GruntDoc covered this article from the WSJ (also see Pittsburgh Post-Gazette, no subscription required) just fine from the Emergency Medicine perspective. Seems the author and the quoted neurologist don’t really have a grasp on healthcare realities. There are no stroke centers everywhere, because there are no neurologist eager and willing to provide emergency services to degree necessary that we see in the article’s analogy to trauma system and centers. They seem as equally ignorant about the realities of EMS system throughout the country. Trauma is easy to discern in the prehospital environment — physical evidence is usually abundant. Neurologic deficits are often subtle, masked, denied, and confounded by other clinical conditions. We don’t have widespread cardiac centers for the same reason, and yet we do have EKG that may be useful in triaging.
It really comes down to how much, in terms of money and personnel, are we willing to front-load EMS systems to do all the necessary triage prior to arrival at an Emergency Department. If we, as a society, believe that this is important then the next question for the proponents of front-loading a system is how do we accomplish this smartly. I don’t believe it is prudent in terms of long-term health policy to raise an entire class of healthcare workers to a level sufficient to accomplish moving triage and the initial evaluation from the hospital to the “field.” To borrow from the intensivist — the intensivist does not need to be physically present 24-7 in the ICU, but there must be sufficient information coming from the ICU so that the intensivist cognitive skills may be brought to bear on a 24-7 basis (eICU). Will the day of “eEMS” arrive? I think it will have to, and the drivers will be to deliver patients to the “appropriate facility” the first time.
Great case last night, fifty year old male with no prior history of cardiac disease, had intermittant chest pain for five hours prior to calling 911. Many times you can tell from the paramedic’s call in exactly what the patient has — patient was hypotensive and bradycardiac — of course it was a big inferior wall myocardial infarction (7 mm ST segments inferiorly with reciprocal changes laterally). Door to needle time for the TNK (Tenecteplace, TNK-t-PA) was under 15 minutes and to the cath lab (10 miles away) via CCT within 90 minutes. Patient had normalized ST segments within 20 minutes of TNK administration (first set of cardiac markers negative).
With the paucity of a neurologic infrastructure (neurologists and neurosurgeons willing to be as available as cardiologists and cardiothoracic surgeons) it is inconceivable that stroke centers will have any immediate or widespread successes as cardiac centers.