to my colleagues watch lectures, things I'm interested in. Within emergency medicine like ultrasound, medical devices. One thing we did with friends is is found a company called heart hero, which is a ad that runs on a couple of household batteries, which I think will revolutionize the ad market at being an automatic External Defibrillator. So the things you see on the airports everywhere are the walls, that, you know, miniaturizing it and having it run on a couple of household batteries. So just, you know, maintaining just current engagement in emergency medicine, reading the free newspapers that they put in your mailbox every month, and just staying abreast is really important.
Patrick Kothe 40:31
You didn't mention sales representatives or companies.
Paul Davidson, MD 40:35
Right? Do you
Patrick Kothe 40:38
do not see sales reps?
Paul Davidson, MD 40:41
Well, yeah, it's been tough with COVID. Because the the representatives for device companies have been, you know, essentially banned from the hospitals because they just didn't want extra bodies around in the hospitals there. So drug people, you know, that sell drugs, devices have it one of the startups that I'm involved in called DB medics, which makes a bladder ultrasound scanner. So this is a device that tells you how many milliliters of pee are in your bladder, which is believe it or not as important. But that company, which I'm an investor in has had difficulty getting into hospitals over the last year, they're just starting to get back in. But yeah, our sales took a serious hit. As a lot of devices have, during this this COVID-19 pandemic,
Patrick Kothe 41:23
for two reasons. One, just the number of patients that are out there. Number two, the access to decision makers.
Paul Davidson, MD 41:30
It's right, that's right, the stakeholders, decision makers, you know, we've they've had the device companies and drug reps have had to be very creative with things like zoom, you know, in holding sales businesses, you know, business meetings that way. Yeah. And plus hospital budgets have just been directed toward obtaining PP, and other things, with less income coming in the door because of all the surgery, cancellations that you know, elective surgeries. way a lot of these hospitals stay afloat and make money is through elective surgery. So it's been a really hard time for healthcare in the last year,
Patrick Kothe 42:05
when you see a technology or product that looks really interesting to you. Typically, what is it about it that interests you? Is it the clinical outcomes? Is it the speed of use? Is it how friendly it is to us? Is it the cost? What what what kind of is your criteria look like?
Paul Davidson, MD 42:24
That's a good question that I think it has more to do with is the patient going to benefit from this technology at the bedside. So in terms of like, let's say the Arctic's on where you're improving their neurologic outcomes, 30% to 60%, you know, being neurologically intact, going back to your job. Yeah, that's what makes the difference to us as physicians is how it's going to impact the outcome of patients. You know, am I going to have a better first try success rate with this new glide scope, this new intubation device? You know, am I going to puncture less carotid arteries and puncture less lungs need that is going to cause me to cause harm to a patient have to put a chest tube? If I use ultrasound to put in this ID in the neck? Yeah, I mean, it really, we really live our lives around our patients, and what's going to happen at the bedside. And so for me, it's always outcomes is this patient going to have a better outcome if they're defibrillated earlier, because we, you know, designed this really cool defibrillator that you could carry in your purse that runs on household batteries. That is amazing, you know, so we'll be able to defibrillate many more people, you know, within eight minutes, which is really when you need to shock a patient back to life with something like heart hero, and have defibrillators in the home, you know, where they really need to be they're there. They're just so expensive, and just clumsy and big, you know, if we can trick the Add down to six inches by six inches by one inch, and have that run on household batteries and connect to your cell phone, that'll be revolutionary. So yes, it's always about, to me, it's always about the outcomes.
Patrick Kothe 44:03
So kind of going back to the sales rep thing, pre COVID did a lot of sales reps show up in the emergency department. And if they did, we what stands out between a good sales representative and one that's not so good.
Paul Davidson, MD 44:18
You know, so we Yes, we did have a lot of typically more pharmaceuticals with antibiotics or cardiac medications, those sorts of things devices. In emergency medicine, they typically don't visit the emergency department that often. You know, good. A good sales rep is somebody that is respectful of your time, that maybe schedules things outside of a hectic shift, maybe schedules a lunch, or sort of a table. You can drop by after your you know, particularly emergency physicians have a monthly meeting, a business meeting and educational meeting. If it's can be scheduled around that that's better than just showing up in the emergency department where we're really busy and distracted. So I think the good ones plan ahead for things like that, maybe planet, let's say, a happy hour, or even just coffee and bagels at a business meeting is just smarter. So I think, yeah, they have to be respectful your time, they have to be knowledgeable and be able to feel questions, they have to be able to bring peer reviewed literature. So you don't want to just take the sales rep, word for it, you want to see patient trials and studies and you know, actual data, because we try to practice evidence based medicine, which means that you have medical evidence, not just somebody saying it's good, you know, prove to me that it's good. So bringing in literature and, you know, plugging that into evidence based medicine paradigms is really important for us.
Patrick Kothe 45:37
So you mentioned a little bit ago that you've been involved with companies that are innovating, both as a speaker as well as an investor, angel investor in these companies. How did how did that start? How
45:50
did that come about?
Paul Davidson, MD 45:53
Well, we had just a really great group of emergency physicians in Denver that work with cintura. So the name of the group initially was emergency physicians at Porter hospital, because that's where the group was founded. And one of the first entrepreneurial things we got into was an app called I triage was led by Peter Hudson, really amazing forward thinking mercy physician in our group. So we all invested in this app that eventually sold like four years later to Aetna, for a large sum of money. And so yeah, yeah, no, it was great. It was good for patients. It's really a neat app that hooks up the physician or hooks up patients were having medical problems with doctors and dancers health questions. For them, it was a really intuitive iPhone app. So that's how we got started. And then the next thing after that was this bladder scan company called DB medics, which is led by Bill cork, one of the other physician in our group. So it all became investors in that. And then after that, there was a heart hero, which was one of the physician assistants in our group, a guy named Gary, who founded heart hero along with Bill and got involved in that device, which is just approved for sale in Europe, we've obtained the CE mark, and will hopefully be getting FDA approval, you know, we hope in a couple months, so I've just been really fortunate to be in a physician group where entrepreneurship is celebrated. And innovation is, you know, is celebrated and ultimately invested in
Patrick Kothe 47:31
what interests you that you would invest in a device,
Paul Davidson, MD 47:35
they have to have the right team. So it's got to be, you know, you have to have a capable CEO, and a functioning board to really get a product to launch I think. So that's first, it's got to be a great idea. It's got to lead to better outcomes and patience, it's got to be executed properly, through the verification, validation process, and marketing and all those pieces have to be in place. And you know, to have confidence to that that's going to be a successful investment.
Patrick Kothe 48:11
So you mentioned you've got got a couple that have been or have been successful, or in the process of being successful. Have you had some that haven't been
Paul Davidson, MD 48:19
on I'm, well wasn't really a device, but it was a piece of software that we were trying to develop as a group that was called karno. md, and it was all about physician data. It's about sort of is that physician productive? Is that physician? You mentioned patient satisfaction, we were able to parse that data. And, you know, basically have a dashboard for an emergency physician. Are you sitting? How are you compared to your peers, seeing numbers of patients? Are you capable making them happy? Do you have better outcomes? And it was nobody wanted to buy it? We developed this great piece of software that nobody wanted. You know, in terms of devices. I haven't had a failure yet, but I've been pretty picky about what I've invested in. I've let you know several things go. Just took a look at it. I didn't either like the team. I didn't like the idea. I just felt like they didn't it wasn't going to be successful. And I've been in the ASAP innovation, sort of judge.
Patrick Kothe 49:20
He says being American College of Emergency Physicians,
Paul Davidson, MD 49:23
right, I should spell that out. But yeah, merkaz mercy physicians every fall or October meeting, they have a innovation competition hardware one year, one year. And so you get to you get to vote on what do you think are the best devices coming out? I've been a judge on that panel and you just see some really great ideas, but maybe not a very good team, not a very good execution in and then you've seen some really fantastic ideas. So it's kind of a combination of is it really going to help the patient the bedside? Is this the right team to lead this to market? Are they going to get approved and And, you know, voting in that, in that capacity, I think it's been really fun to see the things going on.
Patrick Kothe 50:06
So you mentioned, you know, kind of two things, the team and the technology. Is it 5050 for you? Or does it weigh one way or the other?
Paul Davidson, MD 50:14
Yeah, I think it is, it's an even split. You've got to have, you know, a visionary, hard charging person in charge of the company to can explain the mission and explain to investors, how they're going to get it to market and more importantly, how they're going to get their money back. Yeah, and what timeframe? They're right, exactly, it always takes longer than you think, you know, you could just take what they tell you and probably multiply it by two, and you'll get an accurate when you're getting your money back. But yeah, you have to have that that sort of visionary, hard charging person that is going to take the reins of the project and is going to have accountability.
Patrick Kothe 50:54
I think it's it's really interesting that you kind of straddle both sides of things, your your user of the product, but you're also an investor to product. So you kind of can have an idea on what is going to be clinically relevant. But you're also you have your business hat on to say, what is going to be able to get there? And are we going to be able to really commercialize the technology.
Paul Davidson, MD 51:15
Right, I think, you know, as a practicing physician, you have the advantage of seeing patients at the bedside. And I think especially emergency physicians have a great bs detector, to be able to say what, you know, is this really gonna change outcomes, you know, we're very skeptical by nature that something is going to be better than what we're doing today. But we're open to new ideas as well. So I think we've got a good filter to say if something's really going to help at the bedside or not.
Patrick Kothe 51:46
Is there anything that you think the general public or medical device companies don't know about emergency medicine that they should?
Paul Davidson, MD 51:55
The evidence, I think, for what I'm about to say is, is there is that I think we understand the entire house of medicine, things like surgical conditions, medical conditions, pediatrics, geriatrics, you know, the whole spectrum of patients that come in the door. So I think mercy physicians are like, we understand the entire house of medicine and therefore get tapped often for entrepreneurial endeavors and for also administration. So hospitals see us as a really good fit for things like chief medical officers of the hospital. Because again, we're not hold away in a laboratory, we're not just seeing, let's say, pediatric patients, we're not just seeing Pregnant Patients, we're seeing all patients. So I think emergency physicians offer a really good window to the whole house of medicine. And I've told students this before, that are thinking about becoming a physician or thinking about becoming a nurse practitioner to come rotate with us in the emergency department, and you'll see a little bit of everything. So it's just a really great place to work, you know, in terms of understanding trauma and medicine and old people and pregnant people, pediatrics and gynecology and infectious disease, and you know, orthopedics, neurology, all those things kind of melt in the emergency department and offer a really good view of the world of medicine.
Patrick Kothe 53:12
our listeners are in all different functions within a medical device company. It could be in research and development, it could be in clinical regulatory, CEO of a company sales, marketing, all different types of things. Is there anything that you'd like to say directly to people working within the medical device industry?
Paul Davidson, MD 53:33
I think that it's really important to come spend time with us to come spend time with physicians at the bedside. And I bet you'll get some really great ideas to spending some time, you know, in a physician's office in the operating room in the emergency department to see where the needs are, you know, difficult patients that we have trouble managing from a device standpoint, you know, let's say we have a bladder scanner, that is every time you push the button that gives you a different value. So there's I had a patient the other day, the bladder scanner was telling me it was either zero cc's of urine in the bladder or 400. And depending on how you pulled the trigger, and you're off by a couple millimeters, you know, it just gave this wildly inaccurate thing. So I mean, things like that are a good example of just, you know, you could help us if you came to the bedside more and see what we're actually dealing with every day, you know, or a device that closes skin. I mean, the other thing I failed to mention earlier on the innovation front was derma bond glue. So basically medical grade sterile Krazy Glue, suture lacerations with glue, you know, close lacerations with glue instead of stitches that you have to then go get out. So that's another thing. We're getting those people to the bedside and seeing the outcomes if device people would just come spend a week with us, I bet you would come up with two or three really great ideas to take back to the laboratory.
Patrick Kothe 54:58
Great stuff from Dr. David A few of my takeaways. First, everyone in the industry needs to back this up a couple minutes and listen to his last comments. The only way we can assure we're solving the problems that need to be solved is to be there alongside the physician and see and hear the problems and the nuances firsthand. There are no shortcuts here. It is the most important step in product development. You have to nail the need before you even think about beginning the design. Second, Buying Criteria. He said patient outcomes is the criteria. But he requires clinical validation in the forms of studies publications, and his peers. A shoe shine and a smile may have cut it for a few physicians, but most want the hard facts, make sure you deliver him clearly. Finally, I really enjoyed his comments on where and when to meet him. Because this this isn't just for meeting a physician, but it's with most of our contacts. So many people are focused on the me and my needs. Most people are juggling a lot of things. Make sure you're not the one that just barges in. Come into someone else's world gently and be above them and their needs first. Trying to talk when they aren't ready to listen is a waste of breath. Thank you for listening. Please spread the word and tell a friend or two to listen to the mastering medical device podcast. As interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
