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    (Original post by winter_mute)
    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?
    How many what?

    As with all patients, you take a history and examine them, then use this http://www.nice.org.uk/nicemedia/liv...6257/36257.pdf to decide whether a patient needs a CT.
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    (Original post by winter_mute)
    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.
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    (Original post by Charlottie93)
    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.
    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!
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    (Original post by Helenia)
    How many what?

    As with all patients, you take a history and examine them, then use this http://www.nice.org.uk/nicemedia/liv...6257/36257.pdf to decide whether a patient needs a CT.
    The PDF pretty much answered my question, but what I meant was:

    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?
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    (Original post by Jamie)
    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?
    Indeed. Intercalated after 4th year.
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    (Original post by electricjon)
    A zero tolerance approach to an abusive patient is one thing, but this patient was a final year medical student. Does that change anything?
    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.
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    (Original post by winter_mute)
    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?
    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.
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    (Original post by Helenia)
    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!
    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?
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    (Original post by winter_mute)
    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?
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    (Original post by electricjon)
    I'm not disputing the zero tolerance approach. Given she is a medical student would you take even further action?
    Ah. I'd go so far as getting her consultant/lecturer to have a word with her, maybe even involving the university. Getting the GMC involved? I wouldn't for this. If she did it again, then yes.

    She may be off A&E but she is still doing clinical rounds and if you aren't able to treat your patients effectively either through injury or hangover you're not going to be much good. That by it's definition is fitness to practise, no?
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    (Original post by Charlottie93)
    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?
    It could, though you can't say for sure. But aggression on its own isn't necessarily an indication of a serious underlying injury. Alcohol + head injury is notiriously difficult to assess though.

    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.
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    (Original post by Helenia)
    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.
    I would agree with that. If I were on the receiving end I'd certainly let the consultant/her supervisor decide and let him/her handle it if he wishes to take things further.
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    (Original post by electricjon)
    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!
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    (Original post by winter_mute)
    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!
    No. In fact, if she was, reasonably allowing for intoxication, courteous and polite in her approach, then I would have gladly seen her promptly and referred her directly to OMFS after a quick history and exam to rule out significant head/neck/eye injury. Others might not like letting someone "jump the queue" like that but if she did help out as a medical student then I think it would be unreasonable to expect her to wait.

    As for a student attending a clinical placement after drinking too much?! It's not so much that they'd been drinking too much, it's that they'd been drinking at all! Dangerous and unprofessional, and arguably, as bad if not greater a crime than in this case!
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    (Original post by electricjon)
    Indeed. Intercalated after 4th year.
    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.
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    (Original post by electricjon)
    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.
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    (Original post by Jamie)
    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?
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    (Original post by winter_mute)
    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?
    WEll the 2 hour thing is a bit of a non starter being as by the time they have gotten to the hospital and waited to be seen MOST head injuries are beyond the '2 hour post injury'.
    Exception being trauma calls/dodgy looking ambulance admissions
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    Yes admittedly they are guidelines but the radiologist and/or your senior colleagues might challenge your request if the patient doesn't fulfil them. Conversely, many times I have had a CT request denied despite fulfilling NICE criteria - "I appreciate they may have vomited twice and may have anisocoria but they blatantly don't have a head injury. Just observe them."

    Additionally, CT only picks up significant intracranial bleeds, space-occupying lesions and fractures. It doesn't detect early contusion or contrecoup, requiring an MR scan, so a normal CT doesn't always exclude a significant brain injury.
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    (Original post by Jamie)
    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.
    Thanks Sherlock. Admittedly I am young to be considered a registrar but I have worked in my A&E department for over 12 months. I'm not on an ACCS training programme but I do have experience and responsibilities that extend beyond those of an SHO (such as teaching and supervising medical students and junior A&E doctors) as well as following the "registrar" rota, attending specialty training sessions, receiving "registrar" rates of pay and being the quickest doctor in the department (based on the number of patients seen per hour).

    Yes the use of the term "registrar" is a bit dated post-MMC, but even ST1's technically can be considered a "specialty registrar" even if they may still be at SHO level. As it is, most ST3 ACCS trainess have at best 10-12 months A&E experience, so I feel the term is justified. I will concede that "junior registrar" or "middle grade" might be more appropriate but I really didn't expect people to care - certainly I have never been pulled up for it at work, but since it clearly bothers you I have changed it to A&E Doctor.

    Bit of a patronising way to go about it if you ask me. IF I MAY BE SO BOLD, didn't you study at Cambridge? So presumably you studied "medical sciences" instead of medicine, which means you are largely a research-based academic, and not really a proper doctor?
 
 
 
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