Emergency rooms are the safety net of healthcare. Scott Orrahood, MPAS, EM, PA-C, pulls back the curtain on the reality for emergency providers, the challenges they face, and how patients could and should avoid going to the E.R.
Welcome to Massachusetts College of Pharmacy and Health Sciences Podcast, the Secret to Living to 200. My name is Jennifer Persons and I'm your host. In each episode of this series, we will explore different aspects of health and the factors that allow us to live longer, healthier lives. With the help of a thought leader from the University this year, MCPHS is celebrating its 200th birthday, and what better way to kick off our bicentennial celebrations than with a podcast about longevity and wellbeing? Joining me in the studio today is Scott Orrahood. He is an associate professor of physician assistant studies. Welcome, Scott. Thank you for coming. Thanks, Jennifer. So before we dive into our conversation, we're going to start with an icebreaker question, and that is, if you had a time machine and could travel 200 years into the future or 200 years into the past, which would you choose and why? I would definitely go into the past 200 years just to have taken part in the incredible things that have gone on during that period of time. That's great. Before we begin, I want to talk about your background and your career. You served in the Army for 28 years and retired with the rank of major. I just want to start by thanking you for your service. That's really commendable. Thank you. And it's obviously shaped your entire career. After you left the military, where did you go? Well, after the military, I was in the retirement mode from the Army in Germany, Landstuhl Regional Medical Center, and it was a one year process of retiring after a very long career, having served as an enlisted person and an officer, so it's a long time to get out of the Army out from under your contract, especially when the unit is getting ready to go to war again. So leaving backing up takes time. But from there I moved on to Massachusetts. There was an opportunity that I had interviewed for about nine months before I left the Army, and that was here with this University and the PA studies program in Boston. What was that like transitioning from being overseas to being in a higher education setting? Well, initially it was intimidating. My first year here, I literally worked about 365 days in a row getting everything as best as I could because once I got here, signed the contract, got on board, it was about a three week process till I was teaching, but I didn't realize how deep it was, how deep the subject matter would be. So initially it was intimidating, but in the PA studies program in Boston, I work with some very talented individuals. That's wonderful. I want to go back to your early days as a medical professional. When you were enlisted in the Army and your introduction to emergency medicine--I would say was probably the most intense one you could possibly have--you were serving as a combat medic. What interested you about this career path in the Army and what inspired you to continue doing it throughout your entire military career? Well, initially I became attracted to medicine when I saw my wife give birth to our first son. I didn't really know what was going to do. I was doing labor work, I had been a musician, and when I saw my wife give birth, I was immediately hooked on medicine. My dad was a periodontist. He wanted me to take the medical pathway and I rejected it as an adolescent and early adult. And then what it took was having my eyes open to that. And so initially the Army had an opportunity for me. I didn't have a lot of education then, but throughout most of my Army career, I kept adding on education. Probably close to one half of my 28 years in the Army, I was pursuing education in one shape, form or another. I want to focus a little more on the patient care that you provided. What did you learn from those experiences that you feel supplement your education? The best way I can put that is when you are on a field maneuver, field training exercise--FTS, it's called the Army--or whether you're in combat, you're delivering good medicine in bad places, it's hard to do, but somebody has to do it. And when you go out with your unit, you're there with trained professionals and you're going to get it done. And typically the command structure of the unit you're with will support you in that. The problem solving at that level, it's off the charts. Sometimes you don't even realize how much you've learned till you get back and you get to apply it within the clinical realm in a fixed facility or once you're a civilian clinician. Are those skills and lessons you carry forward to your students today and how do you try and instill those values in them? Absolutely. So I'll share stories, war stories as it's called when I think it's appropriate to make a lesson happen for the students, have them grasp critical thinking skills, utilize proactive learning, not being passive with their learning myself along with other faculty members. Some of us, if not many of us, we don't allow them to be passive learners. We want them to be very active in the process. And so whether it's an Army war story or whether it's in the per diem work that I work right now, and I know my fellow professors, they do that as well. There are lessons learned with clinical case scenarios and so forth. It helps them to apply what they're learning because they, they're very knowledgeable, the students in our program and in so many other programs within this University, but you have to apply it at some point, so we're very big on that. And then what is the standard, once they're through the program, you've kind of instilled those values and those lessons in them, what do you hope they can accomplish as they leave the University and begin to apply this on their own without the support of you and your other professors? We want them to be able to take care of you and your family member. Ultimately, I let 'em know, for instance, it may sound corny, but in the Army, the standard is whether you would share your foxhole with that soldier across from you, would you share your foxhole with them? The standard in medicine is, would I allow you to have my family member cared for by you? Those are the two standards in the profession of arms, in the profession of medicine. And you ultimately want those answers to be unequivocally, yes, I would want you to care for my family. For instance, not only do we want that answer, if a student says to me, I'll try, I say, no, you'll do. It's very affirming. We make sure of that before they go on clinical rotations. Some of the students still have a problem perhaps because they didn't believe the hard-hitting nature of clinical medicine, but I can't change the culture of the medicine. You can't, nobody out there on a clinical rotation can change that. So it is what it is. The students have to know it's coming at'em and they have to find a way to fit in and make it happen. The public, now, we associate emergency rooms with acute and critical injuries. What other purposes does emergency medicine serve? A lot of the U.S. populist knows that emergency department serve as a safety net. That is particularly true if a person does not have a primary care practitioner--a PCP--or if their PCP is inaccessible. A lot of people don't know this, but having served in emergency medicine for years, roughly 85 to 90% of the daily census of patients seen are not emergent patients. So the challenges in emergency medicine is to find that 10 or 15% that if you miss a diagnosis, they're going to die or they're going to have a bad outcome. The morbidity mortality is right there always for 10 to 15%. So the challenge is not to miss that, but also to somehow try to make the other 85 to 90% of patients that aren't emergent happy. And that is a tall task for anybody to try to provide. That's why the burnout rates in emergency medicine are quite high. Wow. What can we do about that as a system, as a society? How can we prevent that and the burnout from emergency medicine professionals? That is a tough question. It's almost a loaded question. Ultimately, it comes down to whether there's, for instance, socialized medicine versus hospital administrators. If it's not socialized medicine, making sure that emergency departments throughout the US are not shutting down at the rate they've been shutting down over the last 10 years or so, and providing clinics, for instance, urgent care clinics in the last five to 10 years, I've seen many popping up, and that is a nice fallback plan, not as expensive to deliver urgent care medicine. And that fits with that 85 to 90% of patients that typically are not emergent. So I would say at more urgent care clinics and make sure that people are finding a pcp if they have to get insurance, get help getting insurance, that's again, that's a tall task as well. Well, and there's only so much you can do if you are working in the ER to do those things. Yes. Working in the emergency department or any clinic, if somebody comes in hemorrhaging or they have an airway issue, they're having a seizure no matter what, anybody else in medicine is going to do what they have to do initially and ask about health insurance later. So there's that aspect of the delivery of emergent care, also immediate care, emergent care. And you mentioned that emergency rooms recently have been closing. I'm also hearing stories anecdotally that they've been in inundated basically since the onset of COVID and that relief hasn't really come. Do you see an end to this trend? I know you alluded to it, but what can we do to try and reallocate that care? That is such a tough question. I don't know how tough it would be to stand up...like in Los Angeles County, I know a couple or more major trauma centers shut down. There's other cities in the U.S. where that's happened also. So the standing up of them, again, that's a question beyond my pay grade, as we used to say in the military. The nation has to be aware. People have to, at the grassroots effort, have to look out for all people getting access to medical care so that if their own care is maintained, they don't need to seek emergency medical care. That's the idea about preventive medicine and having a primary care clinician to help you. That makes sense. When you mentioned that the vast majority are not actually emergent, I didn't know that. And I think raising awareness about that as a potential issue and hindrance to emergency care, that's an important thing to get out there. Yeah, it was a statistic that was repeated to us while I was there in Landstuhl. Initially it was a level one trauma center in Germany. It was for the entire region of Europe and the soldiers coming back from Afghanistan, from Iraq, Syria, et cetera. So while I was there at Landstuhl, there was a big emphasis on us being aware of the ESI emergency severity index, and for instance, a level one and a level two patient, that's somebody that's in a very bad way, maybe in what's called extremis. And then you have a level three person that might have a kidney infection and a fever, maybe some abdominal pain, and then you have level four and level five patients. So it was my experience while I was there, whether I worked on the trauma side of the emergency department or the fast track side of the emergency department, the majority of patients were level three, level four and level five patients. So the allocation...now you're going to have major medical centers, that was called a tertiary care facility Landstuhl Regional Medical Command in Germany. So that that's a given that you're going to have that medical set up right there seven miles away from us with Ramstein airbase where there were a lot of medical assets there. Even there with patients and their family members having access to family medicine physicians and pediatricians, a lot of the patients would still come after hours when it was convenient to the emergency department. So we're going to see them of course, but that's mixed in with while we're dealing with came in a critical condition in extremis. Does that also contribute to wait times in the ER because obviously the people in more severe condition get pushed to the front? 100%. Because also with HIPAA...so one of the challenges that can also bring on burnout to a clinician, especially in emergency medicine, is that the patient that's in the waiting room doesn't get to hear that the person with chest pain is now being resuscitated. They don't get to hear that the female with the GYN problem has an ectopic pregnancy. They don't get to hear that the child that fell off the chair has a possible brain bleed. They don't get to know those things, but their stubbed toe or their sore throat, their perception is they're waiting too long for care. When you work in emergency medicine, you are constantly reminded, hey, the patients are getting upset about the waiting time and you're dealing with life-threatening stuff and just the stress of that. You don't want anybody to have a bad outcome, of course. You have to sleep well at night. You're in the midst of some very tough stuff, tough decision matrices. And yes, the other patients keep coming in and their perception is, I don't want to wait more than hour. I have to go and play chess tonight, or I have bingo scheduled, for instance, if that's what's on their mind, or I have my child to pick up from soccer practice if that's their thing. How do you deal with that as a provider? Do you just have to know that you are making tough decisions and doing what you think is best in that moment? 100%. And you lean into the staff, you listen to the nurses. Sometimes if a nurse came to me and told me, Hey, this person has this or that, I know you're trying to get in to see them, but I want you to know they're fine. Take another few minutes with that patient. Then you can come and see. So this is not done in a vacuum. And the team effort, the collaboration, it's off the charts and it's very helpful because this is not easy stuff in medicine, whether you work in emergency medicine or not, it's not tiddlywinks, it's, it's some serious stuff. What would you want the public to know about the current situation in emergency medicine, knowing the fact that so many emergency room cases are not actually emergent? What would be your message to the general public from the provider's standpoint? From the provider's standpoint, I think it's safe to say people should make wise decisions about going to the emergency department because if they've had, for instance, a sore throat that's been worsening over a three or four day period and they've had a fever the last two days, for instance, they should have been seen yesterday, they should have made an attempt to get seen by their primary care doctor or an urgent care specialist. On the other hand, if they come in on day four with a fever and a sore throat, of course they're going to receive care. But the point is for people to be mindful about their symptoms and not to brush them off and then just say, well, that's okay. If I worsen, I thought it was going to get better, but if it worsens, I'll just go to the emergency department. Because a lot of other patients are thinking that same way. And so if they bypass their primary care doctor or or nurse practitioner and they show up glommed in the waiting area, there's going to be some unhappy people because of the wait. Do you approach the work and the task the same way that you did in the military? Very much so. The challenge of, for instance, working up a patient that might have bronchitis, but if you're not careful as a clinician, you'll miss, for instance, a pulmonary embolism or cardiac ischemia. These things can be subtle, and if somebody knocks on your door and they're saying, Hey, the person down the hallway is upset, are you going to be with them soon? If the nurse knocks on the door and says that, or if the nurse or the knocks on the door and says, Hey, the pharmacist would like to speak with you about that prescription you wrote an hour and a half ago, the patient went home and their insurance doesn't cover that, so you're getting distracted. The step goes on. So the challenge is there. Just the approach and the mindset when you're dealing with patients and when you're teaching students how to deal with patients, is that they're going to be thrown into situations that are difficult and uncomfortable, and they are the ones who have to persevere through them. Correct. For instance, formulating a differential diagnosis list, if you're working in primary care medicine, you're going to think about what is most likely and come up with plausible differential diagnoses, be that three, five, or seven differential diagnoses. Whereas in emergency medicine, trauma care, medicine, your first 3, 4, 5 differentials are on what's going to kill the patient fastest life limb or eyesight. And that's another thing. So when you're performing that type of medicine, there's no room for error, and we want our students to know that, and we do impart that to them, that knowledge. It's a high standard, but sounds like one that you're choosing individuals who can rise to the occasion and you're giving them the tools they need to be able to succeed once they go to work and start doing it. They definitely have all the tools. And from the late Leo Buscaglia, he had been a teacher, I think he taught elementary school before he was at USC. He wrote a book called "Love." It's about platonic love, for instance, and he said in the book--it had a great impact on me when I read it many years ago--he said, "We call ourself a teacher, but we don't teach anything. He goes, we facilitate other people's learning." And so that's really how I see my role with this University is they're smart. They teach themselves, they have all the things they need. They've got the knowledge, now it's let's make it happen. Let's help you be a critical, excellent problem solver, solving problems at High Al and be confident about it. Don't say you're going to try, we need you to do it. They will do it. That's wonderful. And all the problems and challenges you described, the more people we can get into the field with that mindset, hopefully the sooner those things will improve. Yeah, if they believe that they're going to see tough cases, because we don't shy them away from that. We don't give them soft answers. We tell the students, you're going to have challenges during the course of a shift. So yeah, you might have three in a row where it's a stub toe, a scratchy throat, and a rash. But the fourth and fifth patient could be, they're on death store, diabetic keto acidosis, acute alcohol withdrawal, brain bleed. So the first three might be easy, and the next three might be, how am I going to fix this? And they rise to the occasion. Yeah. Absolutely. This has been an internet trend, so I want to get your take on it. With your experience in emergency medicine, what are three things you would do to stay out of the ER? Okay, first of all, number one, obtain a PCP if at all possible. Number two would be listen to your clinician's advisement, so whether that's from a PCP or it was a very kind and caring nurse practitioner or PA that saw you a couple weeks ago, if they told you to do something or not do something, you should listen to that. They're medical professionals. They know what you need and what to avoid. The last thing it's, it's an aggregate that would be wear seat belts, don't drink and drive, get adequate sleep before driving on an extended journey, don't ignore worrisome symptoms. Wonderful. Thank you so much, Scott. I've learned a lot and I know our listeners will too. Thank you very much. Jennifer. We've come to a part of our show called Red's Rapid Fire. I'm going to ask you a short series of questions, and the goal is to answer them as quickly as possible. Are you ready? Yep. Okay. What is your favorite color? Green. Are you an early riser or a night owl? Both. Cats or dogs? Dogs. What is your favorite season? Winter. Would you rather be able to fly or have the ability of invisibility? Fly. Who is your role model? Two individuals, Leonard Mason and Mike Davidson, two of my PA colleagues. Very, very dear to me. What was your dream job as a kid? To be a fireman perhaps long ago? Hard to say. If you could travel anywhere in the world right now, where would you go? Okinawa, Japan. What's the best part about teaching at MCPHS? We get to leverage our skillsets and whatever intellect we have without micromanagement. We have a very, very talented crew that I work with, and the fact that we can bring it and get the very best out of students, I think that's my favorite part. No micromanagement. We bring it. What's one piece of advice you would give to your younger self? Don't party so much right after high school. That's a great tip. Thanks again, Scott. And thank you for listening to this episode of The Secret to Living to 200. We hope you'll join us next time. And as always, stay curious. Cardinals.