Lisa Maurer, MD, FACEP
Immediate Past President & Rural Outreach Coordinator
Earlier this month, the WACEP Board of Directors held our quarterly meeting in beautiful Richland Center and paired it with educational sessions and a dinner reception for board members and regional docs. What a great experience! Shout out to all you EPs working in the truly gorgeous corners of the state. Our Chapter arranged this event to get a better understanding of what rural practice is like and attempted to connect EPs working in rural Wisconsin with colleagues at their typical receiving facilities.
In Richland Center, we were welcomed by the most gracious host and medical director of Richland Hospital, Dr Andy Harris. I’m sure I wasn’t the only one who was impressed and a little bit jealous of the practice environment, hospital support, and the skill of the emergency physicians who practice there.
To paint a picture, Richland Hospital is a pristine, independent critical access hospital with 25 inpatient beds in the southwestern corner of the state, tucked among the bluffs and rivers. When transfers are needed, they partner with receiving facilities in both La Crosse and Madison. They have bedside ultrasound in the ED, 24-hour access to OB support, and are successfully continuing to build on their team of physicians dedicated to the community. Their success is in large part due to the fantastic leadership of Dr Harris, who moved from Illinois to join their staff just two years ago, and who brings a real passion for the area and for rural practice in general.
We had fantastic educational opportunities for everyone involved, ranging from hands-on workshop for bedside ultrasound skills to the ins-and-outs of cutting-edge stroke care for patients who arrive at non-stroke centers. See below for my personal takeaways and lessons learned.
On behalf of the WACEP Board of Directors, I’d like to offer our sincere thanks to 1) the UW Emergency Medicine Ultrasound faculty; 2) Dr. Natalie Wheeler, neurologist who provided updates on transfers from the UW-Madison stroke team; and 3) UW Med Flight team whose participation hugely complimented the conversation on stroke care in rural areas.
Personally, I can attest that the lessons I learned in rural Wisconsin directly apply to my suburban and urban community practice. I found that despite differences in transfer times, more similarities abound between my practice and those of our colleagues in rural Wisconsin. WACEP looks forward to offering another Rural Outreach Program with similar experiences in another rural part of the state next summer. Please let us know if your ED is interested in hosting, and what topics you’d like to see discussed with emergency physicians and specialists you interact with at your primary receiving facilities.
MY QUICK TAKEAWAYS
- When doing an ultrasound-guided peripheral IV, don’t try to advance the catheter off the needle as soon as you see a flash. Advance the needle just a little (3-5 mm) while visualizing it inside the vessel on ultrasound before advancing catheter off the needle. The IV should be long enough to have distal 1/3 of the catheter inside the vein when the procedure is complete.
- When trying to decide if someone's heart has a happy squeeze or a sad squeeze in parasternal long axis view, look to see if the mitral valve leaflets are happily touching the septal intraventricular wall when the myocardium squeezes and the valve flaps open. I picture someone happy saying "yay!" with their arms up and out.
Stroke at a Non-Stroke Center
- Consider moving toward a CT/CTA imaging protocol right off the bat for all acute stroke. Dr. Wheeler is happy to share a protocol if you're interested.
If your facility's protocol is to just do noncontrast CT, consider asking your radiologist to give you a HECTS score - this may help communicate risk of ischemic stroke to your potential receiving neuro team.
The list of absolute exclusions for tPA is becoming shorter and more lenient - talk with a potential receiving neurologist. Even consider calling when you patient has a low NIHSS, seeing as mild stroke syndromes oftentimes progress to moderate to severe stroke syndromes in the first 24 hours.
There is a new trial exploring bolus tPA vs bolus/gtt tPA, which might make delay for transport less of an obstacle for physicians who work with EMS partners who cannot take a patient with a tPA drip going.
Med flight physicians want to stress that they are happy to take over for complicated patients at any stage of the game—even if the patient needs procedures and is not "wrapped up in a bow." They understand that our rural docs are often pulled in ten directions at once.
Capabilities of local EMS teams vary greatly. You do not necessarily have to reserve the use of Med Flight for critical patients. Rather, think of them for any patient that supersedes the capabilities of your local resources.