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I want to find out how we can treat people better who are injured,” says Ronald Maio, D.O., an associate professor of emergency medicine as well as an assistant research scientist at the University’s Transportation Research Institute and director of the U-M Injury Research Center in the Department of Emergency Medicine. “But I’m even more interested in what we can do to prevent people from being injured in the first place.” Broadly speaking, Maio is with that simple statement outlining the two arenas of emergency medicine research. The first is medicine’s version of fire-fighting, the other is more aligned with Smokey the Bear, and both seek to improve the health of society, either by treating patients better or by more effectively keeping them from becoming patients in the first place. The University of Michigan Medical Schools’ new Department of Emergency Medicine is singularly rich in top-notch researchers interested in reducing the number of people who get into the desperate situations that land them in emergency rooms. William Barsan, M.D., the department chair, is a past president of the Society for Academic Emergency Medicine, as is Steven C. Dronen, M.D., an associate professor of emergency medicine. Brian J. Zink, M.D., also an associate professor of emergency medicine and the Medical School’s assistant dean for medical student career development, is the incoming president of the Society: his interest is the effects of alcohol in the early period after a brain injury. Maio is currently involved in two federally funded projects studying the practicality and efficacy of what might be called “pre-emergency” behavioral change. As with Zink, alcohol is center stage in his work. “We think that when a person comes into the emergency department following an injury that represents a teachable moment,” says Maio. “If we can identify certain behaviors that are putting them at risk for future injury, it might be a particularly effective time to make an intervention.” It’s almost symptomatic of emergency physicians that they would try to figure out how to pile this on top of all the other tasks demanding their attention. On the other hand, if it works (and “working” includes minimally disrupting those other tasks), the number of their tasks might actually shrink. Toward that end, Maio is a principal investigator in two studies, one with adults, (Frederic C. Blow, Ph.D., of the Department of Psychiatry is principal investigator) and one with adolescents (with Blow and research scientist Jean Shope, Ph.D. of the Transportation Research Institute as co-principal investigators). Both studies employ computer technology, the first a hand-held device, and the second a laptop, to provide a brief, tailored intervention to change drinking behaviors or, in the case of teens, to prevent alcohol use. For Maio, the beauty of the high-tech approach is its efficiency. “It precludes the need for a lot of personnel-intensive intervention,” he says. “You don’t have to have a lot of counselors and doctors talking to people, which in the emergency department can be difficult to accomplish.” Also difficult, says Zink, is erasing the notion that being drunk can actually protect people from injury because they’re “more relaxed.” “We’ve observed that alcohol worsens injury and increases mortality, after motor vehicle crashes in particular,” he says, “so we’re trying to use a laboratory model to figure the mechanisms that account for alcohol’s potentiation of injury. We looked at breathing, blood pressure, hemorrhagic shock, circulation, and what alcohol’s effects were, and we found that it depressed the respiratory response and reduced blood pressure and blood flow to the brain. Now we’re starting to look at the biomolecular reasons for those physiological changes.” Which is all quite fascinating, but what does it have to do with saving someone’s life? “We are responsible for providing airway control and resuscitation of trauma victims,” says Zink, “and if these changes that we see in laboratory animals are happening in injured humans, then we need to be extra aware that alcohol-intoxicated people may require a different level of airway control or resuscitation. “We also need to be aware that physiological changes we might attribute to the injuries could actually be caused by the alcohol, and it also becomes important in anesthesia,” he adds. “Then there is the public health perspective. If this information is correct, relying on a designated driver may not be enough to save your life. If you’re sitting in the passenger seat intoxicated and you’re involved in a motor vehicle crash, your chances of dying or being seriously injured may be greater if you’re drunk than if you’re not.” So it appears that alcohol is a double whammy, increasing both the likelihood of a traumatic event and the severity of its effects. It’s the sort of insight that transcends academic boundaries. It’s also the sort of insight that emergency medicine’s broad scope facilitates—as does the oft-lauded and very real interdisciplinary inclination of many of Michigan’s researchers. “I don’t think I could have done this research at any other institution,” says Maio. “It’s truly interdisciplinary, involving people from the Department of Psychiatry, the School of Public Health and the University’s Transportation Research Institute, as well as many graduate students from the School of Public Health and the School of Social Work who are working as research assistants. That’s what makes this such a great place to work.” And that’s what leads to breakthroughs. While squarely in the mainstream of emergency medicine’s historic concern with public health, broadly defined, the studies Maio’s leading also represent a rather dramatic departure. “In the past, emergency physicians concerned with prevention have been involved in education and trying to influence policy, activities outside of the emergency department clinical setting,” he says. “What we’re trying to do, at least with our studies, is incorporate prevention activities into the normal clinical practice of a busy emergency department. That’s the challenge, and I can’t tell you that it’s going to work. It really is an experiment.” The technology developed at the U-M obviously helps. “That’s why we’re ahead of the pack,” says Maio. “It’s also fortunate that we staff the emergency departments at Hurley Medical Center in Flint and Foote Community Hospital in Jackson. From a research standpoint, that gives us a look at three different populations and makes it easier to generalize.” The relative absence of walls between disciplines at U-M was a factor in luring Zink to Michigan. “One of the reasons I came was the opportunity to work with these people who were doing some very interesting alcohol research,” he says, meaning Patricia Waller, who recently retired as director of the Transportation Institute, as well as Maio. “Dr. Waller did a landmark study in North Carolina, before she came to Michigan in the late 1980s that was the first to show, using sound methods, that alcohol seemed to worsen injury and increase the risk of death following motor vehicle crashes,” says Zink. “Then Dr. Maio got here in 1989 and started working with Dr. Waller. What they were doing was giving me ideas for what to test in a laboratory setting, and my laboratory results were giving them ideas that might explain what they were seeing, so there was a lot of potential for brainstorming and collaboration between us.” As with many of their colleagues, the keen sense of mission felt by both Maio and Zink was fueled in part by personal experience. “A real good friend of mine in college got killed by a drunk driver,” says Maio, “and I had several acquaintances from my college years that were killed in motor vehicle crashes. Then my best friend in medical school was killed in a small plane crash, so the idea of injury and how it can destroy young people’s lives has always kind of directed me.” When Zink was an undergraduate at Allegheny College in Meadville, Pennsylvania, he signed up for a work-study program at the town’s tiny hospital. “I worked as an orderly or technician in the emergency department and got to do a fair amount of hands-on work with patients and observe the physicians,” he says. “None of them were emergency physicians but I liked what they were seeing. A lot of people say this and it’s a little bit trite, but you really feel you have your finger on the pulse of society when you’re in the emergency department. Everything is kind of unmasked.” No one was more surprised than Maio himself when his enthusiasm for research surfaced. “When I went to medical school and even afterwards, I just wanted to practice clinically,” he says. “Then I did some small-scale health services research when I was in the military and realized how, as a clinician, you can have an impact on that one person you’re dealing with, but if you do good research, you can have an impact on the lives of thousands of people you’ve never met. When I first got into emergency medicine, the sicker the patient and the bigger the challenge, the more I liked it. The more pro-cedures I could do, the better. Now I’m more excited about trying to prevent injuries.” “All the issues that we deal with in emergency medicine on a daily basis are societal issues,” says Zink, “whether it’s access to care, potential rationing of care, or the problems of drug abuse and domestic violence. We truly are a safety net for people who have no place else to go, who are desperate. We take pride in always being there and always being ready and always trying to help, no matter who you are or what time it is or how ‘undesirable’ you might appear. We will treat you all the same. In many ways, the emergency department is the great equalizer in terms of patient care.”
Also: 25 Years
of Progress
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Copyright 2001 University of Michigan Medical School
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