Although hospitalists may work alongside neurological specialists, they are increasingly on their own when responding to neurological emergencies, such as strokes, in hospitalized patients.
There are times the neurologist may be in the clinic, out of the hospital after hours, or otherwise unavailable, so responsibility for managing neurological conditions falls back on the hospitalist. But he or she may not have received sufficient exposure to neurology during medical training.
S. Andrew Josephson, MD, of the neurovascular division, director of the neurohospitalist program and assistant professor of neurology at the University of California-San Francisco (UCSF), regularly speaks on neurological issues to hospitalist audiences.
“I ask how many hospitalists in the room are primary caregivers for stroke in their hospital, and a surprising proportion raise their hands,” he says. “We do a good job of teaching neurology residents and fellows how to treat strokes. But it is important that we train internal medicine doctors as well, as they are seeing the majority of these patients nationwide.”
Depending on the setting, there may be wide variation in the hospitalist’s responsibility for neurological cases. “Here at UCSF, hospitalists almost never see stroke patients because we have a dedicated stroke service staffed by neurology attendings and residents,” Dr. Josephson says. “But at many community hospitals, they [care for neurological patients] all the time.”
David Likosky, MD, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash., concurs. “Neurology training in internal medicine residencies can be fairly limited,” he says. “After entering practice, these doctors are on the front lines in the hospital managing patients, many times without readily available neurologist backup.”
Dr. Likosky’s colleague at Evergreen, hospitalist Tony Yen, MD, says there are several neurological issues hospitalists are likely to encounter on a regular basis.
“Often the first responder to a stroke is the emergency department [ED] doctor or the hospitalist,” notes Dr. Yen. “Strokes are a time-critical, high-volume condition for our community hospitalist practice.”
Another important diagnosis is uncontrolled seizure (status epilepticus) that is unremitting for 10 minutes or more. Prompt response is critical.
Dr. Yen recalls the case of a young woman who collapsed while playing soccer. She was brought to the hospital and found to have suffered a brain-stem stroke. Physicians had three hours from the onset of symptoms to decide whether the patient was a candidate for tissue plasminogen activator (t-PA), a thrombolytic clot buster.
“I worked alongside the interventional radiologist and neurologist,” Dr. Yen recalls. “We were able to quickly establish a definitive diagnosis and then treat with intra-arterial t-PA.” The patient had a prolonged stay in intensive care and was on a ventilator for a couple of weeks but eventually recovered and walked out of the hospital.
Stroke: The most common neurological emergency hospitalists are likely to see, whether on the floor or through the ED, is acute stroke, Dr. Josephson notes. “The evaluation of stroke requires a non-contrast computed tomography (CT) scan of the head to exclude intracerebral hemorrhage,” he says. “You can’t tell by looking at the patient whether it’s an ischemic stroke, the more common variety, or hemorrhagic stroke. But the difference is crucial because drugs to treat ischemic stroke can make hemorrhage worse. We view stroke as such a time-sensitive emergency that it always gets priority in the radiology department.”
It is also important to ascertain, as much as possible, when symptoms first began or when the patient was last observed to be normal. The treatment of choice in the first three hours following an ischemic stroke is intravenous t-PA. From hours three through six or eight, endovascular therapies (intra-arterial thrombolysis or mechanical clot retrieval) are an option. Signs suggesting a possible stroke include a new unilateral weakness, one-sided numbness, vertigo or imbalance, visual changes, inability to talk, and new headaches—although indications of a stroke can be subtle. The National Institutes of Health has issued a stroke scale, with training modules, accessible at www.strokecenter.org/trials/scales/nihss.html.
Seizures: Prolonged seizures that don’t resolve on their own within a reasonable amount of time require attention because the longer they last, the more likely they are to cause brain damage, Dr. Josephson says. Medications to treat the seizure work more effectively the earlier they are administered. He recommends a protocol for treating status epilepticus that starts with lorazepam (Ativan), proceeds to fosphenytoin (Cerebyx), and is followed by a general anesthetic such as midazolam (Versed) or propofol (Diprivan).
Intracranial pressure (ICP): This could be the result of a stroke or hemorrhage, brain tumor, or trauma. Fast action to control ICP is important because permanent brain injury can result. “I emphasize to hospitalists who are used to targeting ICP that it is better to look at cerebral perfusion pressure (CPP),” Dr. Josephson says, offering the following equation: CPP equals mean arterial pressure minus ICP. He also emphasizes raising the head of the patient’s bed, hyperventilation in early stages of treatment, and using osmotic agents such as mannitol to remove water from the brain.
Neuro-muscular emergencies: Acute disorders of the peripheral nerves, including Guillain-Barre Syndrome (an autoimmune neuropathy often triggered by infection), present a subacute onset of weakness and numbness. “We have good treatments for Guillain-Barre, such as plasmapheresis and administration of intravenous immunoglobulin,” Dr. Josephson says. “But recognition is important because the breathing may be affected. If the disorder reaches the diaphragm, it could kill the patient.” Disorders such as Guillain-Barre commonly present with ascending weakness, from the toes up.
A lumbar puncture (demonstrating few if any cells with an elevated protein) or an electromyogram (EMG) may be required for diagnosis. Hospitalists also are urged to watch for impending respiratory weakness, which can be measured by forced vital capacity or mean inspiratory flow. “Consider this diagnosis for anyone presenting with general weakness,” he says.
Exams on the Run
There is a standard technique for assessing and diagnosing neurological conditions, called the neurological examination. Unfortunately, a full, detailed neurological exam can be time-consuming and unrealistic, given caseload demands and field judgments required from the working hospitalist.
“As a hospitalist, you don’t have to perform an hourlong neurological examination,” Dr. Josephson says. “But for patients presenting neurological symptoms, you need to do a screening examination tied to their specific complaint. Your hypothesis-driven exam can be done in a few minutes if you know which elements are high-yield screening tests.”
These brief screening tests can be part of a routine assessment of the patient, Dr. Likosky adds.
Hospitalists can learn a lot just by walking into the patient’s room. “The bulk of such a neurological exam can be performed while talking to the patient, if you pay attention,” he notes. “There may be subtle signs of weakness. For example, when the patient is lying in bed, the feet should point straight up.” Note if one foot points to the side, or if the patient uses both sides of the face equally when talking.
“You can do sensory exams and test reflexes very briefly, as well,” Dr. Likosky says. “If those issues are on your radar screen, you can do much of the screening work in a stepwise fashion. The rest depends on clinical observation.”
There is not a huge spectrum of neurological disorders likely to confront the hospitalist, but it is important to know about the most common conditions and remember that time is of the essence, Dr. Likosky says. “Most neurological conditions are garden variety, but keep in mind the differential diagnoses, for example, for weakness and headache—common conditions that may rarely have an uncommon cause.”
Beef Up Training
Heather A. Harris, MD, a hospitalist at UCSF, illustrates the divide between academic medical centers and community hospitals when it comes to management of neurological diseases. She did her internal medicine training at UCSF and in 2003 went to a community hospital, Eden Medical Center in suburban Castro Valley, Calif., to help establish a hospitalist group. Suddenly, she was seeing lots of neurological cases.
“I’ll be frank: My internal medicine training at a wonderful medical institution had not prepared me for the reality that many new hospitalists face regarding neurological disorders,” says Dr. Harris. “You may see strokes as a resident, but it’s very different when you are the physician primarily managing strokes as they roll in. Yes, you may have a neurologist back-up, but they can’t always come in right away. The first time you see a patient with a stroke, it can be quite intimidating. You’re really learning on the fly. Plus, stroke management has advanced substantially in the last few years and there may be controversy, for example, over the use of t-PA in a community hospital setting.”
Feeling that her exposure to neurology was insufficient, Dr. Harris sought additional training at SHM meetings and talked to hospitalist colleagues in other community settings. “Hospitalists like me were trying to beef up our neurological knowledge and skill set.”
Dr. Harris developed a keen personal interest in neurology. In 2007, she returned to UCSF, where many of the hospitalists rarely see neurological patients. But she joined a new co-management service where hospitalists work alongside neuro-surgeons, helping manage the inevitable medical issues that arise in these patients.
Based on her first-hand appreciation for what hospitalists in community settings need to learn, Dr. Harris is also part of a team developing a new, hands-on training curriculum at UCSF for working hospitalists from community settings. That team is making sure neurology is adequately covered in UCSF’s curriculum.
“My overall experience is that if you’re going to be a hospitalist in a community setting, you’ll have to face a wide range of neurological emergencies,” Dr. Harris concludes. “It behooves us as hospitalists to learn the skill sets to manage these issues. There are also medical-legal issues that may put hospitalists out on a limb for doing too much too far outside of their knowledge and training. These are issues for SHM and our specialty to address.” TH
Larry Beresford is a regular contributor to The Hospitalist.