Dr. Andra Blomkalns, Chair of Stanford Department of Emergency Medicine, discusses how emergency physicians can turn everyday clinical frustrations into meaningful healthcare innovation through the biodesign process. Drawing on stories from the emergency department, she explores how needs-finding, iterative problem-solving, and multidisciplinary collaboration can transform bedside insights into real-world impact. The conversation also examines why emergency medicine—with its fast-paced, unscripted environment and constant exposure to system gaps—is uniquely positioned to drive the future of patient-centered care. In this episode: How to identify unmet clinical needs during everyday clinical practice Why failure is a necessary part of innovation and design How the biodesign process helps translate ideas into practical healthcare solutions Why emergency physicians are uniquely equipped to lead innovation in healthcare
Dr. Andra Blomkalns, Chair of Stanford Department of Emergency Medicine, discusses how emergency physicians can turn everyday clinical frustrations into meaningful healthcare innovation through the biodesign process. Drawing on stories from the emergency department, she explores how needs-finding, iterative problem-solving, and multidisciplinary collaboration can transform bedside insights into real-world impact. The conversation also examines why emergency medicine—with its fast-paced, unscripted environment and constant exposure to system gaps—is uniquely positioned to drive the future of patient-centered care.
In this episode:
Dr. Matthew Strehlow: In the emergency department, frustration is often the spark for invention. A device that fails, a workflow that slows you down, a problem that no one has solved. Today, we explore how biodesign helps physicians turn that spark into something tangible, moving from bedside insight to real-world impact. Hello everyone, and welcome back to the Stanford Emergency Medicine Podcast.
I'm your host, Dr. Matthew Strehlow, vice chair of the Department of Emergency Medicine at Stanford. Today, I'm joined by Dr. Andra Blomkalns, professor and chair of Emergency Medicine at Stanford. Dr. Blomkalns is a strong advocate for emergency physicians as leaders in innovation, not only within the ED, but in shaping and transforming healthcare across the broader system. She's a former Biodesign faculty fellow, holds an MBA in innovation and entrepreneurship, and has served on intellectual property and technology development advisory committees. You may know her as a past president of the Society for Academic Emergency Medicine. Dr. Blomkalns. Andra, welcome.
Dr. Andra Blomkalns: Thank you so much, Matt. Happy to be here.
Dr. Matthew Strehlow: So, before we get started, I think people that know you, know that you are an outdoor enthusiast, a lover of animals and an avid fly fisherman. Tell us, what is the go-to place that you went to recently for fly fishing?
Dr. Andra Blomkalns: Oh, I don't know if there's really a go-to place, but I had a great trip with my dad on the Snake River not too long ago, for Cutthroat, and we had a lovely time, caught some beautiful fish, released all of them happily, and it was a really memorable trip, so I'm eager to go back when I can.
Dr. Matthew Strehlow: That sounds lovely. And I've always wanted to go to the Snake River. I grew up in the Northwest, but that's one of the places that I haven't actually been.
Let's dive in. Stanford has this world-famous design school and the Mussallem Center for Biodesign. Tell us, what is design thinking?
Dr. Andra Blomkalns: Design thinking is a deliberate step-by-step path whereby a problem can be identified through much observation, and then there's a step-by-step path by which to evaluate potential solutions, different facets of those solutions, and then ultimately working towards a product that, may be feasible, evaluating that product within the marketplace, as an investment and how it can work better and make patients' lives better. It's really…the key about Biodesign is it's a process. It's not just a thing, it's a process by which many ideas can be evaluated and then brought through almost a standard curriculum to hopeful success.
Dr. Matthew Strehlow: So with that framing for design thinking as being a process, how would you explain biodesign then to the busy emergency medicine physician on shift?
Dr. Andra Blomkalns: Well, you said before, I'm a big proponent for emergency physicians, and one of those things is because emergency medicine is such a unique field in that it's the only place that's truly unscripted in medicine. There's no plan. Any individual emergency physician walks into their shift and has no idea what they're going to be faced with, and then has to rather quickly draw upon their knowledge and experience to move forward and find the best opportunity and the best outcomes for their patients, which I think is a perfect, perfect place for biodesign. So, if Biodesign, can have an environment where I think it'll flourish, it would be in the emergency department.
But for an individual emergency physician, like you mentioned, it is that feeling when you don't have exactly what you need or there's not a piece of equipment or there's not an approach, or the patient's not in the right condition for what you need to do something optimally. And that's where that spark can come from, of what could be a great idea.
Dr. Matthew Strehlow: So this core principle biodesign is identifying needs, right? And then through engagement with healthcare practitioners, this obviously resonates really deeply with you. Was there a specific moment for you in the ED where you saw a problem and thought that is exactly what biodesign is meant to solve?
Dr. Andra Blomkalns: Well, there's a moment when I thought about this and I didn't have the wherewithal to understand it was biodesign at the time. And that is…it's okay if I tell a couple stories, right?
Dr. Matthew Strehlow: Tell away.
Dr. Andra Blomkalns: Excellent. So. There was once as tends to happen from time to time that we have foreign bodies in various orifices that we need to get things out of. And we had a gentleman with a, a sewing pin or a sewing needle, excuse me, a sewing needle in an, uncomfortable location. And sure, the patient could have been scheduled to go to the OR. However, it's middle of the night on a Saturday night. It's unlikely that that will happen. The needle definitely needs to come out. It's very painful. It's in a, it's in a bad position.
And then a resident, one of my senior residents and I concocted the idea of, “Well, I have these rare earth magnets in my backpack, and let's see what we can do about it.” And it was just so exciting. It didn't take very long. It was just a few minutes, and so we shoved like six of these guys—they were about the size of an eraser head or a little bit smaller—into the thick part of the nasal cannula tubing and aligned it with the sewing needle. And it perfectly aligned, it smacked up against the side of the sewing needle, and we were able to withdraw the sewing needle without any internal damage or anything.
And it got me thinking about innovation and design and so forth, and I started doing some research into it. Then I read an article that said the two most prolific inventors, in terms of the type of person, are fishermen and physicians. And I thought to myself, “I'm both. This is fantastic. I can do this.” It got me thinking, how do you go about doing this?
Now, I understand that magnets in a piece of tubing are not going to be the next best invention for mankind. It won't solve major diseases. However, it got me thinking that emergency physicians often have their brains in this place where they have to think outside the box, so to speak, and that we're in a great position to move forward with innovation if we just put our minds to it.
Dr. Matthew Strehlow: That probably was an amazing invention though for the individual who needed that needle out of whatever orifice it was in.
Dr. Andra Blomkalns: He was pretty pleased.
Dr. Matthew Strehlow: Yes, he was pretty pleased. And I'm sure the resident who was running around with rare earth magnets was finally like, “I did it. I found a use for them.” Otherwise, I'm not sure why they were in the backpack.
Dr. Andra Blomkalns: They're cool.
Dr. Matthew Strehlow: That was a lovely example of a sort of complex, sort of simple invention to solve a problem. I think oftentimes a lot of things that we see in the emergency department seem simple, especially to outside observers, but when you dig into them, they're quite complex. The processes around them and the actual needs of an individual patient can be quite complex.
What's an example of a need in emergency medicine that sounds simple or obvious, but when you unpack it through the biodesign process, turns out to be quite complex or challenging?
Dr. Andra Blomkalns: So every single medical condition or presentation has so many factors around it, and it is part of the biodesign thinking to really get to each of those factors. The real biodesign process actually involves non-clinicians who observe very intentionally in different environments and develop a list of potentially hundreds of needs—and I did say hundreds. Then they chisel through them by criteria such as: What does the market look like? Are there other alternatives? Is there a pathway for reimbursement? Is there already intellectual property in this area? What would be different about this one?
It's a very staged, methodical process whereby finding the best need is really the most important item.
One example might be that we know decubitus ulcers are common and very difficult to manage in long-term care facilities. Several companies and inventors have been trying to figure out how to help people with that condition. There are a number of devices and lotions and creams and wound-care devices that help, but no one's been able to solve the problem.
The problem is that people have to be recumbent in bed, and that causes undue pressure on certain locations. No matter what you do, humans weren't made to be recumbent. We're bipedal upright animals, and being recumbent too long causes significant problems. There are some things we'll just never fully get around. But that's just one example where there's been a lot of work in that area, with variable success.
Dr. Matthew Strehlow: That is a great example. I know that we spend a huge amount of time and energy in the emergency department, especially our nursing staff, looking for decubitus ulcers and documenting them, because you can get fined, I think by the federal government and through all kinds of other mechanisms, if you haven't done a good job managing wounds during a hospital admission.
And it seems like a totally solvable problem, but yet we know it's causing massive morbidity, even mortality and cost. With that frame—that we have a problem here in front of us that we should be able to solve, and everybody's been trying to solve it, like you said—I think that brings up the conversation around failure in biodesign and the way that failure is managed or thought of in biodesign, which might be different than the way physicians typically think about failure.
It took me decades to accept that failure is part of growth and definitely part of innovation, and to become more comfortable with failure. We live in Silicon Valley, and Silicon Valley is all about “fail fast, fail forward.” But in emergency medicine, failure feels personal, and it's really high stakes for us. We often think of failure as directly causing or leading to the death of an individual patient.
Dr. Andra Blomkalns: Mm-hmm.
Dr. Matthew Strehlow: Do you think medicine, and especially emergency medicine, is uncomfortable with failure? And does that hold us back in the innovation space?
Dr. Andra Blomkalns: Oh, absolutely. And I think that's where biodesign really comes into play, because it takes the idea—or ideas—out of that high-pressure environment. And yes, you're absolutely right: particularly as emergency physicians, we're conditioned to think of a solution fast, execute, pivot if we need to, and keep going.
But the biodesign process helps you take it out of that context. You're no longer on shift, and there aren't patients' lives directly associated with your idea. You can chisel through different facets of the problem or different ideas—and often people pivot to different ideas—and really examine how to look at the problem in a much more complex way. You can take the time to think of a hundred ideas to solve that problem, and then slowly and deliberately weed through them to find the very best ones.
But you're absolutely right. Particularly for emergency physicians, that's one huge, honest weakness: we have to take our brains out of that scope and turn it into an on-paper problem, not a visceral person problem.
Dr. Matthew Strehlow: Can you share an example where you were trying to solve a problem or invent or innovate in an area and you had a failure? Just to make us all more comfortable with the concept. Failure, fail-forward…
Dr. Andra Blomkalns: Several thousand. So, yeah.
Dr. Matthew Strehlow: All right. Any specific one you wanna share?
Dr. Andra Blomkalns: Sure. And I think it's where I like to make mistakes and then help other people not make the same mistakes I did. So I'll share a story where I thought of a need—or thought there was a need. And this is where I will tell you the end in the beginning: you get so fixated that something is the best possible thing ever that you won't listen to anybody else, and that is so damaging.
So for some reason, I thought it looked weird that when we were accessing IVs, we were trying to put a straight thing into a straight thing at an angle. And that doesn't make any sense. Frequently, you go through the vein in the back. So I thought, why don't we make an IV that's curved?
And the certain sign of ultimate failure is when you start naming the thing before you've even created it. So I called it “the Curvy”—not the IV, the Curvy. And I thought if it could be a curved manifestation that could just glide into the vein and then deploy the IV catheter, that it would be so much less damaging and so forth.
And I spent so much time—and tortured several biomedical engineering graduate students—trying to make this Curvy. In the end, I laugh at myself because it didn't pass the “so what?” test. Like, so what if there's a curved IV that's slightly better? You have millions of IVs being placed every day, and most of them do okay.
And is there really a need? It goes back to need, need, need. Is there really a need to have a slightly better one? And the answer is probably not.
But I see this happen a lot at conferences and so forth, where you talk to small startup companies that have invested so much energy into one single thing, and they're banking on that one thing—even though it might not work. And when it goes further in the process, often way past the point where you would hope to fail, they learn that the device fails and then potentially have to dissolve an entire company.
And that's where, once again, biodesign helps you go through all that failing upfront. So when there is finally a product, an idea, or a device that has been vetted in multiple different ways, it stands the best chance of success.
Dr. Matthew Strehlow: That's a great example. I had worked with the Biodesign Group when they started Stanford India Biodesign a number of years ago. It was their first round, and they brought together these amazing individuals from across India: engineers from top engineering schools, professors, a businessperson, a physician. They spent a lot of time actually embedded in emergency departments and on ambulances in India.
At the end of the day, they came up with a number of different ideas. And I remember very explicitly sitting in a hotel room evaluating one of their ideas, which was an immobilizer for broken limbs in the pre-hospital environment made out of plastic. And I kind of had this “cardboard works, right?” moment. And I'm like, “Okay, okay, but we'll test it out.”
So we tested it out, put it on ambulances—it broke a few times, the EMTs didn't like it—and ultimately it didn't pass the muster of: so what were we going to replace? A cardboard box with this much more complicated, more expensive thing for only a minimal improvement in performance.
But I think that's one of the things most physicians are really uncomfortable with about the biodesign process—or unaware of—which is this idea that you've taken something to the prototype stage, but the whole time you're also looking at the business side, the policy side, and all the other aspects of it. Is someone going to pay for it? Is there incremental benefit substantial enough that funders and payers are going to respond?
And that is an uncomfortable place for most of us as physicians. I think that's why this multidisciplinary approach, where a lot of the people on the team are not physicians, is really important.
Well, let's move from the concept of failure to: how do you get started?
Dr. Andra Blomkalns: Mm-hmm.
Dr. Matthew Strehlow: If someone came to you and said, Hey, I wanna start thinking in a biodesign way on my next shift, what would you tell them to do differently?
Dr. Andra Blomkalns: I would say when you see that frustration—or that thing you don't have, or wish you had for the patient—whether before the patient got there, while the patient is in the emergency department, or even afterward, ask yourself: what potential things—plural things—might help in this situation?
And try not to just think, “Oh, this would solve all the problems.” I mentioned before that emergency physicians latch onto one idea way too early.
But I would suggest something like keeping a digital notebook of needs. It all starts with needs. What is the need that you're identifying for that patient or condition that still has yet to be met? And cultivate thinking about different needs first, before thinking about solutions.
Dr. Matthew Strehlow: Thinking of needs. And I know that in the Biodesign program you're a part of, you tell people they have to come up with at least some number of needs. Give us a rough estimate. What do you tell people? How many needs should you identify before you really start digging into other things?
Dr. Andra Blomkalns: Well, the course and the curriculum will tell you hundreds.
Dr. Matthew Strehlow: That's a lot of needs.
Dr. Andra Blomkalns: It's a lot of needs, but it's important. And because there are so many needs in medicine, it shouldn't be a surprise that even non-medical people can observe in an emergency department for a few days and come up with hundreds of potential needs based on what they see.
But that's the thing that frees you from honing in too quickly on one specific idea. It's recognizing that there are needs all over the place, and asking how we can methodically work toward addressing some of them.
Dr. Matthew Strehlow: Alright. You've provided this advice to residents, faculty, and others in the past, and I'm sure you will going forward. They've identified hundreds of needs, and they've really narrowed in on a couple they want to pursue—or maybe even just one. What do you tell them to do over the next couple of months to get started?
Dr. Andra Blomkalns: I would say, in addition to evaluating the different features, get opinions from other people all along the process: the patient, the nurse, the tech, the patient's care provider, the patient's primary care physician. Get feedback throughout the entire spectrum of a patient's care, rather than focusing only on that one specific problem.
In emergency medicine, we love to solve problems, and we tend to focus on a very specific problem. But how does this fit within the context of everything?
If it's a great home-use tool, it still won't work if the care provider can't use it or can't utilize it. And it could be a great patient-care-level tool, but still not work. As you said, the EMTs didn't like whatever the invention was, or the nurses don't like it. Talk to the people who would actually be involved with that device.
Dr. Matthew Strehlow: Is there something that helps people move to activation? I think a lot of us walk off shift—or are on shift—and we see these needs. We have ideas. Maybe we're writing them down, as you suggested, but most of us never take them from the idea stage, through this process, to the implementation stage.
Is there something you've seen that differentiates the people who just think about the challenges and ideate solutions from those who actually carry those solutions forward into something that achieves real impact or change?
Dr. Andra Blomkalns: So I think it's two things, and the first one is not going to surprise you. It's that fire in the belly. It's the notion that I can impact healthcare, I can impact disease, and I can make it better.
And the second thing is patience and discipline, in combination—the ability to say, “I'm going to look very carefully at this from several different angles.” Physicians are impatient, but you have to be willing to examine a problem from multiple angles and try to work toward the best solution.
Physicians seldom want to take that time because, very often—I'd say more than 90 percent of the time—they go straight toward the solution they think is going to work. And it's really hard to step back from it.
What I keep trying to tell people, again and again, is that you have to step back from it. And the fear of stepping back is that you may very well find out your idea is not going to work. But that's okay. You have the capacity to develop other ideas.
And what you said earlier about failure is resonating with me a little bit. Failure seems like a waste of time, and physicians don't have a lot of time. But unless that time is invested in a very precise thought experiment, you won't find something that is potentially meaningful for patient care.
Dr. Matthew Strehlow: That idea that we have to try a thousand different ways to actually make a light bulb and each attempt is moving us forward.
Dr. Andra Blomkalns: Right. Exactly.
Dr. Matthew Strehlow: Biodesign is something that you preach on a daily basis. It's deeply ingrained in the Stanford culture, and I'm sure it's one of the reasons you chose to come here.
If biodesign and the biodesign process are successfully integrated into emergency medicine, tell us a little bit about how you think the emergency department of tomorrow—10 years from today, I should say—will look different from the emergency department we're all practicing in today.
Dr. Andra Blomkalns: I'm going to try to answer your question, and if I'm understanding it correctly, you're asking whether emergency medicine, by embodying biodesign thinking, has the potential to change emergency medicine in the future?
Dr. Matthew Strehlow: Yeah.
Dr. Andra Blomkalns: Okay. Well, that's great, because I agree—and I agree not just for the emergency department, but for the overall ecosystem of medicine. Once again, I'll go back to the fact that emergency physicians are in that unique position where they have to think broadly, think quickly, and think in a very solution-oriented fashion.
So the more physicians who are familiar with this concept, and who understand the rigor and discipline it takes to work through an idea in this way, the better.
I think there are so many incredible ways we can make life better for patients. And as we move to a world where more patients are going to be cared for on an outpatient basis—with less time in the hospital, less time staying after procedures, and more time going home or to another location—that area in and of itself is completely wide open for innovation.
Dr. Matthew Strehlow: Is there a textbook, a book, an article, or maybe a podcast you follow that you would recommend to someone who's interested in this but isn't at Stanford—something that gives them a place to get started when all of this feels kind of all over the place?
Dr. Andra Blomkalns: Well, there is a textbook—a biodesign textbook—that's been recently updated and goes through the entire process. There are also different programs through Biodesign that allow the process to be learned in a variety of formats. They offer programs of different lengths and different approaches depending on the professional background of the individual.
Quite frankly, I think the first step would just be reading and going to the website to see whether the concept makes sense to you. And it doesn't make sense for a lot of people, because a lot of people, once again, hone in on their idea and don't want to go through the discipline of the process.
But I really believe in it. And you can certainly look through the list of biodesign devices that have emerged over time—some really incredible devices of all types. I don't want to name any specifically because they're all wonderful, but they demonstrate that the process works. The process works really well.
There have been a number of companies and devices that have gone on to become successful companies, be acquired, or go public, and they've really impacted patient care. So there is a way to make this happen.
Dr. Matthew Strehlow: All right. Andra, what is the sacred cow in emergency medicine? Something that is long overdue for redesign.
Dr. Andra Blomkalns: Well, I'll say the area of patient care where we usually admit people overnight—or for less than a couple of days—whether that's for IV antibiotics, additional imaging, observation, or something else. How much of that can we manage in a different environment: at home, in a hotel, in an apartment—someplace that doesn't cost as much as the hospital and also makes the patient feel much more comfortable?
There's such a strong push toward that across all specialties.
I think emergency medicine is uniquely poised to think about this because we're always asking: does this patient need to be admitted, or can they go home? And if they go home, what do they need in order to get better at home?
That's the space I think is perfect for innovation, and where emergency physicians can really focus.
Dr. Matthew Strehlow: That's probably the biggest decision point in healthcare, at least from an expense standpoint: do they go home, or do they get admitted?
And what you're saying is that the redesign is finding that middle ground—some version of hospital-at-home or other home-based services that can keep patients from needing admission.
I agree. People are trying to tackle that, but there's obviously tremendous opportunity in that space.
Dr. Andra Blomkalns: Absolutely.
Dr. Matthew Strehlow: You are out there preaching biodesign thinking and the biodesign process, and we're seeing people in our area and in your networks take up this mantle. Should this be done more broadly? Should every EM resident be trained in the needs-finding process?
Dr. Andra Blomkalns: Well, you're certainly taking on a bias of mine, and I would say yes, because I also think it helps even in the real-time care of patients—the process of thinking through and evaluating ideas in a methodical fashion.
We'll have to talk to the ACGME about what they'd like to see in their curriculum, but for now we'll certainly keep that in mind and keep it active for our residents here at Stanford.
Dr. Matthew Strehlow: I'm sure there's many people that want to talk to the ACGME right now, so we'll get in line for that. Have we unintentionally convinced EM clinicians and EM practitioners that innovation is someone else's job?
Dr. Andra Blomkalns: Well, I don't think so, because who would have told them that? But at the same time, no one has really come out and said to emergency medicine broadly—or to emergency medicine trainees broadly—that part of your role is to make an impact on healthcare over the course of your career.
Yes, you'll take care of hundreds or thousands of patients. But what is your legacy? What do you leave behind afterward? Whether it's knowledge creation, scholarly activity, or a new device that helps patients with their illness or acute condition, those things can be incredibly valuable. People just don't know where to get started.
And I hope the conversation we've had today helps reinforce the idea that there is a place to get started. There are ways to think about this. You don't have to be a natural inventor or know exactly where to go, or understand whether the IP is correct or whether you need a patent, a license, or all those things.
There are resources, and Biodesign is not the only one. But there are resources specifically for physician inventors that you can tap into to help guide you through the process.
Dr. Matthew Strehlow: I really appreciate you coming and talking to us about structured innovation and biodesign. We like to end on a lighter note though. I know you have probably more pets than I could count.
Dr. Andra Blomkalns: Only three.
Dr. Matthew Strehlow: You probably have some adopted ones you don't fully claim, but you have three pets. I was wondering what is it you want to design for or have designed for one of your pets or animals?
Dr. Andra Blomkalns: Oh, that's a lovely question. Right off the top of my head, I can think of three, but I'll just give you one.
Cutting the nails or claws of cats and dogs is so difficult that sometimes people take their pets to the vet just to get it done, because otherwise you're risking injury to yourself or to the animal.
So I was thinking: what if there were a little pad or block that you could place the paw on, with small holes where the nails would go? You could gently hold the paw there, and then something underneath would either sand them, cut them, crimp them off, or do something so that you could do the whole paw at once. Then you could just do all four paws, and it would hopefully be easy and not traumatic for the animal.
There's a lot that would need to go into that, and I'd have to think through it methodically, but man, cutting those nails is just not fun.
Dr. Matthew Strehlow: I support that problem. My dog hates it. We hate it. We don't take him to the vet. He just runs around with sharp nails.
Dr. Andra Blomkalns: Okay. I can help you, Matt. I can help you.
Dr. Matthew Strehlow: All right. Well, I want you to design this thing that is going to make it simple and every one of my kids can use it on them. on the dog, I mean
Dr. Andra Blomkalns: Yes.
Dr. Matthew Strehlow: That's a wrap for today's episode. Huge thanks to our chair, Dr. Andra Blomkalns for sharing her insight and experience. Clearly, we've only scratched the surface of biodesign in the innovation process. Keep tuning in for more on this topic in future episodes. For those listening, be sure to check out the show notes for links to Dr. Blomkalns's latest work and studies. If you like today's episode, don't forget to subscribe, leave a review and share it with a colleague.
And as always, we want to hear from you. Send us your questions, ideas, or feedback at the link in the description. Thanks for tuning in.
We'll see you next time. Until then, keep taking care of anyone, anything, at any time.