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.