Indeed. However, I'm afraid that the sobriquet I gave a few years ago of the
Department for the protection of the Electron is alive and well. For many
years my Trust simply stated that it did not recognise the NICE guidelines,
and we had to resort to that old trick of inventing history and findings to
achieve our aim. I am pleased to say that is now history, but there are
still problems on occasion. 

However, I do want to stand up for on call radiologists. My Consultant
colleagues are often  disturbed on an hourly basis on nights on call with
requests for emergency and urgent advanced imaging and intervention, and I
have argued for expansion of their numbers on many occasions. Equally, one
mentioned the other day that he had spent some time overnight discussing and
refusing scans with a junior from my department which is not acceptable as
the junior should have been seeking advice from the on-call Consultant
first, so we need to get our house in order sometimes too.

Finally, I would like to lay to rest some odd ideas about timing. I'm sure I
am not alone, but I teach and practice that we should be obtaining chest and
pelvis X-rays on arrival - that is to say within 3 minutes of the spine
board hitting the bed, and simultaneously with the primary survey. As all on
this list will know, a patient who can tell you their name tells you plenty
about A to D and you then do the log roll and do the secondary survey. Time
spent in an ED without definitive care is time wasted. Those of you also on
the trauma.org mail list will recall Ken Mattox' claim that his quickest
time from wheels stopping to skin prep starting is 47 seconds. I have no
doubt he is right. I set a standard of care of 23 minutes max in the resus
room for all patients with multiple trauma and we need to aspire to high
speed care and decision-making in these patients.

Best Wishes,

Rowley. 

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
Sent: 08 February 2008 08:39
To: [log in to unmask]
Subject: Re: Resus gantries / DR


Sorry Rowley, but don't the recent NICE guidelines suggest CT cervical spine

for the following:

GCS < 13 on arrival to ED (or patient intubated)
or
Patient being scanned for multi-region trauma

or have I misinterpreted your meaning? Anyway, we no longer carry out plain 
c-spine films for these types of cases, but instead go straight for CT, and 
our radiologists are "happy" with that arrangement (are radiologists ever 
happy?).

Good debate, by the way. Agree we need to move towards more imaging in 
trauma patients. Agree that patients are more likely to suffer harm as a 
result of delayed imaging/decision making than not, and that the benefits of

CT in trauma easily outweigh the downside associated with transfer to scan 
or with radiation dosage (has anyone ever had 1000 abdominal CTs?).

And finally, radiologists/radiographers "asleep in bed at home" is not an 
acceptable argument to avoid scanning such patients!

Regards

AF

----- Original Message ----- 
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, February 06, 2008 9:18 PM
Subject: Re: Resus gantries / DR


We have great difficulty in persuading our imaging colleagues to undertake
CT neck without a plain lateral neck film. Your comment suggests you do not
have this problem.

Best Wishes,

Rowley.

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Doc Holiday
Sent: 06 February 2008 20:46
To: [log in to unmask]
Subject: Re: Resus gantries / DR

From: [log in to unmask]
> ...Three low-quality radiographs per patient...

--> I don't disagree with your questioning of how "necessary" an 
--> overhead gantry is.
But why THREE radiographs?? I can work out two...

> we should be moving to whole-body CT for multiple trauma

--> Although this change will take time, as EDs are built/re-designed, 
--> it will be interesting to see what effect the increased availability 
--> of
RAPID-CT-adjacent-to-resus has not only on reducing plain films (your point)
but also reducing the use of FAST. With CT scanner only a couple of metres
away from the trauma bay and portable monitors and full trauma teams and
pre-hospital primary surveys and permissive-hypotensive-resuscitation and
airway management, etc - all these advances seem to point to a reduction in
the classic contra-indication to CT of the "doughnut of death"... We already
lack the main "indication" for the use of EM ultrasound in the UK which they
have in the USA - being able to "bill" for it ;-)
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