EPs do not accept the strategy of “lumbar puncture first” in subarachnoid hemorrhage

It has been proposed that the workup of suspected subarachnoid hemorrhage should begin with lumbar puncture (LP) rather than computed tomography (CT) scan. We investigated whether EPs would in fact advocate this strategy in an index hypothetical case and in variations of the index case. An eight-question survey was distributed to EM physicians attending national continuing medical education meetings. Questions included whether the responders would advocate “LP first” in the following scenarios: (1) the index case in which the patient’s symptoms had been present for more than 12 hours, other diagnoses were very unlikely, the patient was fully insured, and CT scan was available immediately; (2) a case in which the patient is not insured; (3) a case in which the respondent is the patient; and (4) a case in which there is a delay in obtaining a CT scan. Two hundred forty-one of 275 surveys were completed for a response rate of 88%. Given the index scenario, only 22.8% of the respondents would advise patients to have an LP first versus 17.9% if they themselves were the patient (P = .11). Compared with the index scenario, 34.0% of respondents would advise LP first if their patient did not have insurance (P < .0001); a majority, 57.1%, would advise LP first if the CT were delayed (P < .0001). The “LP first” strategy for workup of subarachnoid hemorrhage was rejected by most EM physicians except when the CT scan would entail delay. Compared with the index case, an added number of physicians would advocate this strategy if the patient was uninsured. The ethical implication of advocating a strategy because of financial concerns and that most physicians would not favor for themselves or their patients merits attention.