Post-Traumatic Headache

Billy is 24 years old, he works for the Post Office from Monday to Friday and he always does his best to make the most of his weekends. 

This Saturday night was no different.  He had consumed a few drinks with his mates and made it home in the wee small hours of Sunday morning. 

With his standard after party meal of six burnt pieces of toast and a pint of the ‘Bru in hand, Billy made for the stairs.

Unfortunately he’d forgotten the mound of washing waiting on the floor at the top.

With the ease at which he had downed that lovely single malt earlier in the evening, Billy suddenly found himself six steps lower and six bits of toast lighter.

He had not cuts but a growing bump on the back of his head and the stickiest floor in history. Even in his dazed state he knew he’d have to take care of it – otherwise his current throbbing head would be nothing compared to what his missus would dish out tomorrow.

After a bit of remedial cleaning Billy sloped off to bed. 

Sunday was spent nursing a moderate hangover, bad headache and one or two vomits - probably worse than normal as his regular phenomenal remedy had found the floor instead of his stomach.

He thought he would be OK to get to work on Monday but when he set off to the depot at 6am he still felt pretty rough.  He pushed through until 8am but then decided to call his GP. 

He got an appointment for 9.30am that day. He told the doctor how he was feeling - bad headache, wobbly on his feet, somehow detached from the world, tired with poor concentration and not really very hungry. 

His GP noted the firm bruising on the back of his head and was concerned about the possibility of bleeding inside the skull and around the brain.  This is a potentially serious condition that can only be diagnosed with a scan of the brain.  He sends Billy up to the Emergency Department to see if we agree and to organise a scan if required.

Billy arrives in the Emergency Department on our busiest day of the week. He is seen by one of our triage team and some routine measurements are taken - pulse, blood pressure, temperature, respiratory rate, blood sugar. 

He looks well enough and is walking around comfortably. He is given a ‘standard’ triage category based on his reasons for coming to us, the time since his injury occurred and his clinical assessment at triage. 

He is seen by one of our junior doctors, who goes over the story again with Billy. He pays particular attention to the timing of events and symptoms. The doctor does a full neurological examination of Billy, checking how his nervous system is functioning, as well as looking at the area of his head that was injured in his fall.  We are now at the crucial decision point - do we scan Billy's head or not?

The doctor has worked in the department for less than six weeks and, while she has reviewed the head injury guidelines carefully, these decisions are still tricky.  She comes to ask for my advice and we go back into see Billy together.

As it turns out, it is not really a question of whether there is blood in or around the brain.  This might inform us of Billy’s likely recovery time but based on his present symptoms, his normal neurological examination and the time since his injury the chance of there being a significant amount of bleeding is very low. 

The chances of there being any bleeding that would require an emergency operation by a neurosurgeon are almost zero and this is the single most important reason to get a brain scan. 

Billy is reassured and given some details about his condition (Post-concussion syndrome). He is discharged and told he’ll be back to feeling his old self in around two weeks.

Billy heads home via the local corner shop - a bottle of juice and some washing powder for that pile of clothes!

Test heavy

Modern medicine has become increasingly reliant on advanced testing for conditions and diagnoses. 

It is almost impossible to come to hospital these days and not get some form of test or investigation done.  This has led to earlier detection of diseases and an improvement in outcomes in many instances.

However, many forms of testing are not perfect.  X-rays and CT scans use radiation to get their information, which across a population may cause an increased likelihood of tumour formation.

Blood tests can often be inaccurate and unreliable and some tests are very dependent on who is doing them and what they are done for.  Asking the right questions of the test before you order it is the key.

 In Billy's case, we would have just administered a dose of radiation to his brain for no good reason, when the overwhelming evidence suggested that his condition would get better with time.