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Emergency Department Stroke Care.

Emergency Department Stroke Care To the Editor In his Editorial,1 Caplan retells a story of a patient he encountered in 1962 as he provides an opinion on the article by Topcuoglu et al2 on stroke recrudescence. Caplan suggests that taking a careful history and administering a physical examination could reduce unnecessary testing and treatments. He also suggests that “inexperienced doctors” in emergency departments (EDs) who follow checklists contribute to indiscriminate care. In 2000, JAMA published the Brain Attack Coalition recommendations to establish primary stroke centers, with a key requirement being multidisciplinary collaboration.3 The current guidelines continue the philosophy: successful stroke programs require the expertise and collaboration of emergency physicians (EPs) and neurologists. The equal partnership between these 2 highly respected professions has taken acute stroke care into a new era. The United States has about 5000 EDs and approximately 50 000 board-certified EPs. By contrast, there are approximately 1000 primary stroke centers in the United States and only 1100 vascular neurologists.4 Most of the 800 000 annual US ischemic strokes are first seen in the ED by EPs. Over our careers, stroke outcomes have improved markedly, tumbling to the fifth leading cause of death from the third. We believe one contributing factor is early care delivered by EPs. At Massachusetts General Hospital, over a 16-year period, Topcuoglu and colleagues saw approximately 10 000 patients who had a stroke yet only found 153 recrudescence episodes.2 Most patients had detailed and expensive evaluations. Recrudescence episodes were notable for their abruptness; stroke physicians would want prompt evaluations and treatment for patients with sudden deficits, such as arm weakness, facial palsy, and dysarthria. Also, when speaking to patients and families at the bedside, the question patients most often ask is “how can you be sure this is not another stroke?” Both Caplan and the investigators in this study have a luxury that people in the ED do not: an abundance of time and the observation that the symptoms resolved later. In acute stroke, 1.9 million neurons are dying per minute.5 We do not have time to defer our acute decision making. At the University of Michigan, EPs and neurologists are equally experienced and respected partners in the treatment of acute stroke. We take careful histories and follow appropriate guidelines. Caplan’s implication that patients receive poor care by physicians in EDs is incorrect. We strongly maintain that EDs that are directed by EPs in partnership with vascular neurologists provide exceptional care to patients who have experienced strokes across the country.