There's no hiding the facts: Across the medical device industry, Europe's ongoing fiscal nightmare has plagued revenue growth. Looking back on the recent swath of earnings reports, we can see a number of companies missing on revenue projections – with most taking tough blows from across the Atlantic, even while the domestic market continues to supply ample growth. With the Affordable Care Act's medical device excise tax set to hit soon, however, the industry had better hope that Europe solves its problems fast – or medical device makers could see pain on both sides of the ocean.

A European nightmare
It's hard to find a large company in the medical device industry that didn't miss on revenues this past quarter. Industry goliath Johnson & Johnson (NYSE:JNJ) managed to just beat estimates, but everyone from well-entrenched companies like Stryker (NYSE:SYK) to turnaround prospects such as Boston Scientific (NYSE:BSX) all fell short on revenue estimates. A common theme appears when digging into their filings: International sales are almost unilaterally falling.

While countries such as Japan and China have had a rough go recently as well, it's Europe that's really putting the hurt on the industry. Boston Scientific, which didn't have the greatest quarter anyway, reported an annualized 14% drop in quarterly sales in Europe, the Middle East, and Africa. They're certainly not alone: Stryker reported international  sales down as well despite recording gains domestically, and even Johnson and Johnson took a massive hit. The medical titan's sales rose in every region except Europe, where they fell by 3.4% from last year's third quarter.

Only growth-oriented Intuitive Surgical (NASDAQ:ISRG) managed to withstand the European bloodbath, posting strong 20% sales growth that actually outdid its American numbers.

It's a problem that the companies themselves are well-aware of. Johnson and Johnson and Abbott Labs (NYSE:ABT), among others, cited Europe's economic mess as inflicting pressure on growing device utilization. Unfortunately, since Europe makes up the second-largest region by sales for most of the industry's members, these companies can't simply ignore the problem and hope it goes away -- not while Spain teeters on the razor edge of 25% unemployment and austerity hammers consumer pocketbooks with none of the precision of a surgical scalpel.

Other regions can't be counted on for across-the-industry gains to offset Europe's maladies. China's health care system is a labyrinthine mess of bureaucracy and regulations for foreign companies, and fellow leading economic power Japan has, like Europe, inflicted top-line pain for numerous medical device makers.

So, where are the best places for your investment if Europe continues to implode? Fortunately, there are a few companies -- from dividend giants to small growth kings -- who've managed to weather this storm better than the competition.

The best bets for your money
Let's first show who's not doing well on the international and European front. While I might like Boston Scientific's recent acquisition, the company still has a lot of work to do to get back to profitability; with its sales down in Japan and the U.S. to go with Europe, it sure doesn't look like a safe haven. Boston Scientific is appealing only to those of you who believe in the company's ability to spark some innovation and turn around its best-selling divisions.

Similarly, Baxter (NYSE:BAX) and St. Jude Medical (NYSE:STJ) also didn't do great internationally. The majority of Baxter's sales come from outside of the U.S.; it's thus disconcerting that international sales declined by 5% for the quarter. St. Jude has seen sales decrease across the map except in Asia, which makes up only around 10% of total company revenues. The Affordable Care Act's excise tax certainly won't give any relief to those results.

On the other side of the coin, Johnson & Johnson is still a reliable bet, especially for you income investors interested in a safe health care dividend. The company's Asia-Pacific and African growth alone offset European losses, and this reliable juggernaut's sheer diversity of products and geographical reach means that it won't leave you hanging high and dry should Europe fail to show any economic progress. That 3.9% dividend adds a nice safety blanket as well.

For the growth-minded investor, it's hard to go wrong with the up-and-coming robotic surgical companies. Intuitive Surgical is an obvious play given its position as the leader of this fledgling industry, but don't ignore upstart MAKO Surgical (NASDAQ:MAKO.DL). The company operates almost entirely out of the United States, and while the excise tax will hurt, it shouldn't cripple young MAKO's drive to profitability given its push toward improving efficiency as it continues to reduce its losses.

Europe's health care blues
While a few good companies, such as Intuitive, have done a good job succeeding in Europe despite the continent's economic woes, the region's recent impact on the medical device industry at large is undeniable. With international sales down, many companies can ill afford to have the excise tax strike at the one reliable geographic area for growth: the powerful American market. As an investor, keep your eyes open for the companies that can best manage their European exposure while continuing to grow both here in the United States and in other developing regions. Anything less could set your portfolio up for a medical mishap.

This article represents the opinion of the writer, who may disagree with the “official” recommendation position of a Motley Fool premium advisory service. We’re motley! Questioning an investing thesis -- even one of our own -- helps us all think critically about investing and make decisions that help us become smarter, happier, and richer.