Introduction

The actual moment of invention is fleeting. It happens in an instant. Our unconscious mind produces an insight. It’s like hiking in the mountains: when the fog clears, there is a moment when the way forward is visible. Sometimes inventiveness happens under extreme pressure when there is only a Plan A and you desperately need a Plan B. What does this physically feel like? Have you ever shut someone down with a comeback, on time and on demand — not later, in your head? You didn’t know what it was before it came out of your mouth but, in that instant, when you needed it, you produced it. That is what it feels like to invent something.

When the idea has been born, the work has just begun. From then you carry it, you rotate it in your mind, you take it apart and you reassemble it like a toy in a Kinder Egg. You share the idea with other people. You persuade them that it’s a good idea. For the fortunate and persistent, the idea spreads and a group forms around it. Like apostles, they carry and disseminate the idea, perhaps modifying it as they learn. In medicine and technology, a prototype is made, a test is performed, money is raised, more testing happens, and eventually it’s used in a human. This can be a lean, minimalist journey, a voyage, and sometimes a saga...

Inventing a medical device often involves balancing contradictory ideas, accepting their interrelationship, and finding a resolution despite their perceived or actual incompatibility. The commitment, the engagement, the skin in the game, the responsibility on your shoulders as the person who must find a solution, the physician of last resort: those are the elements that bring about invention. It comes from conviction, not consensus. This is not the time for brainstorming. This is a time for immediate action. The language used in these key moments is a vocabulary of war: “battling the disease,” “a hill you’re willing to die on,” “losing one’s battle with a disease,” “a lastditch effort,” “the whole nine yards” (a reference to the length of 50-calibre ammunition belts in Second World War machine guns, meaning that you’re willing to attack with everything you’ve got). These are moments that most people will never experience, and this military language captures their imperative nature. Creativity and improvisation in those moments of desperation fuel medical invention.

But conviction will take you only so far. One of the key challenges is always to find appropriate levels of technology for each specific situation, to ensure that what you introduce is sustainable after you leave. Some medical inventions are so cheap and cost-effective they can be used anywhere, by almost anyone.

The biggest medical challenge for the monks in the monastery was preventing diarrhea, from worms and parasitic infections, largely caused by drinking water that became heavily contaminated during monsoon season. It was essential to find a cheap and efficient means of chlorination — a method used to kill parasites and bacteria in water; the same method used in swimming pools — to prevent a regular natural event making the monks ill. I visited a local medical school and the professor’s suggestion was stunning in its simplicity and efficiency:

1. Take a 10-litre water container and cut two small holes in the side.
2. Fill it with 6 kilograms of clean sand and 1.5 kilograms of chlorine.
3. Cover the top and suspend it 1 metre below the surface in the water tank at the top of the water tower.

The sand allows the chlorine to gradually diffuse out into the water. So I climbed about twenty-five feet up to the top of the water tower on a rickety ladder and put our device into the tank. The idea worked; we had safe, chlorinated water for 2,200 monks at a cost of about two dollars a week. It was efficient, maintenance free, and the result of readily available technology.

The paper I wrote about the Tibetan experience was my first publication. It’s still the paper I am most proud of because it captures what I believe as a person and as a doctor: that those two things are indivisible. Being a doctor is not a career choice; it is a vocation. It is not a lifestyle; it is a cause. It’s an engaged role in society, and it’s a liberal art. To quote W.H. Auden, “Healing is not a science, but the intuitive art of wooing nature.”

Modern medicine has developed through the cumulative impact of physician inventors, confronted with high-pressure moments, driven to save the lives of their patients. These inventors possess a commitment to an idea that they feel will reduce suffering and pain. Their drive is not a financial one but a passionate cause — how to make something that will save those lives. Resilience, persistence, and determination are key characteristics in the personality types of those who decide it is incumbent on them to create a better world for others. They often do this despite the resistance of their peers, or the medical system in which they work. Their restlessness makes them unable to tolerate unreasonable authority from the medical establishment, which often rejects a new idea. Medicine is dominated by peer review, which supports the expected, or minimal variations thereof. If you deviate too far from the accepted norm, you can be rejected as non-collegial, as dangerous, or as scientifically unsound. We see this rejection of new approaches in every chapter of this book. It is remarkable that the inventors we describe here eventually succeeded, but we do have to wonder how many succumbed to the pressure to align with the status quo.

When confronted with a patient with complex needs, an inventor’s nature is to unleash their talent and find a solution by pilfering widely from all fields of medical experience. This is common to all the great inventors I have encountered, but it is still an unusual approach, when you really think about it. Most people follow well-mapped paths in problem-solving, retreating to what they know rather than exploring things they do not know or only partially know.

All my own inventions have also come from a clinical problem. If a doctor calls me and asks for help, I always say yes. Later, in the middle of the night, I lie awake in angst, wondering how the hell I’m going to develop something that can fix that patient. Why did I say yes? But from that anxious apprehension comes the solution, the technique, the device, and the invention.

Sometimes the idea is driven by guilt born from something that has happened, which I hope I never see again. A good example is a device for detecting adequate chest compression during cardiac arrest; I invented it with Jesse Klostranec, one of my fellows, a gifted biomedical engineer and physician. In 1989, I was an intern in St. Peter’s Hospital in Albany, New York. An extremely sick elderly woman with emphysema went into cardiac arrest in the intensive care unit (ICU). I began chest compressions and, with the first compression, all the patient’s ribs broke. She was so frail that her ribs were like paper straws. She entered something called electromechanical dissociation, becoming unresponsive. I put in a chest tube. We did everything we could, but nothing worked. She died.

As we left her room, I saw her son walking down the corridor to visit her. I took him by the arm and stopped him. It was September 1989. I can still clearly see his head drop in disbelief; still see his shock, his grief, his loss.

For the next thirty years, I wanted to make sure this never happened again. And, in 2019, my colleagues and I developed a simple device to detect adequate brain blood flow during cardiopulmonary resuscitation (CPR). This device allows a physician to deliver gentle pressure to a small, frail, 100-pound person, while a 250-pound marine in the battlefield can receive greater force. The CPR flow device will be made in Salt Lake City, Utah, and has been assessed by the Defense Advanced Research Projects Agency (DARPA, the defence research organization of the U.S. Government) and the U.S. Naval research group for use by the forty-four thousand medics in the battlefield. Hopefully, it will soon be with every defibrillator and code cart in our malls, airplanes, and hospitals. Harrowing moments like that in September 1989 stay with us all our lives. When we finally envision a solution, we seize on it to salve our guilt.

Inventing is a journey. You carry your invention with you for years, through doubts, dark nights of the soul, dreams of success, and the reality of overdrafts and debt. On the journey of medical inventiveness, you will experience trials, tribulations, tragedies, and, hopefully, triumphs. Sometimes you fail. You lose money — your money, your friends’ money, your family’s money. We hurt or lose friends. There is guilt and remorse. What could you have done better? But these failures are valuable experiences. You make better decisions the next time, and this wisdom makes success more likely in the future.

Throughout this book, I will share the conclusions I have drawn from conversations with hundreds of friends and inventors over the last thirty years, with yet another new idea. It is called the Innovation Equation. In brief, it is the coming together of inventors (those with the drive to invent), funding (the necessary financial supports for inventors), cultural alignment (the readiness of the medical establishment or society at large to accept a new idea), and timing (how the process coalesces through a convergence of ideas, needs, and other considerations), which creates the optimal circumstances for innovation.

Welcome to the essence of invention: the culture, the timing, the resilience, and perseverance that have saved lives and made procedures safer for patients. I hope I can inspire you to join the ranks of those who invent.