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ACAD-AE-MED  March 2012

ACAD-AE-MED March 2012

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Subject:

Re: ACAD-AE-MED Digest - 4 Mar 2012 to 8 Mar 2012 (#2012-18)

From:

"Bethel, Jim" <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Fri, 9 Mar 2012 09:39:47 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (570 lines)

As I recall there were some lone acute severe headache (LASH) guidelines published by I think the clinical effectiveness committee - I'm sure they are searchable - this lady I  am sure would have fit the bill for a scan  - LASH + high risk factors for bleeding (warfarinised/previous dissection)

Jim Bethel 

________________________________________
From: Accident and Emergency Academic List [[log in to unmask]] on behalf of ACAD-AE-MED automatic digest system [[log in to unmask]]
Sent: 09 March 2012 00:00
To: [log in to unmask]
Subject: ACAD-AE-MED Digest - 4 Mar 2012 to 8 Mar 2012 (#2012-18)

There are 15 messages totaling 1928 lines in this issue.

Topics of the day:

  1. loan severe headache (15)

----------------------------------------------------------------------

Date:    Thu, 8 Mar 2012 00:53:04 -0000
From:    John Ryan <[log in to unmask]>
Subject: loan severe headache

How would the list manage a 63 year old lady with loan sudden severe headache out of hours ?  Presents with occipital headache at midnight.  On warfarin for previous vertebral artery dissection.  GCS 15 no focal neurology.

Scan now at any cost ?  (and lose a radiographer the next day)
Scan tomorrow morning or earlier if deterioration ?
Reverse warfarin ?  Vitamin K ?  Octaplex ?
Other ?

------------------------------

Date:    Wed, 7 Mar 2012 21:54:50 -0500
From:    jonathan malin <[log in to unmask]>
Subject: Re: loan severe headache

Hi John.
  Hope your Meribel trip was great.
  Nothing new here. We're short handed and am working extra shifts to
cover.
  I'm sorry but I don't I'll be able to get away to attend the conference
in Dublin this June. I'm trying.

With reference to the above case...
 My 2 cents would be to call in the radiographer given the chance of a
possible posterior fossa bleed that could progress precipitously leading to
acute hydrocephalus, herniation or both.

How's the acute medicine clinic working out?  I can't imagine how it fits
within the ED.

Cheers,

Jonathan


On Mar 7, 2012, at 7:53 PM, John Ryan <[log in to unmask]> wrote:

  How would the list manage a 63 year old lady with loan sudden severe
headache out of hours ?  Presents with occipital headache at midnight.  On
warfarin for previous vertebral artery dissection.  GCS 15 no focal
neurology.

Scan now at any cost ?  (and lose a radiographer the next day)
Scan tomorrow morning or earlier if deterioration ?
Reverse warfarin ?  Vitamin K ?  Octaplex ?
Other ?

John Ryan

------------------------------

Date:    Thu, 8 Mar 2012 09:05:24 +0000
From:    Matthew Dunn <[log in to unmask]>
Subject: Re: loan severe headache

I'd go for an out of hours CT scan myself. Given that I probably have a higher threshold for out of hours CTs than the majority of UK Emergency Physicians I'd be surprised in many people wouldn't. Obviously you've got the problem that you're actually looking for a small posterior fossa bleed which CTs aren't all that great at picking up (although the newer CT scanners are a lot better) so you'll get some false negatives. Next question is reversal of the warfarin. Answer is that I think you probably would. I suppose you could go straight to angiography of some sort (outside my area) without LP, but there's a high enough risk of a bleed there in any case you'd probably want to reverse. Not sure what the probability of bleed in isolated sudden onset severe headache is, but presentation out of hours tends to increase the probability of signficant pathology for any collection of symptoms. You've also got the fact that you don't stay on warfarin all that long post carotid artery dissection so with a bit of luck she's about due to come off anyway. I'd also probably want to correct right down to INR of 1, so octaplex in preference to FFP. Vitamin K takes too long. In any case it would be in discussion with a haemtologist.

Matt Dunn
Warwick


This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.

------------------------------

Date:    Thu, 8 Mar 2012 09:10:24 +0000
From:    Matthew Dunn <[log in to unmask]>
Subject: Re: loan severe headache

The other point I'd make: if I was going to decide to wait until morning for the scan I'd need to pretty sure that there wasn't any neurology at all. That tends to mean laying hands on the patient myself. Incidence of missed subtle neurological findings is high. Usually it doesn't matter. In this case it does. The other reason for coming in is that it's a tricky case that might need a fair bit of discussion about the pros and cons of various options. That's often easier to do from the hospital than from home.

Matt Dunn


This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.

------------------------------

Date:    Thu, 8 Mar 2012 09:32:25 -0000
From:    Rowley Cottingham <[log in to unmask]>
Subject: Re: loan severe headache

You have to scan her if only to exclude a subarachnoid, especially if she
already has evidence of vascular integrity failure and no neurology.

That will inform your decision on her anticoagulation and other management.


> How would the list manage a 63 year old lady with loan sudden severe
> headache out of hours ?  Presents with occipital headache at midnight.  On
> warfarin for previous vertebral artery dissection.  GCS 15 no focal
> neurology.
>
> Scan now at any cost ?  (and lose a radiographer the next day)
> Scan tomorrow morning or earlier if deterioration ?
> Reverse warfarin ?  Vitamin K ?  Octaplex ?
> Other ?
>
> John Ryan


Best wishes,

Rowley.

------------------------------

Date:    Thu, 8 Mar 2012 09:46:05 +0000
From:    Jason Carty <[log in to unmask]>
Subject: Re: loan severe headache

I'd say scan, there's enough of a risk profile.  Would you scan her straight away if she arrived at 12 midday instead of 12 midnight?  If the answer is yes, can you justify waiting and sitting on a worst-case-scenario diagnosis?

I have just written a report concerning a review of a "worst headache ever" sent home on a bank holiday.  It was before my time in the hospital here, but I worry that it could still happen.  Outside the 9-5 is where all the risk is.

Jason Carty


EM Consultant
Kerry General Hospital



On 8 Mar 2012, at 09:32, Rowley Cottingham <[log in to unmask]> wrote:

> You have to scan her if only to exclude a subarachnoid, especially if she
> already has evidence of vascular integrity failure and no neurology.
>
> That will inform your decision on her anticoagulation and other management.
>
>
>> How would the list manage a 63 year old lady with loan sudden severe
>> headache out of hours ?  Presents with occipital headache at midnight.  On
>> warfarin for previous vertebral artery dissection.  GCS 15 no focal
>> neurology.
>>
>> Scan now at any cost ?  (and lose a radiographer the next day)
>> Scan tomorrow morning or earlier if deterioration ?
>> Reverse warfarin ?  Vitamin K ?  Octaplex ?
>> Other ?
>>
>> John Ryan
>
>
> Best wishes,
>
> Rowley.

------------------------------

Date:    Thu, 8 Mar 2012 10:13:09 +0000
From:    adrian moughty <[log in to unmask]>
Subject: Re: loan severe headache


I think it has to be CT scan immediately with loss of radiographer the next dayBy lone headache i assume you mean classical presentation with no associated features right? Based on information given the Hunt and Hess classification is grade IHowever that is based on competence of examining physician Hunt and Hess I has a mortality of say 30%Add in some very subtle neurology and it's Hunt and Hess II with mortality of 40%If they are a little drowsy ("expected" and may be "accepted as normal" after midnight) then it's Hunt and Hess III and now mortality is 50% So very subtle variations in presentation profile and more importantly assessment can have significant repercussions Risk of rebleed is approximately 5% in the first 24 hours so reasonable risk of a rebleed while waiting for the scan alone Irrespective of CT scan result i think one has to reverse the warfarin as if scan normal a subarachnoid haemorrhage is presumed So vitamin K + octaplex before the CT scan as i assume the warfarin would have been a short term course and no ongoing need for same In terms of what to do post "normal" CT scan i guess MR angiogram early to look for an aneurysmal sourceIf no aneurysm then risk of rebleed becomes that of the general population  Adrian MoughtySpR in Emergency Medicine

------------------------------

Date:    Thu, 8 Mar 2012 10:33:43 +0000
From:    conor deasy <[log in to unmask]>
Subject: Re: loan severe headache


Adrian - Slow down Tiger!!
Do we need to be so quick as to 'Reverse warfarin irrespective of CT.' The Ottawa folks tell us that the sensitivity a modern third generation CT is 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%) if done for suspected SAH within 6hrs of headache onset (Perry JJ, BMJ 2011 Jul 18). What if she's on warfarin for her mechanical valve??
Looking forward to catching up in Dublin at ICEM 2012 - looks like a great line up.
Conor Deasy
Emergency Physician,
Alfred Hospital, Melbourne.



Date: Thu, 8 Mar 2012 10:13:09 +0000
From: [log in to unmask]
Subject: Re: loan severe headache
To: [log in to unmask]





I think it has to be CT scan immediately with loss of radiographer the next day
By lone headache i assume you mean classical presentation with no associated features right?

Based on information given the Hunt and Hess classification is grade I
However that is based on competence of examining physician

Hunt and Hess I has a mortality of say 30%
Add in some very subtle neurology and it's Hunt and Hess II with mortality of 40%
If they are a little drowsy ("expected" and may be "accepted as normal" after midnight) then it's Hunt and Hess III and now mortality is 50%

So very subtle variations in presentation profile and more importantly assessment can have significant repercussions

Risk of rebleed is approximately 5% in the first 24 hours so reasonable risk of a rebleed while waiting for the scan alone

Irrespective of CT scan result i think one has to reverse the warfarin as if scan normal a subarachnoid haemorrhage is presumed

So vitamin K + octaplex before the CT scan as i assume the warfarin would have been a short term course and no ongoing need for same

In terms of what to do post "normal" CT scan i guess MR angiogram early to look for an aneurysmal source
If no aneurysm then risk of rebleed becomes that of the general population


Adrian Moughty
SpR in Emergency Medicine




------------------------------

Date:    Thu, 8 Mar 2012 11:14:36 +0000
From:    Stuart Carr <[log in to unmask]>
Subject: Re: loan severe headache

Excellent point about the sensitivity of a modern CT scanner, but is this based on a neuroradiologist interpretting? Obviously in the middle of the night the scan is being read by a radiology reg who is potentially tired and it may only be his first time on call.

Certainly if it was a mechanical valve one would be very wary about reversing warfarin but in this instance it would probably be prudent.

Shame she didn't just go to the neurosurgical centre in the first instance who obviously have better access to CT radiography in the middle of the night - having worked in such a centre I was always amazed at the amount of folk who would travel past a number of EDs to arrive on my doorstep in the middle of the night with such a history!

Stuart Carr
EM Consultant
Dublin

----- Original Message -----
From: "conor deasy" <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, 8 March, 2012 10:33:43 AM
Subject: Re: loan severe headache


Adrian - Slow down Tiger!!
Do we need to be so quick as to 'Reverse warfarin irrespective of CT.' The Ottawa folks tell us that the sensitivity a modern third generation CT is 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%) if done for suspected SAH within 6hrs of headache onset (Perry JJ, BMJ 2011 Jul 18). What if she's on warfarin for her mechanical valve??
Looking forward to catching up in Dublin at ICEM 2012 - looks like a great line up.
Conor Deasy
Emergency Physician,
Alfred Hospital, Melbourne.



Date: Thu, 8 Mar 2012 10:13:09 +0000
From: [log in to unmask]
Subject: Re: loan severe headache
To: [log in to unmask]


I think it has to be CT scan immediately with loss of radiographer the next day
By lone headache i assume you mean classical presentation with no associated features right?

Based on information given the Hunt and Hess classification is grade I
However that is based on competence of examining physician

Hunt and Hess I has a mortality of say 30%
Add in some very subtle neurology and it's Hunt and Hess II with mortality of 40%
If they are a little drowsy ("expected" and may be "accepted as normal" after midnight) then it's Hunt and Hess III and now mortality is 50%

So very subtle variations in presentation profile and more importantly assessment can have significant repercussions

Risk of rebleed is approximately 5% in the first 24 hours so reasonable risk of a rebleed while waiting for the scan alone

Irrespective of CT scan result i think one has to reverse the warfarin as if scan normal a subarachnoid haemorrhage is presumed

So vitamin K + octaplex before the CT scan as i assume the warfarin would have been a short term course and no ongoing need for same

In terms of what to do post "normal" CT scan i guess MR angiogram early to look for an aneurysmal source
If no aneurysm then risk of rebleed becomes that of the general population


Adrian Moughty
SpR in Emergency Medicine



------------------------------

Date:    Thu, 8 Mar 2012 11:28:19 +0000
From:    Matthew Dunn <[log in to unmask]>
Subject: Re: loan severe headache

A couple of points prompted by Conor's post:
She's not on warfarin for mechanical valve: it's for carotid dissection.
I hadn't read the paper (or had read it and forgotten). Thanks for mentioning it.  Having looked it up, it's available full text. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138338/
Does seem a good paper. I think the key point is that all 67 patients who were scanned within 6 hours and had a bleed showed up on the scan. The authors mention the new scanners. This ties in with my own experience that the old scanners (and until fairly recently we had one of the first in the West Mids- a single slice scanner installed in the mid 1990s) didn't visualise the posterior fossa well and the new ones do.
I hadn't thought about the higher sensitivity with earlier scanning- that obviously pushes towards a scan at night.
Worth noting that Emergency Physicians missed a few bleeds.

So in light of this paper and nothing to contradict it, I'm changing my view to scan at night then consider octaplex if there is a bleed.

In response to Stuart, the paper has the reporting by a mixture of general and neuro radiologists. I'd guess if you confine to sudden onset occipital pain and report by general radiologist you'll get lower numbers so a wider confidence interval. But if you're wanting to play safe, you could go for negative scan report at night means admit and neuroradiology report next day.

Matt Dunn


From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of conor deasy
Sent: 08 March 2012 10:34
To: [log in to unmask]
Subject: Re: loan severe headache

Adrian - Slow down Tiger!!
Do we need to be so quick as to 'Reverse warfarin irrespective of CT.' The Ottawa folks tell us that the sensitivity a modern third generation CT is 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%) if done for suspected SAH within 6hrs of headache onset (Perry JJ, BMJ 2011 Jul 18). What if she's on warfarin for her mechanical valve??
Looking forward to catching up in Dublin at ICEM 2012 - looks like a great line up.
Conor Deasy
Emergency Physician,
Alfred Hospital, Melbourne.


This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.

------------------------------

Date:    Thu, 8 Mar 2012 11:31:41 +0000
From:    Matthew Dunn <[log in to unmask]>
Subject: Re: loan severe headache

Should add: as the study authors say:
Computed tomography has unacceptably low sensitivity for subarachnoid haemorrhage when it is performed after six hours from the time of headache onset

To me that means if a patient presents within 6 hours and you delay the scan you are pushing them into a more invasive and expensive investigation. Even without the issues around the anticoagulation that's probably worth getting the radiographer up for.

m



This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.

------------------------------

Date:    Thu, 8 Mar 2012 15:13:43 +0200
From:    william niven <[log in to unmask]>
Subject: Re: loan severe headache


What if the patient had fibromyalgia, frequent attendances to the ED with similar presentations and absolutely no discernible neurology? I personally agree with the consensus view that the worse case scenario needs to be outruled with immediate but as Matthew touched on earlier, one needs to consider the patient's examination as well as presentation. Furthermore radiology registrars are often put under departmental pressure not to scan unnecessarily out of hours. This places an inordinate burden of responsibility on them considering firstly that they can only make decisions on the information provided them (from potentially inexperienced ED staff) and secondly that they themselves may not have sufficient experience or sleep to either perform or read the scan out of hours.Will Niven

Date: Thu, 8 Mar 2012 11:31:41 +0000
From: [log in to unmask]
Subject: Re: loan severe headache
To: [log in to unmask]











Should add: as the study authors say:
Computed tomography has unacceptably low sensitivity for subarachnoid haemorrhage when it is performed after six hours from the time of headache onset

To me that means if a patient presents within 6 hours and you delay the scan you are pushing them into a more invasive and expensive investigation. Even without
 the issues around the anticoagulation that's probably worth getting the radiographer up for.

m


This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.


------------------------------

Date:    Thu, 8 Mar 2012 14:30:32 -0000
From:    Rowley Cottingham <[log in to unmask]>
Subject: Re: loan severe headache

No discernible neurology is a pointer TOWARDS SAH. The problem is more the
migraineurs who can present with a sudden onset 'worst ever' headache.

I missed a herald bleed in such circumstances as a junior many years ago
and got roundly criticised. We do very few repeat CTs if the context is
considered. I asked a neuroradiologist once how many scans it would take
on a shunt patient (who get scanned at the drop of a hat) before he
started getting concerned about radiation dose and he said he'd get
concerned at the hundredth. Ever since I have been duly sceptical of the
IRMER shroud-waving. Beware also of crying wolves.
>
> What if the patient had fibromyalgia, frequent attendances to the ED with
> similar presentations and absolutely no discernible neurology? I
> personally agree with the consensus view that the worse case scenario
> needs to be outruled with immediate but as Matthew touched on earlier, one
> needs to consider the patient's examination as well as presentation.
> Furthermore radiology registrars are often put under departmental pressure
> not to scan unnecessarily out of hours. This places an inordinate burden
> of responsibility on them considering firstly that they can only make
> decisions on the information provided them (from potentially inexperienced
> ED staff) and secondly that they themselves may not have sufficient
> experience or sleep to either perform or read the scan out of hours.Will
> Niven
>
> Date: Thu, 8 Mar 2012 11:31:41 +0000
> From: [log in to unmask]
> Subject: Re: loan severe headache
> To: [log in to unmask]
>
>
>
>
>
>
>
>
>
>
>
> Should add: as the study authors say:
> Computed tomography has unacceptably low sensitivity for subarachnoid
> haemorrhage when it is performed after six hours from the time of headache
> onset
>
> To me that means if a patient presents within 6 hours and you delay the
> scan you are pushing them into a more invasive and expensive
> investigation. Even without
>  the issues around the anticoagulation that's probably worth getting the
> radiographer up for.
>
> m
>
>
> This email has been scanned for viruses; however we are unable to accept
> responsibility for any damage caused by the contents. The opinions
> expressed in this email represent the views of the sender, not South
> Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly
> stated. If you have received this email in error please notify the sender.
> The information contained in this email may be subject to public
> disclosure under the NHS Code of Openness or the Freedom of Information
> Act 2000. Unless the information is legally exempt from disclosure, the
> confidentiality of this e-mail and your reply cannot be guaranteed.
>


Best wishes,

Rowley.

------------------------------

Date:    Thu, 8 Mar 2012 15:52:04 +0000
From:    Mark Nicol <[log in to unmask]>
Subject: Re: loan severe headache

Topical subject...I was asked for expert opinion (on phone, after pt had died) regarding  a pt on remand (not in hospital) who had a headache, occipital then collapse and (? duration of) loss of consciousness, was NOT seen assessed by prison GP..but nurse communicated all hx to GP.No referral to hospital.pt continued to have headaches over few days and vomited twice.Further collapse and then sent by 999 ambo to hospital...now coroners inquest.
How many folk would NOT have CT on first collapse!


________________________________
 From: Rowley Cottingham <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, 8 March 2012, 14:30
Subject: Re: loan severe headache

No discernible neurology is a pointer TOWARDS SAH. The problem is more the
migraineurs who can present with a sudden onset 'worst ever' headache.

I missed a herald bleed in such circumstances as a junior many years ago
and got roundly criticised. We do very few repeat CTs if the context is
considered. I asked a neuroradiologist once how many scans it would take
on a shunt patient (who get scanned at the drop of a hat) before he
started getting concerned about radiation dose and he said he'd get
concerned at the hundredth. Ever since I have been duly sceptical of the
IRMER shroud-waving. Beware also of crying wolves.
>
> What if the patient had fibromyalgia, frequent attendances to the ED with
> similar presentations and absolutely no discernible neurology? I
> personally agree with the consensus view that the worse case scenario
> needs to be outruled with immediate but as Matthew touched on earlier, one
> needs to consider the patient's examination as well as presentation.
> Furthermore radiology registrars are often put under departmental pressure
> not to scan unnecessarily out of hours. This places an inordinate burden
> of responsibility on them considering firstly that they can only make
> decisions on the information provided them (from potentially inexperienced
> ED staff) and secondly that they themselves may not have sufficient
> experience or sleep to either perform or read the scan out of hours.Will
> Niven
>
> Date: Thu, 8 Mar 2012 11:31:41 +0000
> From: [log in to unmask]
> Subject: Re: loan severe headache
> To: [log in to unmask]
>
>
>
>
>
>
>
>
>
>
>
> Should add: as the study authors say:
> Computed tomography has unacceptably low sensitivity for subarachnoid
> haemorrhage when it is performed after six hours from the time of headache
> onset
>
> To me that means if a patient presents within 6 hours and you delay the
> scan you are pushing them into a more invasive and expensive
> investigation. Even without
>  the issues around the anticoagulation that's probably worth getting the
> radiographer up for.
>
> m
>
>
> This email has been scanned for viruses; however we are unable to accept
> responsibility for any damage caused by the contents. The opinions
> expressed in this email represent the views of the sender, not South
> Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly
> stated. If you have received this email in error please notify the sender.
> The information contained in this email may be subject to public
> disclosure under the NHS Code of Openness or the Freedom of Information
> Act 2000. Unless the information is legally exempt from disclosure, the
> confidentiality of this e-mail and your reply cannot be guaranteed.
>


Best wishes,

------------------------------

Date:    Thu, 8 Mar 2012 18:27:28 +0000
From:    Matthew Dunn <[log in to unmask]>
Subject: Re: loan severe headache

Regarding the fibromyalgia one, I'm with Rowley: you still scan (usually). Yes it's radiation, but it's set against a very serious condition. If you don't scan at night you're still scanning in the morning (and it's not such a good scan so you need to do more investigations and increase the risks to the patient). Maybe an exception for the patient who turns up twice a week with "worst ever headache", but I haven't seen many of them. (Of course in the past, "worst ever headache" earned you a LP so you didn't get may repeat presenters. Maybe if we are relying on negative scans we'll have more repeat business).

Regarding the radiology registrar, I agree that it's a high burden of responsibilty, but it's always one they could pass up to their consultant. (For that matter I wouldn't be overly happy with a registrar who hadn't seen the patient deciding that haemorrhage could be excluded without further investigation when a registrar or consultant who had seen the patient felt it could not). Lack of experience to interpret scans out of hours isn't so much of an issue: if it needs something doing straight away the scan is usually relatively easy to interpret; if there's doubt, there's consultant backup; and if you can exclude the need for immediate neurosurgical intervention but not the need for further investigation the final report can wait until morning. The important thing is to acquire the images within 6 hours of onset of symptoms if possible.

Matt Dunn

From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of william niven
Sent: 08 March 2012 13:14
To: [log in to unmask]
Subject: Re: loan severe headache

What if the patient had fibromyalgia, frequent attendances to the ED with similar presentations and absolutely no discernible neurology? I personally agree with the consensus view that the worse case scenario needs to be outruled with immediate but as Matthew touched on earlier, one needs to consider the patient's examination as well as presentation. Furthermore radiology registrars are often put under departmental pressure not to scan unnecessarily out of hours. This places an inordinate burden of responsibility on them considering firstly that they can only make decisions on the information provided them (from potentially inexperienced ED staff) and secondly that they themselves may not have sufficient experience or sleep to either perform or read the scan out of hours.
Will Niven



This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.

------------------------------

End of ACAD-AE-MED Digest - 4 Mar 2012 to 8 Mar 2012 (#2012-18)
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