We are a DGH seeing 43000 patient p.a we have had head injuries under A&E 
for many years and admit approx 1 a day.Only recently have they been lodged 
in co-located obs unit if adults, and paeds ward for children.
We do not have 24hr middle grade but the ortho SHO supervises the head 
injuries that are outliers on remote orthopaedic ward if obs ward is full, 
the paed SHO supervises the kids; and both liase directly with A&E 
consultant at home if required.
In the 4 years I have been in macclesfield there has only been 1 patient on 
my oncall who unexpectedly deteriorated on the ward and died-this was from 
GI bleed due to steroids which the neurosurgical reghistrar had authorised 
for a subacute subdural (despite CRASH trial result).Many many more have 
expectedly died-the old demented with large subdurals that neurosurgeouns 
have no interest in.
We have unhibited access to CT scan -with the explicit guideline that all 
CT's from A&E are requested after d/w A&E consultant-and essentially follow 
NICE guidelines 0800-2400hr-but have not quite coerced our radiology 
colleagues to agree to it formally but expect it soon.
I read all the head CT scans I request when I am on shop floor and the 
radiologists value this-it saves them being interupted.
Image link to your neuro surgical centre is really helpful, until it breaks 
down.
There is respect from other consultants when they know you have admitting 
rights.Those patients that have mutliple injuries not requiring transfer to 
neuro centre are surprisingly few.
We have a political issue in that neurosurgical registrars ignore DGH 
radiology reports and always review emailed CT scans before accepting unless 
it is youngster with Extra dural.
There is lack of clarity about who looks after/folows up the recovered head 
injury who has impaired cognitive function-but our rehab consultants have 
been helpful.
CT scans and MRI scans are not the b all and end all for deciding fitness to 
discharge-there have been several patients with significant ataxia 48-72hr 
post head injury with nothing on scanns and we just had to wait for them to 
get better.
Th physicians are comfortable taking over care of the old head injuries with 
small subdurals that neuro.s are not interested in acutely.
Juniors are consistently bad at considering c.spine injuries; and poor at 
writing up medications, also juniors overlook the UTI that caused the fall 
and head injury.
In the absence of 24hr middle grade we routinely do ward round without any 
junior dr at all so do the discharges, medcation sheet, request additional 
imaging etc-this is a bug bear on those weekend shifts where there three 
head injuries.
mark nicol
01625 421000 bleep 5015



>From: "Reid, Cliff" <[log in to unmask]>
>Reply-To: Accident and Emergency Academic List <[log in to unmask]>
>To: [log in to unmask]
>Subject: Inpatients with Head Injuries
>Date: Wed, 8 Mar 2006 17:29:48 -0000
>
>Anyone working in a unit where the emergency physicians look after all 
>inpatient head injured patients?
>
>Would be grateful if you could share your experience of the pros and cons.
>
>Cliff Reid
>Basingstoke
>
>
>Disclaimer - March 8, 2006
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