Speaker 3: Bringing you conversations with leaders within the operating room and healthcare community. This is Scrubbing In.

Todd Schlosser: Hello and welcome to this episode of Scrubbing in, a podcast powered by Specialty Care. I am Todd Schlosser and today my guest is Andrew Goldsteinn, the manager of biomedical engineering at Specialty Care. In this conversation Andrew and I discuss what led him to a career in healthcare, his work with Richard Brown in the early stages of intraoperative neuromonitoring and how he is continuing to utilize his technical expertise to ensure that Specialty Care is able to provide the highest level of patient care. Enjoy the conversation.

Thank you for joining us here on Scrubbing In, I’m Todd Schlosser and joining me today is Andrew Goldsteinn. He is the manager of biomedical engineering here at Specialty Care and I like to start off with this question because it sort of interests me as someone who didn’t enter the medical field immediately when I got out of school, what is it that drew you to that medical field when you were going through school, maybe even picking what you wanted to do as a major.

Andrew Goldstein: My major is actually biomedical engineering. Prior to that, growing up I always had interest in both electronics, engineering and medicine, kind of shifting back and forth. Somewhere in high school I did a project and stumbled across biomedical engineering and it just seemed to be a great mix of the two. As I went into college, I kind of decided that I’d make a better engineer than I would a doctor. I went, I’m a little squeamish on such things.

Todd Schlosser: You mean like surgery?

Andrew Goldstein: Surgery, things-

Todd Schlosser: I completely understand that.

Andrew Goldstein: It was odd going into surgery-type fields with that, but definitely the engineering side and still having that attachment to healthcare was what interested me.

Todd Schlosser: When you went to school, you did your biomedical degree, right?

Andrew Goldstein: Right, Bachelor’s in medical engineering.

Todd Schlosser: Your Bachelor’s in that, right, so when you left that what path did you take?

Andrew Goldstein: Initially I was looking at going to work for medical device manufacturers and things like that. This was a few years ago and there weren’t very many undergraduate biomedical engineering programs, so the manufacturers didn’t really know what to make of us. Most went into graduate degrees and such. I happened to find a position with a research division at a hospital and got involved with one of the pioneers in intraoperative monitoring.

Todd Schlosser: You sort of just applied for a job and ended up with the, forgive me, I don’t know his name, but the person who pioneered intraoperative neuromonitoring as a field of study?

Andrew Goldstein: Right, Richard Brown had as his PhD dissertation at Case Western Reserve, which is where I graduated, he had built the first computerized evoked potential machine for use in the operating room and he was continually revising. His first one was done in the ’70s. By the time I joined him in the late ’80s, he was on the third major revision of the system. He hired me to design and build that, but he also wanted anybody working on it to know actually what it was doing. Actually before I went into the lab to design, my first day on the job was a 12 hour spine case.

Todd Schlosser: Your first day on the job?

Andrew Goldstein: Yes.

Todd Schlosser: They were like, “Welcome to this new company, Scrub In, you’re going to be in a spinal surgery.”

Andrew Goldstein: It was, “Stand here, watch what I do.”

Todd Schlosser: Sure, of course they weren’t letting you cut someone open or make calls among the monitoring.

Andrew Goldstein: Right, or monitoring, right, but this is what we do. This is what you’re going to be doing half of your time.

Todd Schlosser: They want someone to wash out quick if they can’t handle that, which, of course, you were able to handle and you stayed with them. That’s very interesting. You not only helped design the third iteration and maybe other iterations that came after-

Andrew Goldstein: There’s beyond that, yes.

Todd Schlosser: You were also trained on how to do the functionality of the job itself.

Andrew Goldstein: Correct.

Todd Schlosser: You did more than just put the mechanics in the box, you actually made sure you knew how to do it.

Andrew Goldstein: Right, we would go in there-

Todd Schlosser: That’s a really good idea.

Andrew Goldstein: It was good, it was how that was built. It was also, for me just graduating as an engineer, was fun. It was a lot of fun. I’d grown up doing electronics projects, hobbyist and things like that, but to build a machine and then use it in the OR and then the next day roll it up into the lab and let’s make some changes, and then the third day roll it back into the OR and see those changes, these days you probably couldn’t get away with that as much.

Todd Schlosser: That was such a new field then.

Andrew Goldstein: It was a new field, we were under the research division of the hospital, so we had all that support. We had the support of biomed checking out the equipment, making sure it was safe for the patients, but yeah, we did all that. It was a great time.

Todd Schlosser: That’s fascinating. You would have cases where you would be in the operating room and you would see something that, I don’t know, maybe you were like in your mind, “I wish are engineer had done this differently,” and you the next day were the engineer you were giving that feedback to.

Andrew Goldstein: Right.

Todd Schlosser: That’s incredibly interesting, and also, I think, very valuable because I think in a lot of, and maybe not just healthcare fields, but I’ve noticed this in some things, the people who use the instruments and the tools aren’t the ones making them. There are a lot of iterations before they find a happy marriage between the engineer designing it and creating it and the person who’s actually the end user of it, if that makes sense. You were both of those people.

Andrew Goldstein: Same both sides, yes.

Todd Schlosser: That’s very interesting and I think very forward-thinking of the person who hired you.

Andrew Goldstein: It was what he was also, he was an engineer who had gotten into this and been involved in healthcare and he just had a great love for patients and patient care. It was a great way to do things.

Todd Schlosser: Yeah, it seems like it. How long did you work on that project?

Andrew Goldstein: I was there for just about 10 years.

Todd Schlosser: You really watched, maybe not the birth of IONM, but you sort of came on shortly after its conception and then fostered it through its infancy then.

Andrew Goldstein: Right, that was the era when the commercial systems were starting to be produced. By the end of that period was when some of the equipment that we’re still using in the ER was first introduced. We actually, myself and doctor Brown, took the system that we had and put it through FDA approval. Before I left there it was actually an FDA approved device ready for sale. Unfortunately for us, but fortunately for patients and the community, the commercial manufacturers had gotten into it. With their resources they had surpassed what two people could do on their own. Computers had kicked in really significantly at that time. When I started we were still using old microcomputers which were the size of a refrigerator.

Todd Schlosser: They’re not very micro.

Andrew Goldstein: No, but that was what they called micro. By the generation that I was working on and the subsequent ones, we were on PCs and Windows PCs came out.

Todd Schlosser: You started on this, even doctor Brown started on this before there was a computer in every home in America. You wouldn’t even see people building them in their garage in the late ’70s. That’s why Steve Jobs and Bill Gates took off so well, because they were the people who founded that technology. He was doing that around the same time. That’s amazing.

Andrew Goldstein: We even did things in the early ’90s. We were actually doing remote monitoring.

Todd Schlosser: In the ’90s?

Andrew Goldstein: In the early ’90s, the web came out in ’93. We actually were doing remote monitoring where we had the equipment set up in the operating room and we were running over a phone line to doctor Brown’s office-

Todd Schlosser: Like just regular dial-up?

Andrew Goldstein: Dial-up on the other side of the hospital so he could view the cases remotely while somebody else was in the room doing some monitoring.

Todd Schlosser: You didn’t have bandwidth issues, I mean a 56K modem or whatever, that seems so insane.

Andrew Goldstein: This is why we were only going-

Todd Schlosser: Across the hospital.

Andrew Goldstein: Across the hospital where he was two minutes away. We weren’t going across the country at that point like we are now.

Todd Schlosser: If he needed to, he could sprint down.

Andrew Goldstein: Yes.

Todd Schlosser: Yeah, okay, that’s …

Andrew Goldstein: That’s really most of what it was. It was to let him know when-

Todd Schlosser: He needs to cut you down.

Andrew Goldstein: When the slow points in surgery were or when the points that needed his attention were going on, but that way we could also monitor continuously throughout there, even without him in the room.

Todd Schlosser: That’s something that we still do to this day. We still do remote monitoring further than the hospital.

Andrew Goldstein: That’s an essential element of monitoring today.

Todd Schlosser: It’s like a safeguard system. It’s like having two surgeons there in case someone-

Andrew Goldstein: Two sets of eyes on the data. You have a continual source of consulting and reference and it allows the service to go to more areas than it was. This service, intraoperative monitoring, started out only in university hospitals and didn’t go beyond that because there weren’t enough people to spread beyond that. Technology has allowed it to spread way beyond the original.

Todd Schlosser: You and doctor Brown sort of helped start and pioneer where the technology went and for about 10 years you did that. Where did your career go after that?

Andrew Goldstein: At that point I went for a few years to work with one of the manufacturers helping a little with development, but actually it was mostly a sales role, but I was there because I had the familiarity to go into the OR with the equipment and really describe the equipment to the end users. I did that for a few years, but sales wasn’t really my calling. I was more interested in the patient care side of things. After a few years of that I went to work for a small company that worked pretty much the same as specialty care, had mobile equipment and set neurophysiologists around to do monitoring at different hospitals.

Todd Schlosser: Right, pretty much the same business model we have then.

Andrew Goldstein: Right, but on a much smaller scale. I also did some of the technology for that company, established their remote monitoring program and oversaw their equipment to an extent. I stayed with them for about eight years traveling around and doing that until the traveling portion of it got a little old for me.

Todd Schlosser: Sure, yeah, you’ve got to strike that good work-life balance.

Andrew Goldstein: One of the issues with the smaller companies is that their accounts were so scattered, I’d be driving two hours one direction one day and two hours the other direction the next day and kind of waving at my house in the middle of the night as I passed. That got old. I very briefly went back to another manufacturer that was looking at expanding their IONM product line, but it turned out not to be the right time for them to invest in it. I was there briefly, and then met up with Surgical Monitoring Associates, which is one of the companies that Specialty Care eventually acquired.

Todd Schlosser: Yeah, I actually recognize that name.

Andrew Goldstein: Tony Sestokas was there. I went to work for them not as a clinician, just as a head of their biomedical engineering and their information technology departments. Built that up and eventually got acquired by Specialty Care, absorbed into the information services department here and being that it was a much larger group, I was just responsible for biomedical engineering over intraoperative monitoring equipment.

Todd Schlosser: That actually has changed recently, right?

Andrew Goldstein: Yes. I just took over responsibility for the profusion biomed group as well, so now I’m manager of biomedical engineering for both service lines.

Todd Schlosser: Now you’re managing those who actually go out and repair the equipment?

Andrew Goldstein: Repair or maintain, inspect.

Todd Schlosser: You haven’t done it yourself for 20 years?

Andrew Goldstein: Yes, that helps. That’s where I got into it in the IOM side. The IOM side we also do technical support of the equipment where our clinicians in the field, if they have technical problems with the equipment, especially with the computers and the hardware, they can call us and we can support them and help them with that since we have the understanding of the electronics and the computer components which most of the clinicians are very good with that, but it’s not their focus. I’ve had the extra exposure to that and can evaluate that sort of issue and we’ve trained our engineers to do the same and they’re very experienced on the hardware portion of it.

Todd Schlosser: I imagine it’s a different skillset. Maybe not high level, but once you get into it, because you’re still looking at the electrical wiring, ones of the body, ones of an actual computer system and the components that you hook up to the actual patients, but people who are working the IONM part of it, the techs that are actually in the OR are focused on patient care and technicians are focused on making sure that they have the best equipment they need to be able to provide that patient care, both valuable in their own respects, but very different, although you have a background in both.

Andrew Goldstein: That leads to my focus of my team’s main responsibility is making the clinicians job easier so that they don’t run into frustrations of equipment problems and things like that. I know what happens when you have equipment that’s questionable or not at 100% and how frustrating it is and how it doesn’t lead to good patient care. You can get false readings, you can just not get readings to begin with, setting up cases and setting up equipment at the beginning of the day is a very stressful part of the day for a clinician and having equipment that you can rely on, make sure everything gets going and they have a good baseline that they can base the rest of the day on is essential. I like to think my team helps them achieve that and put them in a mindset where they can pay attention to the patient and not have to worry about the equipment.

Todd Schlosser: Absolutely. It’s very rare that we get to talk to someone who was on the forefront of the technology that-

Andrew Goldstein: Kind of the middle of, not the very beginning, it’s kind of the middle.

Todd Schlosser: That’s fair, but you worked the guy who pioneered it all, so you got to see firsthand what that was like. For profusion that started in the ’30s, so those people aren’t around anymore.

Andrew Goldstein: Actually, curiously, the co-director of the research program at the hospital that I was working was one of the pioneers in profusion.

Todd Schlosser: Really?

Andrew Goldstein: That was doctor Richard Jones who had worked on heart-lung disk oxygenators back in the ’50s. He actually has a heart valve with his name on it. I didn’t follow that side, I did occasionally do small projects for him since I was part of the department, but it just kind of came full circle.

Todd Schlosser: That’s wild that they both worked in the same hospital, both Brown and Jones.

Andrew Goldstein: It was a small hospital in Cleveland that just kind of had, it just had this amazing research program and attracted people over the years. It’s since closed with the consolidation of hospitals moving to bigger systems, this was a small independent hospital. I believe right until, just before I started there, the head of surgery for that hospital was doctor Cross and there’s a K. Cross disk oxygenator, which was an early heart-lung machine.

Todd Schlosser: That hospital was doing great, that’s amazing.

Andrew Goldstein: Yeah, they were great, and it was actually a sad time when that hospital closed.

Todd Schlosser: I’m sure. Let me ask this, because I was building up to the question of you were there in its maybe not infancy, but its young, early adult life for IONM. What is it like now to see how it is pervasive? I wouldn’t say, it’s not used for every surgery, but it’s used in a lot of surgeries.

Andrew Goldstein: It’s definitely-

Todd Schlosser: What is it like, I mean, I don’t know, and maybe it’s because I’m a little egotistical, I would be very proud of the work that I had done. Do you feel any of that?
Andrew Goldstein: I am happy about participating and I’ve seen the field grow. I’d like to think I played a small part in it, but it’s just amazing how its grown. When we were doing it, most of what we were going was the adolescent spine scoliosis type, and now it’s just expanded into so many different types of surgeries, affected so many people. On the equipment side, going from back at that point where most of the equipment was either home-brewed, or at least home-modified to work in the OR, to where now you’ve got several manufacturers making equipment specifically for the operating room.

Todd Schlosser: Through your career and sort of building these machines, was there ever a problem that was very difficult for you, but you got a lot of satisfaction out of solving? Any obstacle that came up that you just didn’t quite know how to deal with? The only reason I ask it that way is because I know a few people who have gone into engineering and they are sort of pushing new ground, so it’s not like you can go to Google and say, “Hey, how do I monitor someone’s circulatory system,” or, “How do I monitor someone’s neurological system?” You guys are, and I mean engineers in general, are pushing the forefront of what is possible. Have you been able to do that and what was that like?

Andrew Goldstein: Actually, back when we were first using PCs and adapting software that was available for the PCs for intraoperative monitoring, the challenge that we faced was we were using software that was industrial monitoring and control software that was meant to look at an industrial process, get data out of it and then change the input to it. The way monitoring works is you’re inputting signals to the patient and reading what the response is. We kind of flipped the paradigm around. That was the challenge. We said, “Okay, this software can kind of do what we want it to, but we have to use it backwards,” and that’s essentially what we did.

Todd Schlosser: Because they sort of interact and record, right?

Andrew Goldstein: Right, it was, okay, that in the factory is getting too hot, let’s turn down the temperature, whereas with monitoring we’re stimulating something and then looking at what the response is. The input and output was there, it just wasn’t lined up the right way for us, but we were able to take a look at that and even though the software manufacturer, the vendor who had written that, told us that it couldn’t be done, we didn’t accept that. We said, “Okay, that just means you can’t help us, so we’ll just do it on our own.”

Todd Schlosser: That actually is a very engineer-ish type mindset. I know a lot of engineers who think that way.

Andrew Goldstein: Here’s a problem, we just have to figure out how to solve it.

Todd Schlosser: There’s a way to do it, I just don’t know what it is yet, but we’ll figure it out. That’s every engineer I’ve ever talked to, sort of has that mindset, which I find incredibly fascinating. I just want to thank you so much for joining us here on Scrubbing In, I thought it was an awesome interview. I hope you had a good time and maybe we can get you some-

Andrew Goldstein: Thank you very much. I always love talking about the field. It’s just a passion for me.

Todd Schlosser: Awesome, well thank you so much. I appreciate it.

Andrew Goldstein: Thank you.

Todd Schlosser: Thanks for listening to Scrubbing In. Please take a second to give us a rating on your podcast app and subscribe so you won’t miss out on what we have coming up. See you next time.