Caitlin Whyte (Host): Welcome back to In Their Words, the podcast brought to you by the UPMC Pinnacle Foundation and UPMC in Central PA that takes you on a journey through patient stories and provider insights, bringing you up close and personal captivating storytelling, enlightening interviews and real world scenarios.

In today's episode, we're diving deep into the heart of healthcare transformation. Join us as we shine a light on the dynamic duo of healing and compassion. Dr. Greg Swartzentruber, Emergency Medicine physician and Medical Director of UPMC Pinnacle Center for Addiction Recovery, and Street Medicine CRNP Christopher DeLong, together they'll guide us through the intricate web of street medicine and emergency medicine at UPMC in Central PA. I get ready to hear firsthand accounts of meeting patients where they are, and truly making a difference. Join us on this illuminating journey as we learn, connect and uncover the heartbeat of healthcare on the streets at UPMC in Central PA.

Dr. Greg Swartzentruber: I've just had so many really great patient encounters over the past seven years that it's hard for me to narrow it down to one story that really exemplifies why I do this type of work. But I can recall one patient that came to us in the addiction clinic after having been seen by paramedics at her house for an overdose. And she was resuscitated by Narcan. And the paramedics left Narcan at the house. She did not want to go to the hospital. And the paramedics said, "Well, we're going to leave a dose of Narcan here just in case." And they encouraged her to go to the hospital to get treatment for her opioid use disorder and to just engage in treatment.

Well, she overdosed again about 48 hours later, and her husband resuscitated her with the Narcan that was left there at the house by UPMC paramedics. And so, she has since been coming to the addiction clinic. That was a couple years ago. I believe, if I recall correctly, it was near the beginning of COVID. And she's been doing extraordinarily well. She's been in recovery for over two years now. And she has a job, she loves what she does, and she's just doing really well. And multiple times she's told me that if those paramedics hadn't left the Narcan on scene, she said, "I could very easily be dead." And that type of patient interaction, I think, exemplifies what I like most about this. And that is meeting people right where they're at in their moment of greatest need and being willing to say, "Okay, I know that you're not quite ready to go to get treatment right now. But here's something that will at least save your life, and here's a little encouragement to get help." And I think that's probably what I find most meaningful about this type of work.

Host: When Dr. Swartzentruber first started working in emergency medicine, his feelings about working with patients, suffering from substance use disorders began to evolve. Every patient that came through the door expanded his idea of what emergency medicine could be and what form it could take.

Dr. Greg Swartzentruber: I'm formally trained in emergency medicine. And I have to confess, and I say this often, that when I was working full-time emergency medicine, I did not enjoy taking care of people with substance use disorders. We tend to see the same people overdosing, you know, sometimes night after night. And from the pure perspective of an emergency department, you don't know if anyone ever gets better, and that was my perspective for a long time. And it was my medical toxicology training and work in the hospital that first exposed me to people after an overdose when, say, they were admitted to the hospital for some medical complication of their overdose or their addiction, then I started to see these people as people just like me whose lives have been wrecked by an addiction. And it really gave me a lot of compassion for them, and that was kind of preceding me being asked by UPMC seven years ago to start an addiction medicine clinic. And so, I did and not really knowing what I was doing at the time, I don't think. But this addiction medicine work has, kind of like an addiction, taken over my life. And I find more meaning in my career doing this type of work than in anything I've ever done.

Host: When looking back at his time working alongside Dr. Swartzentruber, Christopher DeLong could see how his road to working in street medicine and tending to those facing substance use disorders began.

Christopher DeLong: Prior to my becoming a nurse practitioner, I had worked in the emergency department, and Dr. Swartzentruber is one of the physicians that I had worked with during that time. And when he had heard that I was in my nurse practitioner program, he had actually kind of pulled me aside and asked about coming to work with him in the addiction clinic. And honestly, when I was going through school, addiction medicine was not something that really piqued my interest. It wasn't something that I had thought of as a career after I had finished my nurse practitioner degree. And like Dr. Swartzentruber had said, being in the emergency department, that's where I worked as a nurse for nine years, you get a very narrow window or very small view of the addiction population. And it's not the good, warm and fuzzy side, where typically you see the results of people getting better after going through treatment. But after talking with him and hearing the success stories and hearing how much of an impact you can have on somebody's life for the better and being on the other side of that window and seeing how people can improve after they get treatment, that's how I had gotten into the addiction role. It's an amazing thing to see, someone come into our clinic that is really struggling, no consistency in life, and then after a few months, things start to fall into place. They get a job. They're reconnecting with their family and friends. And there's just a whole new meaning to life for them, and it really is an amazing process to see and help them go through.

Host: Dr. Greg Swartzentruber, an unwavering advocate for street medicine, has always championed innovative approaches to healthcare. And when he brought CRNP Christopher DeLong into the fold, it was a winning collaboration that breathed new life into their team's mission.

Christopher DeLong: And as far as the street medicine aspect goes, because I do split my time between both the addiction clinic and street medicine, that is a whole 'nother side of things. And seeing the people specifically on the street medicine aspect, it's an amazing thing to see and help the people that are really underserved and really in a very, very tough situation. You know, the homeless population really struggles a lot with both mental health and substance use. And similar to what Dr. Swartzentruber had said, we can offer help over and over and over again. And it's important to be persistent because you never know which interaction you have is going to be the interaction that leads them to have a change of heart and want to pursue the treatment and get the help and better their situation.

When it comes to seeing our population as far as the homeless persons go, a lot of times there's major trust issues with anybody that is in a position of, I guess you could say, with professionalism or authority. So, going to their encampments or meeting them in a place that they're comfortable with really helps to gain that trust. And a lot of times for our clients, the first few interactions that we have with them, it takes several meetings and several interactions before they really open up and we're actually able to help them in any way. Then, we've got some fantastic community outreach workers that really, quite honestly, do a lot of that interacting to gain their trust. And then, myself or one of the other physicians that I work with, Dr. Van Scoy, can come in and try and really help them and see what they need medically. And a lot of times, again, substance use, whether it be alcohol or otherwise, is a part of that picture.

Host: The world of Street Medicine is a dynamic tapestry. With diverse nuances and roles that come together to create a comprehensive healthcare experience for homeless individuals and those grappling with addiction. From a symphony of specialties to a flow of services, this well-rounded approach is changing lives on the streets and beyond.

Christopher DeLong: Yes, we have a few community outreach workers. Some of them are medically trained, some of them train more so as like a social worker, a licensed social worker. But the role really is to build a connection, build a relationship with the clients. And then as soon as we kind of gain their trust and they're willing to participate with us in the medical setting, we just kind of dive in and see what their needs are medically. If they don't have insurance, we help them apply for insurance through Medicaid or whatever other options we can pursue. And our community outreach workers really do a fantastic job of helping to coordinate their care, kind of keeping tabs on where our patients are so we can set up visits with them and pretty much meet them wherever, whenever suits them because they're a very transient population and they'll be out walking and going from their encampment to the community resources that are available to them. And we'll stop and meet them on the street corner or along the river. You know, anywhere in time is how it goes.

Host: Exciting opportunities await physicians at UPMC Harrisburg who are eager to deepen their understanding of Street Medicine. Joining Dr. Swartzentruber and Chris on the frontline allows these dedicated physicians to experience the transformative work firsthand. This immersive experience is not just about medicine. It's about empathy, compassion and igniting change in the lives of those who need it most.

Dr. Greg Swartzentruber: I do know that the emergency medicine residents are going to be doing some street medicine work with Chris and Dr. Van Scoy. And I think it will be a valuable experience for the residents. I think it will be good for the patients just to have more physicians meeting them where they're at.

But from the emergency medicine standpoint, often we see patients in the emergency department, we give them a prescription and they come back three days later and the infection is worse or their diabetes is worse and you say, "Well, what happened? I gave you this prescription?" "Well, yeah, but I don't have insurance" or "Yes, but you sent it to the wrong pharmacy," or "Yes, but I couldn't get to the pharmacy for whatever reason." And there are so many barriers to many of these patients getting the treatment that they need. And as a physician working in a hospital or working just in a clinic where people typically come to see you, you might not even know what some of these barriers are. So, this type of experience on street medicine will really open your eyes to know what these barriers are so that you can actually address them real time when you're seeing a patient in the ER. So, let's say I have somebody with a cellulitis, a skin infection, I want to give them an antibiotic. When I'm at the bedside with them, because these barriers to healthcare are floating around in my mind, I'm going to be more likely to say, "Where do you live?" You know, "If you're in an encampment, which encampment are you at? What pharmacy is closest to you that I can send the medication to?" Or, "Can I send the medication to the pharmacy at the hospital so that you can just get it when you're leaving the department?" "What type of insurance do you have?" "Do you have a copay on your medications?" All these things that, unless you're made aware of these as barriers for patients, you might not know of them or know to ask about them.

 If I could add something to what Chris said earlier about the distrust of medicine by many of these patients, a significant number of these patients have mental health issues and substance use issues, but their distrust of the healthcare community is well founded. Many of them have been mistreated in the past or dismissed because of non-compliance or substance use. And I can't tell you how many times I've had a patient come to my clinic and say, "I used this month." I'm like, "Okay. Tell me more." "Are you going to kick me out?" I'm like, "What?" And that's how they've been treated in the past by many in the healthcare field. And so, they're afraid legitimately so, to be honest with us about what they're struggling with because of how they've been treated previously.

Christopher DeLong: That was perfectly said because that is so true for so many of our patients, both the patients that we see in the addiction clinic and the patients that we see in the street medicine. Their distrust that has formulated over years is very understandable given the interactions that they've had in the past. And it takes time and patience to break down those barriers and gain their trust and let them see that we're here genuinely to help them and help them better their situation, better themselves, be healthier, and try and offer them the resources that they need to hopefully succeed, however that may be. Because a lot of our homeless patients, you know, their idea of succeeding is not what lines up with the traditional views that you and I may see as being successful, and that's okay. Not everybody has to fit into the same group and as long as they're happy and they're content and they're healthy, that's the main goal.

Host: The Street Medicine Program is growing in so many ways. And as Dr. Swartzentruber and Chris can attest to this program is only going to continue its remarkable expansion.

Dr. Greg Swartzentruber: We're expanding what we're doing in terms of outpatient addiction medicine. Our clinic has grown over the years with incredible institutional support from a half day a week with just me to five days a week with three nurse practitioners, two physicians, a mobile unit that goes to about five or six different locations multiple days of the week, and now in the past two years, an addiction medicine fellowship where a physician is in a one-year training program that will end with them being board-certified in addiction medicine and able to continue to grow the presence of addiction medicine in UPMC Central Pennsylvania.

So, I've enjoyed immense institutional support over the past seven years as we started this addiction medicine program and it has continued to grow and the inpatients are benefiting immensely from this where we are aggressively treating withdrawal syndromes. We are sitting down and engaging with these patients in the hospital. And we have seen a change just in the past one to two years, even among hospital staff in how they talk to and interact with these patients. So, I think the future is bright for addiction medicine here in Central Pennsylvania.

Host: The future is certainly bright and due in part to a very special opportunity brought to the fold with assistance from the UPMC Pinnacle Foundation.

Dr. Greg Swartzentruber: Several years ago, I presented to the foundation the idea for a mobile unit. We had been given a state grant to expand addiction medicine services. And the idea was to have a central hub of addiction medicine that supported multiple spoke sites. And the spoke sites were intended by the state to be primary care offices that were willing and excited to engage patients with substance use disorders in the clinic.

And for various reasons, I seem to hit a lot of roadblocks with primary care physicians wanting to engage with this population. And so, I saw a mobile addiction unit in Philadelphia and that gave me the idea of doing something similar to that here. So, Philadelphia is obviously a different environment, but we have a similar lack of resources, although it's spread out over multiple counties instead of just being in one city. So, I presented that to the foundation and it was received with overwhelming support. And so, coupled with the state grant and support of the foundation, we were able to purchase a mobile unit about three years ago. And it's been meeting patients in very underserved areas since that time. And it's been very well received by the patients.

Host: Through grant programming facilitated by the UPMC Pinnacle Foundation, this groundbreaking mobile addiction unit has become a reality. Staffed by addiction medicine professionals, this unit journeys to remote corners of our region, extending medical treatment to those who face barriers to travel. It's an embodiment of the commitment to reach every corner of our community with compassionate care.

Dr. Greg Swartzentruber: The mobile unit is able to do everything that we're able to do in the office except for the administration of controlled substances. And that requires some additional licensure, which we are in the process of getting, but that's going to take some time to be able to do. But we can draw blood on there. We can engage with patients for their treatment of their mental health through our collaborative care initiative and our behavioral healthcare manager. We're able to do medication administration for non-controlled substances, so Vivitrol is a once monthly injection that we're able to give on there. And a lot of what we do on the bus is monitoring of Suboxone or buprenorphine therapy for patients with opioid use disorder. So, it goes to a couple locations in Carlisle, York; Elizabethville, which is Northern Dauphin County; and Newport, which is in Perry County. And in all of these locations, we see patients who walk to the mobile unit, because there is literally no other treatment option around.

Christopher DeLong: I see the clients in the Carlisle area every Monday, that's my location. It really works just as an extension of our office. It's set up in a way that we have individual spaces for regular appointments like we would in our office in Harrisburg, and it really functions in the same exact manner. You know, the appointments are scheduled and we see generally the same patients, but it also does open up the door to if someone that we don't know is interested in starting treatment, which is not an uncommon thing. We can see new patients right there on the spot if our schedules allow. And if not, we just get them scheduled for the next week and we see them then.

Host: When asked how they'd encourage others to join the street medicine initiative, Dr. Swartzentruber and Chris both shared the resounding endorsement, reflecting the profound impact this work has, hopefully inspiring a growing community of advocates, dedicated to making a difference.

Dr. Greg Swartzentruber: I would say that there are very few areas in medicine where you can see such a dramatic improvement in a patient in such a short period of time. I'm sure there are others, but this is a very obvious and visible change in people, coupled with incredible gratitude on the part of the patient simply for meeting them where they're at, simply for being kind to them, and engaging with them and encouraging them to find recovery, telling them that you're going to be there for them and that you want to help them in any way you can. I have learners and nurses spend time with me in the clinic and often their response at the end of the day is, "That was transformative." They have never seen addiction from this perspective, like the way addiction is portrayed in the media or the way it's talked about in the hospital or seen in the emergency department Is not at all the majority of what we do in the addiction medicine clinic. And we see people who celebrate these great milestones like, "I have 500 in my checking account" or "Come look out the window, doc. I just bought a brand new car. I want you to see it," to "I have a 401(k) now" or "My family is talking to me again, and my kids are coming back, and I'm off of parole, and CYS is off my back, and my kids are doing well, and I'm doing well." It's just so incredibly rewarding to see these patients meet these goals along the way and find and maintain long-term recovery.

Christopher DeLong: From the street medicine side of things, it's just an amazing opportunity to see, again, the appreciation that our clients have for us. And like you had mentioned before, after we form those relationships, they are genuinely happy and excited to see us when we come down or we do visits with them or an impromptu pop in. And knowing that we're genuinely there because we care about them and we want to help them. It's an amazing thing, and it is really gratifying to have that kind of relationship with our clients, and to know that it's a genuine relationship, and it's not just the patient-provider relationship, but there's more caring involved. And seeing them transform as time goes, and change how things are for them and get them the resources that they need to improve their situation, it's really a gratifying experience.

Dr. Greg Swartzentruber: I would say that at the end of the day, I do feel that positive feeling of having really helped someone today. But the other way that this has affected me is just in my parenting and in my general human interaction. So, many of our patients have been very mistreated by parents, by siblings, by other people. And when I hear their stories, some of them are almost overwhelming to the point that, I think, I bet I would be in the exact same situation that you're in if that's what my childhood was like. And so, it motivates me, even in my parenting, and how I interact and, you know, love my kids just to make sure that my kids know that their dad loves them and cares about them. And that's something that many of our patients didn't have. I mean, there are notable exceptions, of course, but many of our patients have really suffered from abuse and neglect as children. So, I sometimes tell people that when you spend time with people in recovery and you hear their stories, if you're not overwhelmed with the responsibility of parenting, then you're probably not doing it right.

Host: When asked what they would like their colleagues at UPMC in Central PA to know about addiction medicine and street medicine, Dr. Swartzentruber and Christopher DeLong had some insightful suggestions.

Dr. Greg Swartzentruber: I guess I would just want our colleagues who also work in UPMC to know what we do and what we can offer patients and to send people to us. I would say that earlier in my career, One of the reasons I did not engage in this way with people with substance use disorders is I didn't know what to do and I didn't know what resources were available. So, I empathize with people who aren't really sure what to say when somebody says, "Hey, I'm using heroin" or like, "I drink too much. I don't know what to do." So, I would just say know that we exist and reach out to us with questions or, maybe even more importantly, send your patients to us.

Christopher DeLong: I'd just echo that sentiment. Our street medicine patients are frequent consumers of the emergency department. And, you know, I would hope that all our colleagues realize and treat them fairly and know that a lot of times that these individuals, similar to addiction, their circumstances, past experiences have led them to where they are today. And a lot of times, it was outside their control, and to give them a fair chance and listen to them and not just discount any complaints or concerns that the patients may have.

Host: As we wrap up this enlightening episode, we want to extend our heartfelt gratitude to you, our listeners. Your engagement and support means the world to us. We encourage you to share these inspiring stories and empowering messages with others who seek meaningful insights. If you've enjoyed this episode, we'd greatly appreciate your ratings and reviews on your preferred podcast platform. Your feedback helps us reach more hearts and minds. Stay tuned for next month's installment, where we bring you another captivating story that captures the essence of In Their Words. Until then, keep spreading compassion and making a difference.

VO: This podcast is brought to you by the UPMC Pinnacle Foundation and UPMC in Central PA. UPMC in Central PA has seven acute care hospitals, with 1,160 licensed beds, over 160 outpatient clinics and ancillary facilities and more than 2,900 physicians and allied health professionals, and approximately 11,000 employees in Central PA. It is a healthcare hub serving Dauphin, Cumberland, Perry, York, Lancaster, Lebanon, Juniata, Franklin. Adams and parts of Snyder Counties. The UPMC Pinnacle Foundation exists to provide resources to meet the needs of our most vulnerable patients, promote health and lifelong wellness in our communities and support our workforce so we can attract, train and retain the best and brightest talent at UPMC in Central PA. To make a difference and join their philanthropic mission, visit upmcpinnaclefoundation.org.