Transcript of Dr. Leap’s Interview

Neil Haley: We’re back to the Neil Haley Show and also the Media Giant Effect. I’m excited to welcome my special co-host, Rural Doc Alan Lindemann. Doc, what’s going on? I know you’re excited about co-hosting with me today.

Dr. Lindemann: We are very excited. Diane and I are happy here. And how are you doing?

Neil Haley: I’m doing fantastic. And our guest today is Dr. Edwin Leap. He’s an emergency room doctor. And we’re going to talk about… our topic today is rural healthcare and defining rural healthcare. Dr. Leap, thanks for stopping by. How are you?

Dr. Leap: Great. Well, thank you for having me.

Neil Haley:  All right. Let’s talk about it. I’ll let Doc ask the first question about rural healthcare to Dr. Leap.

Dr. Lindemann:  Well, Dr. Leap, you had sent an email to me about some of the things you wanted to talk about. I know that you’re an ER doctor and have been an ER doctor in many places and you have a lot of experience with rural healthcare and your dad was a minister.

Dr. Leap:  That’s right.

Dr. Lindemann:  I enjoy your articles. Can you tell us a little bit… You wanted to talk about emergency medicine and why the waiting list is eight hours and why people get tired of sitting in the waiting rooms. And so just tell us a little bit about those things which are close to you.

Dr. Leap:  Well, right now, even before Covid, small hospitals were struggling a lot. There just weren’t enough physicians, enough nurses, enough beds. And as you know, rural hospitals have closed at an alarming rate over the last few years, and it’s harder and harder for them to function and to stay financially solid.

As that gone along, it got propped up a little bit during Covid because it was federal money. And now that that’s going away, these hospitals are struggling in a way I’ve not seen in my entire 29 years of practice. Hospitals don’t have enough inpatient beds, and part of that is a nursing shortage and part of it is a physician shortage and part of it’s just money for these small facilities. And so not only do they not have beds, they don’t have specialists, they don’t have even often things as simple as obstetricians or surgeons. Not that simple, but I mean it’s fundamental, I should say.

People come to these facilities and have complicated problems, and then they find can’t be admitted at their local hospital because there’s no beds or physicians or nurses. And then when we try to transfer them to a larger center, those facilities have no beds either. All right? We find ourselves stuck between the devil and the deep blue sea here. These people may have aortic aneurysm, they may have atopic pregnancy, they may have sepsis or vascular occlusion.

They simply can’t go anywhere because there’s no beds at the other facility. And frequently there’s not enough ambulances to transport them.

People in these small towns and small communities are really hurting. And this is true of relatively medium-sized rural communities and even especially what we call critical access hospitals, which by definition have to be about 30 miles from a larger center to have that designation and that sort of funding.

During the pandemic, and even after that, I find myself often in small hospitals holding very sick patients that can’t be admitted locally and can’t be transferred. And that’s bad for the patient. And it’s really stressful for the nurses and physicians who care for them. And this is not just me. I wrote something about this recently about how many we were holding in our hospital and I said, “We’re holding 23 patients in a 26-bed ER.” And people wrote back to me and said, “We’re holding 40 in a 20-bed. We’re holding 60 in a 30-bed.” This happens all the time. They’re holding far more patients waiting for admission or transfer than they even have beds for, in hallway beds.

And so when people come to be seen there, their waiting room time is going to be six, eight, 12 hours on a good day, just to be seen. And that’s not even getting your workup done or getting admitted or transferred. That’s just sitting in the waiting room. And what we do know about waiting rooms is that people often get tired and leave the waiting room.

But according to research on that, they often get tired of leave because they’re really, really sick. It’s easy to say, “Well, they weren’t that sick.” They actually were. They might have had a heart attack, they might have had pneumonia. They might have said, “I just can’t be here any longer since I think it’s better to be homesick than in the ER,” that’s when they leave and bad things happen. So, we know that all-causes mortality is up across the country since Covid. And this is devastating. It’s getting worse and it’s getting worse in these places that are small hospitals. Not only because of medical illnesses, but because addiction to drugs and alcohol, depression, suicidality, these things are going through the roof. Small communities are really stuck.

Neil Haley:  So, how can you fix that problem with our healthcare system? Get more doctors to go become certified, to be doctors, getting more nurses, better recruiting? What can you do to help this rural healthcare problem, really?

Dr. Leap:  Well, I think one of the things we can do is try to fund these hospitals in a way [inaudible 00:05:49] control to local communities.

One of the problems is with large corporations buying small hospitals, they’ll buy them and then maintain them for a couple of years and divest themselves of them. But they don’t really have a vested interest in them. I’ve seen this happen. The large system buys a small hospital, takes away all its resources, they’ll take their surgeon, they’ll take their obstetrician and say, “You guys aren’t busy enough to have that. If you have a problem, just send it to us.” And then we try to send it and they won’t take it because they’re [inaudible 00:06:20].

I think it’s a problem that goes up and down the line. We need more doctors and nurses in these small facilities. They need to be funded appropriately, stay open, because these are citizens who deserve the same care as people in urban areas get every day. We need people who go there, people who work there, and we need these jobs to be humane jobs where people aren’t completely stressed out of their mind working there.

I think one of the things these smaller hospitals should do is offer some litigation protection for people who work in them. Because you do take a risk. These are things you might face, problems you simply can’t fix. And you’re worried about being sued. So, many times physicians won’t go to those places because they have fewer resources. And that’s probably true of nurses as well. We need to make it a more amicable place to work that’s not so stressful. But we’ve got to build more hospitals.

These places, even if the small ones, there’s been talking what we call micro-hospitals, maybe in the ER or just a couple of inpatient beds, just to hold people. We have to have something like that. And I think about the [inaudible 00:07:22] in the old days where we needed transit points to get people to larger centers because right now they just can’t get anywhere. Better staffing, better funding and more facilities. And of course, everybody says the same thing. We need more money. That’s the standard response. But it’s just true. You can’t abandon an entire segment of the population to their illnesses or injuries and pretend like they don’t exist.

Dr. Lindemann:  Well, I certainly agree with you as far as litigation goes. This is something I’ve been thinking about for about 20 years. It would really be just a flip of the legislative switch to make this a reality for small hospitals. It would have to be, I suppose, state by state, possibly federal government. But it would be an easy thing to do, and it would encourage many doctors who presently feel threatened or don’t want to put up with the added litigation you might get from a small town.

I’m retired now, I’m 75 and I’ve been retired for a year, but I’ve got about 52 years of medicine under my belt. I’ve seen a lot of things change, a lot of come coming and going. But we live in a town… Well, we live in the country actually, in the real country. Our county has the least density in North Dakota. It’s two people per square mile. Our little town is 650 people, and our little hospital is 25 beds, but about 15 of those are long-term. They’ll probably admit five to eight patients. And we have a two-room ER. We can get busy like you.

And one of the big problems we have is the person who comes in at 2:00 on Saturday morning. This is a real difficult time to get anybody transferred especially people who have a psychiatric condition. I can sit on the phone for six hours calling 12 hospitals and nobody wants to take them. It’s lonely.

Dr. Leap:  And the other thing that we’re noticing is these are not just adult psychiatric patients. These are pediatric psych patients who are suicidal and depressed and psychotic. And it’s even hard to find beds for them. No one will take them. And so they’ll be stuck for days to weeks in the same ER.

Dr. Lindemann:  Yeah, I know. It’s very difficult. We have something here, we have this telemedicine in our ER, and sometimes that is a little bit helpful for dealing with the psychiatric patients. But still, that can take four or five hours just on the computer screen to even just to get some kind of a diagnosis. And that is not necessarily a transfer.

Dr. Leap:  Yeah, absolutely. No, it is rough.

Neil Haley:  I mean, I can’t believe that that’s not coming out, Dr. Leap. I didn’t know about this. I didn’t know about it because people don’t talk about this. So, you’re telling me the deep pockets of corporate companies are taking over the healthcare systems, and even the smaller hospitals, and are not staffing them correctly. It sounds like that’s one of the big problems.

Dr. Leap:  Yeah. They take them over and they just… The old idea was, “Well, we’ll take all the cases. The big hospitals, they want procedures. So, send us your procedures and sick patients because they’ll help it.” But when they can’t take them, then they hurt us because they took what we had to begin with and offered us nothing else.

I worked in one small hospital, they used to have a very, very aggressive surgeon and an obstetrician, the big facility took them over, they took them. Suddenly this hospital, up on a mountaintop, had nothing. And this happens everywhere. Obstetric care is a big problem right now in rural America. People have to go through hours to get obstetric sometimes.

Dr. Lindemann:  Yeah, it’s a real headache because, well, especially here in North Dakota, when it’s January and February, you can have 20 and 30 degrees below zero. And we’ve got pregnant patients having to drive through a blizzard 80 miles to get to the next hospital. These are very life-threatening conditions that we have to face here.

Dr. Leap:  Sure, sure. I mean, I recall during Covid when I had a patient with a suspected ectopic pregnancy, a tubal pregnancy, Neil, and that can be life-threatening, and I had no way to transfer her to an obstetrician. I had her husband put her in a private practice and take her. That was the only option I had.

Dr. Lindemann:  Yeah.

Neil Haley:  Do you think this is happening in big cities, Dr. Leap?

Dr. Leap:  Does it happen in big cities?

Neil Haley:  Yeah.

Dr. Leap:  Well, I suspect it does. Certainly the periphery of them. I mean, I shouldn’t be too cruel to those. I’m not trying to be unkind. The big cities struggle too. I mean, Atlanta recently, they used to have two trauma centers and one of the trauma centers closed. So, imagine Atlanta right now with only one trauma center where they had two.

The people who work in those places are also being crushed. They’re overwhelmed with volume because not only do they have their own catching area, but they have guys like me calling from North Carolina or South Carolina saying, “Can I send you my patient? Because I’ve got nothing.” It all flows in the same direction. It’s just that we have fewer things out in the hinterlands than they have there, but they’re almost just as overwhelmed as we are.

Dr. Lindemann:  Well, how have you been doing with Covid? We’ve been living with that now for three years. And actually, I was kind of lucky because I walked around with Alpha for about a year and a half, and I had never caught it. But some of these people we just couldn’t send because the hospitals were full, everybody was full.

Dr. Leap:  That’s right. Right now, Covid is actually doing pretty well for me. I mean, we’re not seeing a ton of Covid patients. But during the height of it, it was horrible. I mean, because people had… not only did they have respiratory failure, but they had high oxygen requirements.

Neil, someone who had a regular pneumonia, might need four liters of oxygen per minute. These people needed like 60, 80, 90 liters per minute. And so I remember a child that we saw who had multiple other illnesses that we tried to transfer him and we couldn’t fly him because the aircraft couldn’t carry enough oxygen. And we don’t think about that sort of logistic thing. I think the problem in America is we’ve always sort of offered this idea that we have [inaudible 00:14:04], that we have enough of everything. We’ll always have more. And Covid suddenly reminded us that we had not enough of anything.

And when that hit, there weren’t enough ambulances. I remember one that one child, we tried to fly him by rotary wing and they couldn’t fly them. Then we tried fixed wing, but all the fixed wing aircraft were tied up managing hurricane response in the Golf. We just don’t have enough of the things we thought we had. And honestly, Covid, for all that it was bad, had a pretty low mortality as pandemics goes. And I worry about what happens next time when it’s actually 5%, 10%. You look back historically at plague with 50% mortality. What do you do with that? I think you dig a lot of graves, unfortunately.

Dr. Lindemann:  Yeah. We had not a lot of trouble with our Covid here. We were pretty lucky and most of them were handled outpatient. I think one of the things that helped us was we saw everybody right away. We didn’t make them stay at home for a week or two until they got really good and sick. So, most of our outpatients stayed outpatient.

Dr. Leap: Right. Well, that’s good. And we tried to do that also. We started at one point sending people to a home on oxygen. And it was a really simple thing. You sent them home with a couple oxygen tanks. Within a few days, they were better.

Neil Haley:  Do you see many people with Covid now in the hospitals again?

Dr. Leap:  No, it still comes in small ways, but nothing like before, from I’m seeing when I’m working.

Neil Haley:  All right. Doc, any other questions you have for Dr. Leap?

Dr Lindemann:  I can’t think of anything right now. I know what I wanted to ask you. We’ve been talking about problems of rural health, but if you could wave a magic wand in addition to getting this litigation thing straightened out, is there one thing you could think of doing that would help this?

Dr. Leap:  One thing. It’s tough to say, but I think if I could wave my magic wand, that one thing would be to have medical schools and residencies recognize this as an issue and work towards encouraging people to go to these places.

I mean, we have a cultural divide right now, and academic medicine is one of the places where it’s most profound. A lot of our new graduates will not go to these areas because the, A, money’s less, or B, this is a different culture. The people in rural areas have a different outlook.

Dr. Lindemann:  Yes, I know that.

Dr. Leap:  And somehow that’s, I think, considered out there or strange. So, “We don’t go to hang around those people.” And there’s some wonderful residents who go to these places. I feel like the drift of academic medicine is very urban and progressive, and we see that in medical school admissions committees right now and things like that. And if we don’t correct that soon, we’ll have a big dichotomy because people will not go to these places just because of a cultural ideological difference.

Neil Haley:  Oh my gosh.

Dr. Leap:  If we could make this a big part of the medical education, I think that would make a difference.

Dr. Lindemann:  Well, I spent about 20 years trying to educate students and residents to do obstetrics in rural areas, but it wasn’t until I actually moved to a rural area to do obstetrics that I realized what most of the problems were. And certainly, training these people is one thing. And of course you’re right, lifestyle is different.

My wife and I like living rural a lot. We both come from rural and I’ve got 60 chickens out in my chicken coop, and I give the eggs away. I’m still a farmer at heart. I don’t think that’s the real problem. I think that when I started trying to practice what I was teaching, I realized there were layers and layers of administration that stopped things. And one of the big problems was the hospital boards who knew absolutely nothing about what it took to deliver babies safely in a rural hospital. So, lots of education needs to be done on many levels.

Dr. Leap:  Yeah. I agree.

Neil Haley:  And you can get more doctors in the schools, give the opportunity for more people to have the chance to be doctors and nurses. That means really pushing mathematics in schools and not just in the certain schools. And really look at healthcare as still an option for people to really bring something, or else there’s going to at a huge shortage. Dr. Leap, is there a place that we can follow you, check you out and stuff like that?

Dr. Leap:  Absolutely. You can follow me on Substack, and my Substack column is called Life and Limb. And so I’d love people to come by. I write a lot about these issues and other things. It’d be wonderful if you could stop by with my Substack.

Neil Haley:  Do you write it? Do you have a book too?

Dr. Leap:  I did self-publish a couple books over the years. I’m not even sure if they’re available online right now. I wish they were, but one was done by Lippincot, and it probably is, but I haven’t put links up for a long time, but I appreciate that. But probably the best places to go is to my Substack account right now.

Neil Haley:  All right. We appreciate it so much. Thank you again, Rural Doc. All right, guys.

Dr. Leap:  Thanks for having me. Nice to meet you, guys.

Neil Haley:  All right, you’re listening and watching the Neil Haley Show, and we’ll be back in just a moment.