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Rapid Responses: Rapid Responses published:
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Managing minor head injury in children
- Alan M Leaman (2 September 2006)
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Radiology response
- Richard M Wellings (3 September 2006)
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Misleading picture
- Robert M Bethune (7 September 2006)
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It isn't always all on the CT!
- Barbara J Boucher (6 December 2006)
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Alan M Leaman, Consultant in Emergency Medicine Princess Royal Hospital, Telford, UK TF1 6TF
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Let us imagine that you take your young son or daughter to a radiology department and fire one chest x-ray’s worth of radiation through their head - then another - then another. When would you want to stop? After the 12th exposure? After the 32nd? A CT scan of the head involves one hundred chest x-rays worth of radiation and whatever Harvey Marcovitch thinks (1), is not safe (2). If I have a choice as to how my child’s minor head injury is managed, I will always take a plain skull x-ray and a few hours observation on a children’s ward over a CT scan and early discharge. (1)Marcovitch H. Managing minor head injury in children BMJ 2006; 333: 455-6 (2)Hall P et al. Effect of low doses of radiation in infancy on cognitive function in adulthood; Swedish population based cohort study BMJ 2004; 328: 19-24 Competing interests: None declared |
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Richard M Wellings, Consultant Radiologist CV2 2DX
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Marcovitch in his commentary on the main paper about the cost effectiveness of early CT . States " Clinicians may have litle difficulty in predicting the response of their radiological colleagues to a request to image all patients presenting with minor head injuriy, however much they point out the savings of about £135 per patient" I resent the implied crticism of radiology as a whole . The demands upon a radiology CT service have grown massively in the last 5 yrs 40% in our own service on a background of reducing budget . What are we being accussed of ? Unwillingness to implement a cost effective clinical intervention because of radiation hazards? or because the significant increase in activity will place additional pressures on a service without any additional resources in Radiology? My own Radiology department developed a local policy for adult and Paediatric CT in head injury settings ,in partnership with the Emergency Department , Neurosurgery, Intensive care, Paediatrics and regional Paediatric Neurosurgery unit, after the 2003 NICE guidance . This has almost abolished Skull x-rays and it was done to improve patients safety. No additional resources were offered to radiology for this increased workload but it was implemented to the benefit of our patients. It has been maintained on top of a 40% rise in CT demand over the last 18months and the standard 3% p.a. cost savings expectation. If the wellbeing of patients is to be balanced against its cost effectiveness as it clearly is then it is a prerequisite for this to be able to be implemented that savings in one area of the pathway are transferred to the areas where increased activity is required for the process to work. This model shows that by restructuring of a pathway, equal health benefits can be acheived with a freeing up of finnancial resources to be invested in additional patients benefits. It requires that the "silo" structure of funding within the NHS is loosened to spend money where it produces most benefit not where it has been historicaly allocated in fixed budgets. Competing interests: Consultant Radiologist with Trauma interest and father of three |
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Robert M Bethune, trust grade accident and emergency Yeovil District General Hospital
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EDITOR – As an accident and emergency middle grade doctor I read with interest the editorial1 and two research papers2,3 on minor head injury. I initially noticed the front page picture of a young child (looking 4-5 years old) and then read the editorial. I read it all, although rapidly, and surmised that the two pieces of research later in the journal showed that computer tomography and early discharge is as good and cheaper than 24 observation. The editorial talked about the difficulty of getting a good history from a child who had not yet started to speak, and I sympathised. With the picture of a 4-5 year old in my mind, and the editorial talking about young children I briefly scanned the two later articles, decided that they appeared methodologically sound, and agreed with the conclusions in the editorial. At work that day we were discussing a minor head injury in a 4 year old child and I confidently added to the discussion having read the BMJ that morning. When I went home I re-read the articles more carefully. To my surprise I found that both research papers were not primarily about children, and in fact no children under 6 were included in the study at all. This amazed me as I had assumed that the whole series of articles was about this age group. Pictures influence our thinking more that words, and can be hugely beneficial in helping understanding. However, they can also easily mislead. I do not think I would have been the only person who saw the picture of a young child and reasonably assumed the published research was about that age group, which it was not. Robert Bethune Competing interests: None declared 1 Marcovitch H. Managing minor head injury in children. BMJ 2006;333:455-456. (2 September.) 2 af Geijerstam J-L, Oredesson S, Britton M, for the OCTOPUS Study Investigators. Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial. BMJ 2006;333:465-468. (2 September.) 3 Norlund A, Marké L-Å, af Geijerstam J-L, Oredesson S, Britton M, for the OCTOPUS Study Investigators. Cost comparison of immediate computed tomography or admission for observation after mild head injury: randomised controlled trial. BMJ 2006;333:469-471. (2 September.) Competing interests: None declared |
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Barbara J Boucher, Hon Senior Lecturer ICMS, Queen Mary, 4 Newark St. London E12AT
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Editor -The cover of the recent BMJ reporting on the role of computerized tomography[CT]scans after head injury features a striking photograph of a child with a minor head injury to highlight the useful reports suggesting that early discharge after CT scanning is likely to prove both safe and cost effective; pp455, 465 and 469. Had I seen the patient, however, I would have been as concerned to know whether this child might have fragilitas ossium as to know whether there had been significant intracranial damage from the head injury since the dark blue colouration of the sclerae is as striking as the damage to the forehead. Barbara J Boucher, Hon Senior Lecturer, Diabetes & Metabolic Medicine [Queen Mary, University of London] Competing interests: None declared |
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