This is very depressing bur all too familiar. What we have managed to agree
with our radiologists is that we use the SIGN head injury criteria for
trauma scans and for non-trauma we will scan
and for non-trauma we will scan:
clinical SAH with altered LOC, focal signs or persistant vomiting.
Using these we have aa audited pick up rate of about 30% for trauma and 20%
for non-trauma abnormal scans.
The last time I was faced with an SAH problem like the one described I
pointed out to the radiologists:
"I am genuinely worried this person has a subarachnoid haemorrhage - if they
dont, then we don't need to worry much, if they do they have a 25% chance of
being dead in the next 24 hrs and I would transfer them to our neurosurgery
unit tonight if the diagnosis confirmed"
Other points - a negative scan is not some kind of defeat, it is a win-win
situation - we do not have to take any other immediate action and the
patient doesn't have a life-threatening condition. Hoorah! Also a negative
scan in someone GCS3 with fixed pupils mandates continuing intensive care
until other diagnoses are excluded (TCA OD is the most common one).
Before anyone says I have not forgotten about LP in suspected SAH with a
normal scan. This is also a common ploy to dissuade us from scanning
Radiologist "Is this patient going to have an LP if the scan is normal"
Me "yes - WHAT'S YOUR POINT?"
In short- yes, you are a clinician and they are not. Offer to swap.
----- Original Message -----
From: <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, June 24, 2003 7:10 PM
Subject: Are we Clinicians?
> I've just had the most staggering conversation with a radiologist. I was
requesting an urgent CT scan on a young patient with acute onset of
headache, left sided hemiplegia and a history of previous SAH secondary to
an AVM. The radiologist smiled and said:
> "Has this lady been seen by a clinician yet?"
> When I suggested that I was the clinician dealing with this patient (and
to imply I was not a clinician was somewhat insulting) he refused to accept
my standing and insisted that she be seen by "a clinician".
> It would appear that five years of general training, five years of
specialist training, three postgraduate exams and a consultant job in
waiting is not enough to be classed as a clinician.
> Besides this general insult was the opinion that a CT for a ?sub arachnoid
was urgent and not an emergency as it would make no difference to the
immediate outcome. Now within reason I can just about understand this. I
don't request CT scans at 5am for 95 year olds with acute hemiplegias but at
16.35 for a lady in her 30s?
> Am I completely out of touch with reality?
> Dr Simon McCormick
> SpR Emergency Medicine (on of the last clinical specialties left)
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