One of the biggest misconceptions about freestanding ERs is that they are the B team. The junior varsity group. The substandard substitute for a “real” ER tied to a hospital.
Nothing could be further from the truth.
Freestanding ERs are staffed by emergency-trained and board-certified physicians, with all the equipment and medicine that you will find in a hospital ER.
With that background, here’s exactly how we respond to a stroke at Emergis ER and all other ERs and trauma units where I work:
Freestanding ER and Strokes
All of the FSED facilities I work in have tPA in our pharmacies. When a patient comes in with a stroke (called a “cerebrovascular accident,” or CVA) the first thing you do is a CT scan, not give the drugs. The CT enables us to ensure that there is no bleeding. If tPA was given with a hemorrhagic stroke, it would be lethal for the patient. If the CT comes back with no hemorrhage, and the patient is within the 3.5 hours window of onset of symptoms, tPA can be used. Onset of symptoms outside of the 3.5 hour window kicks you onto the next time clock which is about 12 hours for intravascular clot retrieval.
A CT Angiogram (CTA) is performed to look for a clot. If a clot is found, the patient is a candidate for neurovascular intervention. Most hospitals and freestanding emergency departments can perform the CTA, however neurovascular intervention is indeed a service that is only provided at a hospital, but not all hospitals provide it. Within the DFW area there are only a small number of hospitals that provide neurovascular intervention. Any patients who are candidates for this service are typically transferred from the initial facility to one of these hospitals where a clot retrieval procedure is offered.
FSEDs Provide Critical Initial Care
So where do the FSEDs stand on this? All of the hospital ERs and freestanding ERs I work in stock tPA and have CT and CTA capabilities. We also stock Mannitol which is critical for intervention in some cases of hemorrhagic stroke. With a cerebrovascular accident (CVA), time is brain. If an FSED has the capability to save you 20 minutes—and they do—then it would be irresponsible to encourage a patient to bypass a facility that is capable of providing emergent intervention.
These CVA patients can be treated and transferred to a stroke center who can then provide further neurologic services. I have worked and continue to work at Level 1 – 4 trauma centers, and the procedures and time to treatment in those centers are no different from the Emergis FSED. Whether you ship from a hospital ED or an FSED to a neuro interventionist, the procedure is the same; however, getting that initial tPA as soon as possible is critical.
We can’t talk about strokes without discussing on-site neurosurgical services for the hemorrhages. Unless you are a Level 1 and maybe a Level 2 trauma center, neurosurgery is not in house 24/7. With our transfer agreements in place at Emergis ER, we can often beat the neurosurgeon to the facility, if emergent surgery is indicated at all. Except in extreme hemorrhages, many times the patient will be simply observed for a period of time.
Final Word: Hospitals vs. FSEDs
If the argument for hospital ED vs. FSED is made based on immediate neurosurgery availability, then even the vast majority of full-service hospitals don’t meet the standard. That puts hospitals EDs and FSEDs on equal footing, plus FSEDs are more convenient with shorter wait times.
Call Emergis ER Any Time, at No Cost
If you think you or someone you love is having or has had a stroke, go to your nearest ER immediately. If you are close to an Emergis ER location, you can check in online on this website or give us a call to speak directly to a licensed staff member.
About the Author:
Dr. Jon Steadman is a board certified emergency medicine trained physician and the chief medical officer for Emergis ER. You can find Dr. Steadman using his expertise from working at many different emergency room settings within the Dallas area as well as Oklahoma and Mississippi to bring a high level of clinical excellence and patient satisfaction to Emergis ER.