Emergency neurology

[conrad]

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I was reading a random paper that I found online:

Moulin, et al. Impact of Emergency Room Neurologists on Patient Management and Outcome. Eur Neurol 2003; 50:207-214.

Online at: http://content.karger.com/ProdukteD...abe=229676&ArtikelNr=73861&filename=73861.pdf

Granted, it's from France (where there's a different style of EM), but it got me thinking about emergency medicine in the academic center. I wonder if having EM physicians fellowship-trained in the emergency aspects of neurology, cardiology, infectious disease, etc. is helpful in the final outcome of patients who present with these kinds of problems.

For example, would it be better (outcome-wise) to have patients complaining of headache to be seen by an EM physician who has completed a hypothetical fellowship of emergency neurology, and who might be able to admit patients directly to the neurology floor?

 

[FoughtFyr]

I was reading a random paper that I found online:

Moulin, et al. Impact of Emergency Room Neurologists on Patient Management and Outcome. Eur Neurol 2003; 50:207-214.

Online at: http://content.karger.com/ProdukteD...abe=229676&ArtikelNr=73861&filename=73861.pdf

Granted, it's from France (where there's a different style of EM), but it got me thinking about emergency medicine in the academic center. I wonder if having EM physicians fellowship-trained in the emergency aspects of neurology, cardiology, infectious disease, etc. is helpful in the final outcome of patients who present with these kinds of problems.

For example, would it be better (outcome-wise) to have patients complaining of headache to be seen by an EM physician who has completed a hypothetical fellowship of emergency neurology, and who might be able to admit patients directly to the neurology floor?

Maybe, but this would be a logistical nightmare. First, which "fellows" should be on when? Who decides in which system the emergency exists (i.e., is syncope cardiac or neurogenic?). What is the liabilty for a non-fellowship trained EP in assessing the patient?

All of that said, there was been a move at some facilities to combine the hospitalists with the ED because they can "continue care to the floor". I'm not sure this will bear fruit in terms of outcome, here's why. In the ED we can get tunnel vision. We focus on one problem, or diagnosis, and run with it. We may well be wrong. Admiting the patient to a different physician's care, in the ideal setting, allows a fresh set of eyes to analyze the availaible data. I would submit that as many errors that are created by "poor hand-offs" and "missed details" are prevented by re-evaluation of patients by new caregivers. Look at nursing - more medication errors are caught at shift change than at other times (anecdotal from a hospital quality officer I'm married to).

Lastly, I would submit that the idea is not that much different from having separate EMS units for cardiac/medical and trauma (an idea that was tried in the late 1980s). With a few notable exceptions (Seattle's Medic One and Phoenix's psychiatric EMS vans come to mind), the idea was usually scraped due to logistical and financial difficulties.

- H

 

[conrad]

I agree that combining EM and hospitalists would be tricky and may or may not be beneficial. But having fellowship-ed EM docs does not seem to be too difficult, and presumably the extra training would enable these docs to be "even better" at deciding the acuity of illnesses in their realm of subspecialty.

I guess there really isn't a good way to test this hypothesis since there aren't a whole lot of fellowships, but maybe one area that has been developed in emergency medicine is toxicology. Is there a difference in the clinical acumen (and ultimately in the patient outcomes) of EM docs with toxicology fellowship training vs. EM docs without?

I'm not very educated on the liability issues but it seems to me that non-fellowship trained EM people shouldn't be held back in terms of who they could treat. What happens in rural areas where IM/FP docs work in the ER? There'd always be a need for general EM (ie., non-fellowship trained) docs, and then there'd be fellowship trained EM doctors in big academic centers. But on the other hand, maybe the latter is unnecessary because big academic centers usually have super-specialists that can do the workup better....

Just thinking aloud.

 

[FoughtFyr]

I guess there really isn't a good way to test this hypothesis since there aren't a whole lot of fellowships, but maybe one area that has been developed in emergency medicine is toxicology. Is there a difference in the clinical acumen (and ultimately in the patient outcomes) of EM docs with toxicology fellowship training vs. EM docs without?

Well, yes there is but most toxicology services are run as consulting services, the same as others like cardiology, etc. EM is not the only pathway into the fellowship, nor to ACMT accreditation.

- H

 

[Apollyon]

Andy Jagoda (PD at Mt. Sinai) is well-versed in EM neurology (he is one of the editors of the "Emergency Neurology" book for ACEP, has written a lot of chapters on it, and his wife is a practicing neurologist), and yet, had no problem with calling for neurology consults (from the resident, of course) on pts in the ED. What I mean is, this is a strong suit of his (among many others), and he still goes to the specialists.

I think EM training does what it is supposed to - EM generalists. The hospitalist/intensivist line seems logical, because both take most comers, and consult for the balance. I think that is why there aren't a lot of EM fellowships (and the ones there are, are not typical inpatient fields).

 

[roja]

How on earth would you get people fellowshiped in every single emergency? The point of EM is to know what are the important EMERGENCIES of all fields. I consider it my job to know what are the neurological emergencies (ie, spinal cord stenosis, central cord syndrome, TIA, CVA, etc etc ) and activate the appropriate consults.

Just like I think its my job to recognize MI's and ACS (cardiology), hypercalcemia in cancer patietns (oncology), etc etc.

 

[Neuron]

I personally think it's a terrible idea, and a waste of training and resources. EM docs are specialists already, in emergencies. Why have EM-cardios, EM-Neuros etc - how will their roles be different from a real cardiologist, neurologist, etc?