Dr. Brian Evans: Welcome to Mountain Health Today, the show where we explore the people, stories, and innovations shaping health in the Sierras. I’m Dr. Brian Evans, Chief Medical Officer of Tahoe Forest Health System. From everyday wellness to the latest advances in medicine, our goal is very simple, to give you clear, trusted information that helps you and your family live well.
Today we’re going to be discussing my favorite area of the hospital, I call it the center of the medical universe, the emergency department. And who better to join us than Dr. John Swanson, the Medical Director of the ED here in Truckee. Dr. Swanson is a board-certified emergency physician practicing full-time at Tahoe Forest Hospital. He has deep experience managing all kinds of emergency patient care, particularly in the mountain environment in which we live. Dr. Swanson, welcome to Mountain Health Today.
Dr. John Swanson: Thanks for having me.
Dr. Brian Evans: You know, to start us off, can you just tell our listeners about your background? How does one end up becoming an emergency physician? What’s the training involved? We don’t just take people right off the street, correct?
Dr. John Swanson: Yeah. So, you know, as a medical student, you’re exposed to different fields within medicine, such as OBGYN, surgery, orthopedics, pediatrics, many different specialties. And I found during my training that I really enjoyed most of the library of medicine. And, you know, there’s a couple of fields that really pick all that up, and one of them is emergency medicine.
And so as I went through my training, I just, I liked ortho, I liked neurology, I liked OBGYN. And in the end, since I liked it all, I just decided to do emergency medicine.
Dr. Brian Evans: Yeah. I give you a little bit of everything, right? And full disclosure to the audience, I’m also an ER doc, so by background.
And so I feel very similarly. You get that breadth of science and medicine and healthcare, and you don’t have to really pick like one area, but you’ve also got to be ready to go, right? You got to be ready for anything that comes through the door.
Dr. John Swanson: Right. And, you know, we, you know, we evaluate a lot of medical complaints such as chest pain and, you know, stroke-like symptoms, but we also get to work with our hands doing laceration repairs, joint reductions, fracture reductions. And so I also found that really intriguing.
Dr. Brian Evans: And when you say reductions, we’re talking about putting a bone back in the place it belongs.
Dr. John Swanson: Aligning up both bones, you know, making one side look like the other. That’s always a good thing. Yep.
Dr. Brian Evans: Generally, symmetry is good. So you’re also the medical director of the group and the physicians that work in the emergency department here in Truckee. So that’s a, that’s kind of a different sort of a thing, right?
I mean, it’s not just seeing patients and taking care of patients, but you’re also leading the team and making sure that everybody is functioning at a very high level, correct? How long have you been doing that?
Dr. John Swanson: Correct. Yeah. So, you know, I started, I moved to Truckee in 2000 and worked really just sort of in the pit or in the ER as we would call it for 20 odd years.
And the last couple of years I’ve switched over to more administrative work. And one of the things I really enjoy about it is helping to work with the docs that we have, sort of putting them in, you know, other administrative roles where, you know, giving them an opportunity to succeed doing other aspects of providing care in the emergency department. And so I’m involved with clinical policy formation, you know, reviewing patient charts, reviewing patient concerns, you know, and trying in general to make sure that the care provided at Tahoe Forest Hospital is top notch.
Dr. Brian Evans: And things change all the time, right? I mean, how has the emergency department and the science around it and what we know about how to take good care of patients changed in your career?
Dr. John Swanson: Sure. I mean, you know, I would say one of the biggest changes in my career is we went from paper charts to electronic healthcare records, which was, you know, a dramatic change. And you know, there we were in 2000 flipping through, you know, paper charts that were the size of an old dictionary.
And now everything is integrated into the computer, you know, along with computer physician order entry. You know, most of what we do is now on the computer now, and that’s helped make things much quicker and much more efficient and also brought in, you know, more patient safety, making sure, you know, we’re doing the correct orders on the correct patients. And so I think that’s probably been one of the biggest changes in my lifetime.
Dr. Brian Evans: I get a little post-traumatic stress just thinking about switching from paper because I was trained on paper too. And I remember it well when we went to the computers and some docs were really not happy and actually quit the profession at that time because it was just too much to learn how to do these systems. But I mean, back in those days, we had to worry about handwriting, for example, like bad handwriting could be a major patient safety issue.
And certainly that’s been resolved with computers. Yep. You also have been the medical director for EMS. So what does EMS stand for and, you know, what’s involved in that?
How does that interplay with the emergency department?
Dr. John Swanson: Sure. So emergency medical services really kind of is describing pre-hospital care, you know, care provided by, you know, what most of the public would think about, you know, an ambulance per se. And in our community, you know, it’s Truckee and Tahoe City Fire that provides EMS or, you know, patient care outside of the hospital.
And this ranges, you know, they’re called out for medical complaints. They’re called out to ski resorts. They’re called out, you know, onto the freeway in the worst weather imaginable and trying to figure out how to extricate patients from where they’re injured, package them up and get them safely to a hospital where we can take care of them in a nice warm, dry environment.
So they really set the tone for and are critical in providing patient care before, you know, hitting the ER.
Dr. Brian Evans: Yeah. You know, the I think when people think about what is involved in getting patients safely to the emergency department here in Truckee or to our other hospital in Incline where, and I know you work very closely with Abby Young, who’s the medical director of the Incline emergency department for us. It’s sort of mind boggling how people get from where they are, like whether it’s in a crashed vehicle or they’re on a mountain after some sort of an accident and they get in here.
How much does weather really play a role in this? Because it does change the mechanisms that we’re using to get folks in and how we’re responding to that.
Dr. John Swanson: Sure. I mean, in our community, we have everything from remote bike paths that, you know, might need to be accessed with, you know, a litter and a search and rescue team to a UTV or side-by-side type vehicle, which Truckee Fire has to boats out on Donner, boats out on Lake Tahoe. So, you know, we’ve got a myriad of different conditions in the natural environment.
And then, of course, ski season is big for all of us. And we see an amazing number of, you know, patients injured out on the slopes that ski patrol is actually sort of even before EMS, they’re the ones typically getting patients down a slope and into the hands of the firefighters.
Dr. Brian Evans: Yeah, all these things are like little fingers reaching out into the community. They’re an extension almost of the emergency department. But ultimately, the patients arrive and there they are in the emergency department.
What kind of cases do you typically see? I mean, people always wonder what’s an ER doctor doing. There’s a lot of fascination about the ED and like what’s happening there.
So what kind of cases would you expect to see on a typical ER shift?
Dr. John Swanson: You know, a typical ER shift for us, I’d say we sort of have, you know, two big seasons, right? We’ve got our summer season and our winter season. And as every local knows, the shoulder seasons just seem to be going away.
You know, in the winter, you know, you’re typical. We would see often ski or snowboard trauma, sort of simple injuries such as a, you know, shoulder injury or wrist injury. And then we see more complex injuries where, you know, patients will have concussions or trauma to their chest or abdomen.
And, you know, that’s kind of our sort of, you know, winter day trauma that we would see. In the summer, we’re thinking about, you know, we’re seeing patients that, you know, come in after mountain bike injuries, e-bike injuries, hiking injuries, slip and falls. So we do see summer in the trauma as well.
And as most residents from North Tahoe can tell you, the summer really is, you know, probably even our busiest time, busier even the winter. The old mantra is that people came to Tahoe for the winters and they stayed for the summers. So it really is a magical time to be up here.
And with the swelled population, the emergency census swells as well.
Dr. Brian Evans: Yeah, the population definitely jumped up around COVID. A lot of people became more permanent residents and it’s definitely affected the emergency department. Okay, I got to ask you this, Dr. Swanson. So I get asked actually all the time about the pit. All right. This is, for those of you that haven’t seen it, that are listening, the pit is a show about an emergency room in Pittsburgh. And it’s quite popular, won a bunch of Emmys.
Dr. John Swanson: Have you seen this show? I’ve seen it. Yeah, it is an amazing show.
And as we mentioned earlier, people are always like, is the ER really like the pit? And the answer is of course, yes. Although the pit is maybe all of the best cases sort of crammed into one shift.
So you take the best cases of the year and you just cram it all into one hour. So yeah, it’s fun. But I’ve seen almost all those cases that they care for in the pit.
And so it’s always really interesting when you watch it and they’re seeing and doing the same kind of medicine that we actually practice.
Dr. Brian Evans: I noticed you said the best cases. And I’m not sure that a layperson, a non-ER doc or ER nurse would say the best case. They might say the worst cases.
Dr. John Swanson: True. You know, and maybe the way to put it is the exciting cases, right? These are cases that are life or limb threatening. It’s our opportunity as an emergency physician to make a time-sensitive intervention to, you know, save someone’s life, save someone’s limb.
And that makes for good TV and it makes for good medicine.
Dr. Brian Evans: Absolutely. Yeah. I’ve been surprised by just the way that the procedures are depicted on that show. And they actually look very, very realistic. And I agree, like all those things that come in, you know, they’re things I’ve seen in the past, but definitely not on the same shift. Luckily.
Dr. John Swanson: Yeah. Yeah. Very interesting.
Dr. Brian Evans: I mean, the fascination with sort of what’s going on in the emergency department has been a constant, really, as long as I can remember. And I know that we were talking before about some of the TV shows that have been out there. And The Pit is the latest of a long series of them, starting with MASH.
So did you watch MASH when you were younger?
Dr. John Swanson: Yep. And yeah, and I think maybe the surgeon Hawkeye Pierce was maybe my first interest in becoming a physician. He just seemed like a great, fun-loving character, but also really cared about patients and did whatever he could to save the injured soldiers that he was caring for.
Dr. Brian Evans: You know, the docs that you oversee in the emergency department here, I’ve been just remarkably impressed by their skill level, their intellect, their background. They’re all board certified emergency physicians. Why is that important?
What’s involved in that? So that people know, I mean, that maybe you could explain to listeners what the specialty even is. You know, it didn’t used to be a specialty back in the early days.
Dr. John Swanson: So when the emergency department here was founded by Michael McQueary, the ER was typically staffed by docs, either internists and or surgeons who were looking to build their practice. And, you know, these docs would sort of moonlight in an ER. And when they met nice patients or that needed care, they would often pick them up and add them to their practice.
And probably in the late 60s, early 70s, people really saw that there was a need to have a specialty training in emergency medicine, right? I mean, we were doing everything from fever workups on infants to running codes if a patient had a heart attack or a cardiac arrest or they stopped breathing or their heart stopped. You know, we were managing those cases as well.
And, you know, so it was everything from complex medical care to complex trauma care and triage. And so the specialty of emergency medicine was founded. And currently, that means it’s there is a residency in emergency medicine.
It’s typically a three to four year process to train to become an emergency physician. So all of us in the ER have that training and we all maintain that board certification.
Dr. Brian Evans: Yeah, absolutely. Things really have changed. I think the specialty has gotten much more sophisticated over the years.
And I think the expertise and the care that’s provided to patients is much more consistent and very high quality. You know, one thing that people don’t know about our it’s a small emergency department relative to like a big inner city one. But we have added some capabilities or your team has added some capabilities to the hospital in the form of some accreditations.
So we are now a stroke receiving center. We’re also a level three trauma center and recently certification accreditation as a geriatric emergency department. Why are these kinds of efforts, which are I mean, it’s a significant amount of work that goes into that and an effort on the part of a lot of people.
Why is that important for our community and for the patients that receive care here?
Dr. John Swanson: Sure. So, you know, all three of those are excellent examples of the type of work that, you know, emergency physicians have done to really raising the bar in care in our community. The first was, you know, becoming a trauma center.
The American College of Surgeons are the ones that accredit hospitals to as trauma centers. And if you are a level three trauma center, that is telling the lay public or, you know, lay public should feel comfortable with the fact that our hospital is ready to handle most traumatic emergencies. For example, think about a ruptured spleen that might occur if you fell skiing and you injured your chest or abdomen.
Our facility, you know, has the capabilities of caring for most of those injuries. And by becoming a trauma center, that means that we go through a process that a national organization will come in and make sure we have the correct tools and physicians, you know, on board and processes to, you know, care for injured patients. And so, that was a change that occurred in the last five years.
When I first started here 10 years ago, we were not a trauma center per se, but we cared for a lot of injured patients that were injured, you know, either cycling or skiing or just falling down. And so, we were always kind of doing that work. But by becoming a trauma center, it really sort of raised the bar on, you know, in terms of how we care for our injured community members.
The next one, we became a stroke center two years ago. And again, this also made caring for patients that are having strokes and or stroke-like symptoms much higher. We have the ability to bring in a neurologist over a, you know, we call it teleneurology consult, where they appear on a screen and they talk to the patients and they help us make patient care decisions.
And it’s really an amazing way to bring a specialist care into the emergency department where otherwise, because of our small size, we just couldn’t have that level of expertise.
Dr. Brian Evans: Yeah. And I’ll just jump in and say that what some people don’t realize is that neurologist is there seeing the patient within minutes of their arrival typically, which is very, very difficult to do. But we’ve got a process where we rely on neurologists from numerous areas around the country and they jump in and see that patient right away.
Dr. John Swanson: Yeah. And I’ve listened to these neurologists have conversations with our patients and they have an incredible, I think, you know, they can really provide incredible care despite being out of the ER, you know, if you will. And I’ve heard them talk to patients. They explain everything.
They are very helpful. They’re very caring. And they are passionate about trying to improve stroke care for patients in the emergency department.
They help us try to make the hard decision about whether or not a patient might need different treatments for their stroke depending on what’s causing the stroke and how quickly the symptoms started. And then lastly, we became a geriatric emergency department. And that means that our ER physicians have undergone extra training to provide the specialty care that our older patients will require at times as sometimes patient presentations as we age get more difficult.
And so that’s been great training for us. And we have a few goals to improve our care for all of our older patients in the emergency department for the next year. So that’s been a great achievement as well.
Dr. Brian Evans: Yeah, you know, I just I think that recognizing what the community is now and how it’s shifted over the years and noticing, I think, that we’re seeing older people. I’ll just say older, not old people, but older people like me wanting to stay in this community for longer. They want to stay here.
They want to retire here. They want to be here and they want to do things. They want to ski.
They want a mountain bike. They want to do all kinds of things. And they want to know that we’re here for them if something is necessary, whether it’s a heart attack or a trauma situation.
And now the certification of being a geriatric center so that we can really up our game. I think that’s just an incredible thing for you and the team to have offered. So thank you for that.
One thing that’s, you know, in our area of risk is Avalanche. You’ve had a lot of experience with the Avalanche Center is my understanding. And so what drew you into that and how is that important for us?
Dr. John Swanson: Sure. So, you know, again, I was involved in a lot of pre-hospital research and pre-hospital EMS work, you know, everywhere from REMSA to CareFlight. And as I got in, you know, sort of became part of this community, one of the things that I really enjoyed was backcountry skiing.
And of course, that comes with a risk of, you know, Avalanche. And so I volunteered with the CR Avalanche Center for the better part of a decade and helped them with fundraising and was on their board for many years. And that is a great organization, by the way. But so that was my, that’s how sort of I got involved with the Avalanche Center.
Dr. Brian Evans: Okay. Well, what’s the one thing that you’d really recommend to our community out there in terms of staying safe in this area, whether it’s wintertime or summertime, our wimpy winter is kind of ending right now, but what would you recommend to folks just to make sure that they stay safe out there as they go up, go about their busy lives as Tahoe residents?
Dr. John Swanson: Sure. You know, I think, you know, in terms of Avalanche safety or in terms of general safety, really prevention is the key, right? You know, so for example, if you’re going to go backcountry skiing, there are, you know, AVI-1 courses and there are first aid courses that you can do to, you know, try to help manage problems as they arise. But the main thing is, for example, is trying to avoid avalanche terrain and avoid getting avalanched.
I think that’s sort of a good example, right? You know, AVI-1 will teach you, you know, what to do if there is an avalanche, you know, how to find someone and dig them out. But probably the best thing you can do is avoid being in avalanche terrain, you know, from the get go.
And so I look at that, you know, in terms of all of my outdoors activities, right? And that might be, you know, if we’re mountain biking, maybe just sort of ratcheting back speed. If we’re hiking, trying to, you know, just sort of be aware of, for example, you know, the weather and the terrain around us and making sure that we’re prepared for those things.
Dr. Brian Evans: Well, you have your marching orders from Dr. John Swanson. I really appreciate you being here with us today. Dr. Swanson is the Hawkeye Pierce of Lake Tahoe, I believe. So that does wrap up our conversation. Thank you, the audience, for spending part of your day with us. I’m Dr. Brian Evans, Chief Medical Officer of Tahoe Forest Health System. You can learn more about today’s topic or find resources and services at tfhd.com. Until next time, take care of yourselves, take care of each other, and stay healthy here in the mountains. Thank you.
