 Welcome. I'm Craig Thomas, your host on Much More Medicine, part of Think Tech Hawaii's live stream series and assisted today by engineers Rich and Eric. And with me today is Dr. Will Scruggs, an emergency physician and chief of staff elected at the New South Castle. A longtime active member in the local chapter of American College of Emergency Physicians, the group that is sort of our steering and public voice. And thank you for doing that over the years. Congratulations on your new administrative role at Castle, which is going to be challenging and interesting. I'm delighted you're here. Thanks for having me. It's good. I was hoping this morning that we could talk about, first, sort of the current state of emergency medicine from your perspective. You staff, among other places, as we said, Castle, which is a very nice and sort of classic community emergency medicine department, which is where the kind of department most emergency medicine occurs across the country and the kind of department our group staffs a bunch of. And the tertiary centers get a lot of press and TV shows labeled after, but most of the work honestly gets done in the communities that surround the tertiary centers. So what's the state of emergency medicine this year? It's an interesting time. As you and I both know, we both have the advantage of having worked at numerous facilities all over the state and anywhere from busy county-type facilities to the suburban facilities like Castle to a real small, very small emergency department in 24-hour shifts to see 10 to 15 people in that time. So we've both seen the spectrum of that. Yeah. It's a great thing, actually, isn't it? It is. It's a very rewarding way to see emergency medicine, kind of see all of it. And it's an interesting time in emergency medicine because things have changed so much in medicine in general. And watching our specialty come from where it started in the 70s as kind of a positions that didn't really fit anywhere else in medicine start to provide these services that were very much needed into the first emergency medicine residency. I think it was in 72 or 73 at U of C to now being one of the most popular specialties of choice for medical students as they go into residency. And nowadays, becoming part of the larger picture in medicine and really trying to take control and expand our niche in medicine to try to, I should say, when I say expand our niche, it's important that we're just trying to fill the needs of our communities and serve the people that come to see us every day. Yes. And you're right. That's sort of the arc. When I graduated from medical school in 1980, I think there were five residencies and more than 120 now. I don't know exactly. I think so. So that's a big change. And also, when we started, it was kind of like, well, you can staff it at night and maybe take care of the weekends, but us real doctors will be taking care of everything else. And now most doctors stay away from the emergency department because they don't want to know what's going on in there. I mean, it's become its own, clearly not only its own specialty, but its own set of expertise. And expertise is an important word. Other specialties don't come. The emergency room is often because we can take care of most of it. And we know when we need to get that specialist involved. Yeah, I was heard, in fact, I think this is the best definition of the sort of core practice, which is experts at the first hour of everything. And pretty clearly sooner or later, things have to get handed off. But you have to recognize what it is, start the right stuff, call the right people. And those are for things that need additional care. Obviously, we can do a lot of complete care. But some things need services that you need a specialist to provide. So from my perspective, the world of medicine has changed dramatically since I started. Not only has emergency medicine become a key player, in fact, I think in some ways the hub of medicine, acute medicine. But the other elements have changed too. So when I started, the primary care doctors often saw their own patients in the emergency department. And if they needed admission, admitted them. And that doesn't happen much anymore. And hospitalists were a rare breed. Now you have the outpatient world, the inpatient world, hospitalists and the associated specialists. And in between you have us. And I think we've become the urgent and emergent diagnostic and treatment hub. And I think we need to figure out the pieces that would make that more efficient and effective. And from my perspective, that's the current state. And we should focus on things we can do that would improve that going forward. What are your thoughts? I agree. I think we are the diagnosticians, the acute care diagnosticians in medicine now. And people come to us for a reason. We're good at what we do. We have the capabilities in our emergency departments because the hospitals have given us all these diagnostic tools at our disposal. They need to move people quickly through the emergency department so we can take care of the next person. And so we have these tools. We can use them quickly. We have a very efficient way to make the diagnoses for people. And then I think the next steps are sorting out the communication issues that we have. Because in the past it wasn't these discreet entities. It wasn't a discreet hospitalist service. And for those who don't know what a hospitalist is, they specialize in taking care of people in the hospital. They do a very nice job of that. But they've only started up in the last 10 years. But most hospitals now have hospitalists. And so you have these discreet inpatient acute care physicians. In the past, as you mentioned, primary physicians would take care of their patients out of the hospital. And then they would do the admissions themselves. And that doesn't happen any longer. And so now figuring out how we're going to connect those pieces is what's really key and how to do it efficiently. It has to work within our workflow, right? So we're talking about how quickly we can make a diagnosis because we have these diagnostic tools available to us in the emergency department. Within an hour or two, we can usually get to the idea of what's going on with the patient, whether or not they need to be admitted, if I need a specialist involved, or if we need to send them back to their primary physician for further management. And so we have to address those communication issues within that two-hour time frame. And technology should allow us to do that. But certainly I don't think any of us would say has met our needs, or more importantly, our patient's needs. And for me, at least, that's the next big step. There are a few things people have tried. And around the country, there's any number of ways people have tried to address this. Here in Hawaii, we have the Hawaii Health Information Exchange. We have talked on this program in the past about the EDE Information Exchange that Adventist Health Castle signed on to. And we expect other facilities in the state to sign on to that would allow rapid transmission of information for anybody who comes into our emergency department about what other facilities they've been to recently and potentially what other diagnostic studies have been done, what their medical problems are, do they have advanced care directives, all those things that we need to know in a relatively short time window that the old process of calling a facility in the middle of the night and asking for the one person who has access to that information, begging them to please stop whatever they're doing in their busy lives and jobs already and fax us that information and expecting the fax machine to work. All these problems that you and I have seen on a daily basis, the dots don't always line up to make those things happen. To me, that is the next big challenge in emergency medicine is connecting those dots and giving us the information we need to take care of our patients. I think you're exactly right. And just to reiterate the importance of this, medicine's changed in a lot of ways. The way communication requirements have changed is if you were the outpatient doctor, the family practitioner or internist, who did the ED visit admission inpatient management and then saw them back in your clinic, information transmission is much less important. But if it's three different sets of providers and then back to the first one, now you got an issue. The other thing that's changed and you touched on that is the explosion in diagnostic capability. Now, this is mostly a great thing. We're going to talk a little bit about utilization in a minute, but it's mostly a great thing. But it means you need to have access to those results. And it also means that it's highly likely when you come to the emergency department that we'll have the tool needed to figure out what it is that's impacting you. Now, there may not be a therapy. I think our diagnostics often exceed our therapeutic capability. But still, you need to have access to what's been done before. And one more piece of this is patient expectation. And an appropriate expectation, they look at their email and see that within a few seconds, they can get an email sent from a family member across the country. But we can, in medicine, figure out how to quickly access information at another facility. They are frustrated by that. And appropriately so, and we're frustrated by that too. But their expectations are that we should have access to the information and they're not very forgiving. And I don't think they should be necessarily if mistakes are made because we didn't have access to the information that should be readily available. I agree completely. You know, I kind of refer to it as, you know, the branch bank situation. Namely, if I make withdrawal at one branch, the other branch knows about it. Same thing should be true of one clinic or emergency department onto the next. We're going to talk after the break about some examples of other ways of becoming more efficient and providing better care. And also some therapies that can be initiated in the emergency department. So again, this is Greg Thomas with Dr. Will Scruggs, much more on medicine, see after the break. This is Think Tech Hawaii, raising public awareness. I'm getting older. Do I need to worry about falling? Yes, you do. Each year, one in four people, 65 and older, will experience a fall and many will be serious. The majority of falls happen at home, so remove things that could make you trip and install handrails to keep you steady. To learn more about the steps you can take to help prevent a fall, please talk to your doctor. You can also visit aarpfoundation.org or Medicaremadeclear.com slash falls. This message was brought to you by UnitedHealthcare and AARP Foundation. Aloha. I'm Marsha Joyner, inviting you to come visit with us on cannabis chronicles, a 10,000-year odyssey where we explore and examine the plant that the news has given us and stay with us as we explore all the facets of this planet on Wednesdays at noon. Please join us. Aloha. Welcome back. This is Craig Thomas, your host much more on medicine, and with me is Dr. Will Scruggs, emergency physician and chief of staff elected at Advent Health Castle. Nice to see you again. Before the break, we were talking about the, I would say, history and evolution of emergency medicine and sort of current status and challenges. I thought we should talk about a specific example of something that historically has not been done in the emergency department, is an example of a way emergency departments can meet a current health issue. And I think there are many examples that are similar and this might be a model. So let's talk about Hooper and Orphan. Yeah. So I think the opioid issue in general is a great example of all of the things we just talked about. It's exploded in the last five to 10 years. There has been an issue with communication in terms of us trying to find information related to patients prior experience with medications, with drugs, with the active prescriptions that we're receiving, communication between providers to make sure we're not overdoing it with those medications, diagnostic studies that have been done along the same lines. And to me, the opioid issue is one that we, I think, in emergency medicine, very much be a part of solving. I think so, too. But I'd like to add an element that I think is underappreciated of what actually caused this, we call it an epidemic, I think that's a fair statement. And that is expectations and metrics. Because about 20 years ago, there was a big push, pain is the fifth vital sign. And we put a number on it or a little kid, we put a smiley face on it. And the sort of advertising to us as well as to our patients. And of course, the rest of the hospital staff is, we can fix this. Turned out, we're not that good at fixing it and everything has a cost. And we were told it was going to be safe. I'll tell you one very brief story, a very well respected attending of mine when I was a resident laughed at me once because I had a woman with a forearm fracture and I wrote her a prescription for 10 Vicod, an opioid tablet, and 30 ibuprofen tablets. And he laughed at me and he said, you prescribed her more of the dangerous medication than the safe medication. And oh, how things have changed. You know, 15 years later, people look at the cross-eyed if I reversed it. So it's true. Although both of them have their risks. They absolutely do. They absolutely do both have their risks. But there are ways that we in emergency medicine can help to address this problem. And some of the things that we've done around the country involve buprenorphine. It's a long-acting opioid agonist. So it binds to the same receptor morphine does, the mu receptor. It doesn't bind particularly tightly. By that, I mean it doesn't bind strongly enough that it causes euphoria that leads to addiction. It doesn't bind strong enough to cause respiratory depression. It does work a little bit in terms of pain, but it's not a fantastic pain medication. But it's a very high affinity binder to that receptor. So it means it bumps everything else out of the way. It bumps morphine and heroin and Vicod and Norcohydrocodonoxycodone. It bumps all those substances out of the way, so it can bind to that. And so it's being used very effectively and is a first-line treatment for treating opioid addiction. In the emergency department, we've been very hesitant to use these medications for a lot of reasons. Some of them are myths in terms of what we can do legally in our departments. And some of it is our very reasonable concern for what we're going to do if we try to use this medication outside of the emergency department. It is possible, people say it's not, it is possible to be addicted to these medications to buprenorphine. It is very possible to overdose on it. It's harder to do, but you can do it. It's very difficult to treat it if you do. And so there are issues around using it, but I think here in Hawaii, it's not being used out of the emergency department. I think that's a next step. And it's going to take an effort to corroborate work with state officials to get the word out to providers in emergency departments, address patient expectations, work with hospitals, and address the communication issues that we've been talking about related to this medication. And ideally, you would initiate therapy and have a follow-up to plug them into. So that actually addresses the need for communication, the resource that is needed in the community. All of this is manageable. And as we were discussing before, even just an initial therapy in the emergency department is better than letting somebody sit in withdrawal. The problem is withdrawal is a huge driver to go use again. Exactly. And there are a couple of ways people have used this. You're right. The ideal way would be to give a dose in the emergency department. There are several algorithms now that have been created or guidelines or pathways that physicians can use that have been shown to be safe and how we administer this medication. The ideal situation is you pick the appropriate patient, you give them the medication, the emergency department, they feel better, and then you give them a warm handoff is what you'll see in the news where you don't necessarily talk to the place they're going to follow up directly, but you do have some way to communicate with them so they know this patient is going to be coming to them and you continue the pathway for treatment. So it's not just in the emergency department I gave you your dose and we're done. It's you're going to be going to this place for more care. Or worse, you're clearly taking too many narcotics. I know you're in withdrawal, but I don't have anything for you. That's sort of the guarantee of I'm going to go out and somehow get some narcotics. And that's kind of what we do now, right? People come to us for help and we can give them a list of community centers that will help them. We say take this and we hope it'll work. That first pathway I was talking about where you give them the dose of the emergency, Robin, a prescription for a couple of days, that'll double the chance somebody goes on to find effective therapy and is treated for their addiction. There's even a less aggressive way to do this too. Just a single dose in the emergency department has been showed to increase by 50 percent the chance somebody in 30 days is in a treatment program. Just to stem that initial issue they're having with withdrawal from opioids. And so these are things that we in emergency medicine want to make sure we're doing it right, want to make sure it's safe for patients. We need to communicate effectively with the state, with other facilities, without patient providers and treatment programs, but we need to put that together because it's an issue that we have to solve and we can be a part of that. I think it's an excellent project. It strikes me that it has the usual challenges. First of all, change is difficult. It's not a reason not to do anything, it's what we're struggling with on many fronts. And it needs implementation of a standardized approach, an algorithm, support from the state and the other providers and we need to make it happen. And there are actually a number of things like that. I know you're involved in some other care pathway issues because there's a guy named Deming, he's sort of this efficiency and quality guy. And his thing is unnecessary variation is the enemy of quality. And so if for example you do buprenorphone and I do not on the same patients, that's unnecessary variation. And one of us is right, in this case it would be you. So my quality is not as good as yours. The goal is eliminate unnecessary variation in the right way, namely pick the right pathway. And in the right patients, right? Of course. You don't get more, there's no more complicated industry than medicine. Sadly, everything has to be tailored to the patient, but once you find the right patient to fit in the right pathway, I absolutely agree that that is probably going to be the right way to do things in the most efficient way for the patient. Yes. And the key is unnecessary variation. As you said, medicine's complex. And figuring out which path, even if you have pathways for everything, which we have pathways for very few things. But even if you have pathways for everything, you still got to figure out which one's appropriate for a specific patient. Not the easiest thing in the world. In fact, that's often the hardest thing. Or in other words, once you know what's wrong, usually it's pretty easy to figure out what to do next. Until you know what's wrong, not so easy. Even so, it's something that we need to focus on. To me, this is one of the big topics of the era. And I do want to say, along the lines of the opioid issue and the buprenorphine issue, I think we have a very willing partner in the state right now with the Department of Health and the work that Eddie Mercer was doing. And it's an opioid initiative through the governor's office. They have been very responsive to these ideas that we have to try to do a good job with patient care and to listen to our concerns about other ideas that have come forward. So I like the work that's being done on the state in a very collaborative way with other physicians, hospital administrators and patient advocates who all come together and try to do a better job for the folks having trouble in our state. That's exciting. And it's, I think, an excellent project. And honestly, part of the issue with opioids is from the House of Medicine. So we sort of, well, sort of, we owe it to the population to help move it along and fix it. And that obviously impacts on the prescribing side. But it also is on the treatment side. In fact, you can't have one without the other. So I think this is a real project that is, emergency departments are patients with acute needs like, for example, narcotic withdrawal end up. And so we should be the ones who start the therapy. What else would you like to see happen over the next year? I think addressing those communications or continued efforts at addressing the communication issues we have in our emergency departments. And other facilities are finally jumping on board with this too. I hear hospitalists talking about the need to get information from other facilities and they're become more facile using the communication tools that we have now. We have a couple of different ways to access information, a couple of those that we described earlier. But we don't, we still don't have the way to handle this yet. We don't have the single source to go to. The repository is going to have all the information. And we shouldn't be blind. It's not going to happen any time in the suit. It's not going to happen the next couple of years. But we can continue to move the needle forward. And you start connecting these other pieces, hopefully a connection between the information exchange and the Hawaii Health Information Exchange, for example. Hopefully we can make that connection to more rapidly give information between those coming to the emergency department. And really, we should stop saying just coming to the emergency room. We should be saying those coming for acute medical problems. Or for that matter, just going to their own primary care physician. They should have easy access to the information that for the care that I provided in the emergency department too. And vice versa. So to me, that is the key issue in medicine right now is communication between providers in terms of what's been done for the patient and what needs to be done going forward. I think there are issues in how we document in those terms that we've all grown up with that need to change as well. So that's the issue I'd like to continue to work on along with these larger issues we talked about. And just to point out the obvious. In industries where the record is the product and banking is the perfect example. After all, if you make a deposit, the product is a different number in your account. Or if you make a withdrawal, and it might end up with a negative sign in your account. But anyway, that's actually the product. Our product is hopefully improving health. And it certainly consists of delivering care. But the record is separate and parallel. So when you said better ways of creating record or getting information into the system, that's a big challenge. And I'm hopeful that ultimately there are some seamless ways of doing this, but we're far from that. And or as a friend of mine says, and we won't use his colloquial expression. But in essence, everything I get out of the computer is great. Everything you have to put in, pick your own pejorative. But it's true. If we can get information either from the patient's past experience at our facility, or wherever else they've been getting care, it makes our jobs so much better. And our patient care. Our care is so much better. And it's even likely more cost effective. After all, if I know the result of a study that was done last week, didn't help figure it out last week, I'm not going to repeat it. I'm going to try something else. So that's great. Now, his complaint, of course, is trying to get what he did into the system, knowing full well that unless the next provider is back at this hospital, they probably won't be able to access it anyway. So that's frustrating. I totally agree. Yeah. So standardizing care, finding new aspects of things like acute treatment of opioid addiction and withdrawal in the emergency department, threading the balance between too much and too little, we'll have to have a future session for this. I think that just like unreasonable expectations kind of led the medical profession and our patients into the opioid crisis. I think unreasonable expectations are shaping some other harmful things. For example, the expectation that we can achieve 100% certainty in almost anything. Or I'm going to hand you a softball and closing. What do you think of that term rule out? Oh, gosh. Can't be done, right? No. And that's, yeah, you're right. And I think a lot of that, it starts with us as physicians and how we communicate with our patients and letting them know that nothing is perfect in medicine. We do the best we can and we have a lot of great tools, but there's always, there's always that chance we're not going to be correct. And doing more often does not increase and may even decrease the chance of getting the right answer along with other problems. Definitely. My apologies, everyone can lead to other problems. So we'll focus on, there, that's gone. Should have turned that off. We'll focus on conveying the correct care and communicating the issues with our patients and making the emergency department the hub of diagnostics and appropriate acute therapies. And look forward to 2019. Thank you all for joining us. This is Craig Thomas, your host on Much More Medicine with Dr. Will Scruggs. Thanks.