2. Discuss
Neurology is a difficult subject with many critical diseases for most of physicians. It is also a blind spot and difficult area in medical diagnosis and treatment. Therefore, urgent consultation in neurology department is very common in the tertiary hospital center. In this analysis, there are two main findings listed. First, neurological diseases account for 77.8% of total cases in the urgent consultation diseases, which is different from the disease spectrum of inpatients applying for emergency consultation in neurology department reported recently [1]. 57.5% of diseases in the urgent consultation were in line with the urgent consultation criteria. . Second, the most common reasons of urgent consultation were disturbance of consciousness, tic/stiffness, limb weakness and mental disorders. Common neurological disorders were acute cerebrovascular disease (33.6%), epilepsy/status epilepticus, and encephalitis, metabolic or infective toxic encephalopathy.
In 1437 cases of urgent consultation, the actual number of cases was decreased year by year from 573 cases in 2014 to 257 cases in 2017, which may be attributed to the improvement of the clinical skills of non-neurologists in our hospital and the rational and effective management from the hospital medical services section. In this urgent consultation indications assessment, only 57.5% of consultations were in line with the urgent consultation criteria. Therefore, non-neurological practitioners should strengthen the learning of neural diseases; strictly make a judgment on the urgent neurological consultation. And medical manage office should put forward the appropriate management measures to enhance the effective urgent consultaionn.
In urgent consultation, acute cerebrovascular diseases account for 33.6%, including cerebral infarction, cerebral hemorrhage and transient ischemic attack, which was similar with foreign reports [8]. In our hospital, the average age of patients with urgent consultation was 60.3 years old. This older age may be related to the highly incidence of stroke onset increasing with age [6]. Most of the consultations are in line with the guidelines of urgent consultation. However, the urgent consultation cases were decreased. There are several reasons for that. First, the management office has strengthen the importance of basic medical knowledge and basic skills. There are lots of training held during the continuing medical education. Second, the physicians are more skilled in making a diagnosis and treatment the acute cerebrovascular diseases. Third, there is a standardized clinical pathway for the physician to reference on several neurological diseases. There were 177 cases of epileptic/epileptic persistent state, which was different from the common urgent consultation diseases reported in domestic emergency consultation reports. The main reason may be that there is an epileptic center in our department, which is one of the famous epileptic centers in China. There are several experts on epilepsy and a large number of regular follow-up patients, which come from neighbor area with the poor treatment managed by non-specialist physicians before. The metabolic or infective toxic encephalopathy and encephalitis were the third largest group of urgent neurological consultation in our hospital. There are many patients with encephalopathy and encephalitis, who were treated for a longer time. In the hospital, there is a Chongqing Key Laboratory of Neurology, which is operated by full-time personnel. They can detect acid-fast bacillus with more than 80% positive results and abscissile cells. They also can detect more than ten antibodies related to autoimmune encephalitis, which are highly specific and sensitive. The neurological physicians could practice better management in making a diagnosis and treatment of encephalitis.
Some of departments had frequently applied for urgent neurological consultation including intensive care unit (ICU), respiratory medicine, cardiovascular medicine, hematology and nephrology. At present, it is estimated that there are about 10% of patients presented with some neurological manifestations [10-12]. It had been reported that the neurological consultation in ICU was often urgent consultation, which also suggested that the patients had server disease to be managed. At the same time, there are some of ICU doctors lacked relevant knowledge of neurologic critical illness. It advised that resident on internal medicine should be trained in neurological specialty at least 6 months with the 3 years of standardized resident training in China. In addition, physicians in the ICU should take part in more lectures on emergency neurology in our hospital. Most of the patients have a common occurrence of cerebrovascular disease in the department of cardiovascular medicine and nephrology, who have the risk factors of vascular sclerosis. Patients with renal failure are consulted by neurology because of the impaired consciousness or convulsive in dialysis, which are due to the internal environment dysfunction, renal encephalopathy and dialysis encephalopathy. The common reasons for the application for consultation in the department of respiratory medicine include convulsions, disturbance of consciousness, and the etiology is mostly pulmonary encephalopathy, ischemic and hypoxic encephalopathy. First of all, it is very important for them to control the primary disease. If the patients with lung tuberculosis presented with headache, disturbance of consciousness, convulsion, hyponatremia, the tuberculosis meningitis should be considered. And then the patients should be prescribed routine with the lumber puncture for cerebrospinal fluid analysis, dynamic electroencephalogram and brain enhanced MRI examination. Once the patients have been made a diagnosis of tuberculosis meningitis, physicians should prescribe with anti-tuberculosis drugs in combination at enough doses as soon as possible. The main reasons for applying for urgent consultation in surgical department are impaired consciousness. The uncontrollable postoperative epilepsy is one of the special reasons for the neurosurgery department. However, the preoperative evaluation and secondary prevention of cerebrovascular disease are often met in the surgical department, which should be consulted at regular time rather than an urgent consultation.
To take the accuracy case history and the neurologic examination may help the physician in the differential neurological diseases with others. There were 150 cases of non-neurological diseases including restlessness, mental disorder, disturbance of consciousness and headache, which were considered to be related to internal environmental disorders, primary diseases, hypertension, anxiety state and vagal reflex syncope. Some physicians confuse with the aphasia and unclear utterance in mental disturbance. Therefore, in order to reduce unnecessary urgent neurological consultation, physicians should rule out the above diseases before application for an urgent enological consultation. Acute encephalopathy often is secondary to infection after cardiopulmonary resuscitation or metabolic diseases. To control the primary causes is the main measures. Before applying for consultation, it is suggested for the physicians to complete blood gas analysis, electroencephalogram, blood glucose and electrolyte, computer tomography of the skull, and to take the detail history of drug use including sedatives and antidepressants. In the case of urgent consciousness disorder and cognitive impairment after surgery, drugs adverse effects should be considered first. Therefore the physicians should be familiar to the adverse effects of anesthetic drugs. For the tetanus/convulsion, as one of the common reason for urgent consultation, the physician should be familiar with the possible cause of the convulsion including the diseases of respiratory medicine, cardiology and other internal medicine. Only parts of them are diagnosed as epilepsy, which should apply for neurological consultation. Limb weakness is the same with them. Non-neurological diseases accounted for 10.4%. Both internal medicine and surgical departments account for half of them, such as respiratory, cardiology, orthopedics, obstetrics and gynecology, and digestive departments. Non-neurologic diseases usually presented with irritability and delirium with no focal nervous system signs, which may be regarded as the differential criteria with the neurological diseases. Most of the consultation patients with non-neurologic diseases have no new structural damage in the central nervous system [13], and the treatment is mainly to maintain the stability of the internal environment for the treatment of primary diseases. Pain is a common cause of consultation in previous reports [14]. Some of them should be consulted with neurosurgical physician rather than neurologic physician such as cerebral contusion and laceration, skull base fracture, diffuse axonal injury, intracranial tumor, hydrocephalus, subdural hematoma, etc. The physicians should know more about neurosurgical knowledge.
Some of the consultations should be ordinary consultation rather than urgent consultation. For example, a patient with Parkinson’s disease applied for emergency consultation in neurology department because asked for the intravenous treatment of ganglioside. There are 169 cases that could not be diagnosed in the study because of severe diseases failure to complete relevant examinations and physicians’ poor recording in the cases. Medical staff in non-neurologic departments should strengthen the learning of common urgent and critical diseases related in clinics, while the neurologists provide more lectures to the junior physicians in the hospital.