Your first day as a doctor

To be honest I have no idea how a medic goes about assessing that (there are other indications for an intra-cranial bleeds), but how many does the PT need to present before you'd order a scan?

I doubt the Neuro reg would appreciate being called down to A&E for something the medics there can assess.

Not actually call them down to A & E but have them know that you may have to bring the patient up for them to deal with if its something a medic in A & E isn't experienced in to deal with.

How many what?

As with all patients, you take a history and examine them, then use this http://www.nice.org.uk/nicemedia/live/11836/36257/36257.pdf to decide whether a patient needs a CT.

Now, might I be so bold as to enquire what "MBChB MPH Manchester 2008" means?
Does that mean you graduated MBChB plus a public health masters all together in 2008?

A zero tolerance approach to an abusive patient is one thing, but this patient was a final year medical student. Does that change anything?

IIRC the registrar at the A&E I did some shifts in explained that PT's with a subdural haematoma will present with agression, memory loss, vomiting and slurred speech along with a GCS lower than 15. (there were more but I forgot them) and that it's one of the more serious complications from a drunken head injury resulting from a fall.

How many of these conditions would the PT have to present with for the A&E medic to order a CT scan?

Head injury assessment is bread and butter stuff for A&E; generally they would only contact the specialty (neurosurgery in this case rather than neurology) if the CT showed anything needing an operation. You certainly wouldn't get thanked if you called them every time someone like this came into the department!

Of course not. Zero tolerance means exactly that. There's a difference between being upset and saying something rash and being drunk and belligerent. The patient would have no doubt been on the receiving end of this while working in an A&E, so she should most defiantly know better.

I'm not disputing the zero tolerance approach. Given she is a medical student would you take even further action?

Oh ok I guess I'll learn this in med-school if I'm ever lucky enough to get there, so even though she was showing signs of aggression e.t.c. would that just be the alcohol levels then?

As for FtP, I would talk to my consultant (and also to give them a heads-up in case anyone does decide to take her up on her suggestion of complaints!) before going to the med school.

Quite right. The GMC's guidance can be found here.

Illustrating the threshold of student fitness to practise:

Has a student shown a deliberate or reckless disregard of professional and clinical responsibilities towards patients or colleagues?

An isolated lapse from high standards of conduct - such as a rude outburst - would not in itself suggest that the student's fitness to practise is in question. But the sort of persistent misconduct, whether criminal or not, that indicates a lack of integrity on the part of the student, an unwillingness to behave ethically or responsibly, or a serious lack of insight into obvious professional concerns, would bring a student's fitness to practise into question.


However... this particular student has done more than just "a rude outburst"...

Has a student behaved dishonestly, fraudulently, or in a way designed to mislead or harm others?

The medical school should take action if a student's behaviour is such that trust in the medical profession might be undermined. This might include plagiarism, cheating, dishonesty in reports and logbooks, forging the signature of a supervisor, or failing to comply with the regulations of the medical school, university, hospital or other organisation.


So I agree, probably not for the GMC, but I would certainly inform her clinical/educational supervisor, and in this case, maybe the medical school dean as well.

Would you procede with the same course of action if she wasn't belligerent? I'm sure there's students here that have turned up to their teaching hospitals after drinking too much!

Indeed. Intercalated after 4th year.

As the NICE guidelines state - amnesia (>30 minutes before impact), vomiting (two or more episodes) and GCS<15 (two hours after the injury) would necessitate CT. Aggression and slurred speech aren't considered.

The nice guidelines are just that. Guidelines.

Furthermore they set out timescales for those symptoms which were selected as they have the highest linkage with pathology.

However, lack of all these symtpoms does not exclude intracranial injury, and so CT can be sought if the clinician feels it is appropriate.

Worth remembering that.

It does seem to be down to medic's discretion. I thought waiting 2 hours post onset of symptoms to be on the long side.

So what do you use to make up your mind? Intuition could play a part, or is it down to just pure experience of being involved in multiple cases?

So not really an A&E registrar as your profile says then.

Because from what you are saying you are at most an CT1/ST1.