Fall down go boom!!

Well today Dr Sam Wong gave a very nice presentation on pediatric head trauma at rounds. The two take home points I want to summarize are a good rule to predict who needs a CT and some back to play rules for concussion.

1) Catch Study Rule: This based on a Canadian Study of 3866 kids with a score of 13–15on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability (not for kids without these features)

2) Concussion return to play guidelines:

(Here's a handout!)

A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused either by a direct blow to the head, face or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.

2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In a small percentage of cases, however, post-concussive symptoms may be prolonged.

5. No abnormality on standard structural neuroimaging studies is seen in concussion.

A concussion is a serious event, but you can recover fully from such an injury if the brain is given enough time to rest and recuperate. Returning to normal activities, including sport participation, is a step-wise process that requires patience, attention, and caution. Sometimes these steps can cause symptoms of a concussion to return. This means that the brain has not yet healed, and needs more rest. If any signs or symptoms return during the Return To Play process, the player must be re-evaluated by a physician before trying any activity again. Remember, symptoms may return later that day or the next, not necessarily during the activity!

Step 1: No activity, only complete rest. This means no work, no school, and no physical activity. When symptoms are gone, a physician must be consulted. The physician will be able to clear the player to slowly return to some activities.

Step 2: Light aerobic exercise, such as walking or stationary cycling. The player should be supervised by someone who can help monitor for symptoms and signs. No resistance training or weight lifting. The duration and intensity of the aerobic exercise can be gradually increased over time if no symptoms or signs return during the exercise or the next day. Symptoms? Go back to Step 1. No symptoms? Proceed to Step 3 the next day.

Step 3: Sport specific activities, such as skating or throwing, can begin at step 3. There should be no body contact or other jarring motions such as high speed stops or hitting a baseball with a bat. Symptoms? Go back to Step 2. No symptoms? Proceed to Step 4 the next day.

Step 4: Drills without body contact.

Symptoms? Go back to Step 3. No symptoms? Read below:

The time needed to progress from non-contact exercise will vary with the severity of the

concussion and with the player. Proceed to Step 5 only after medical clearance.

Step 5: Begin drills with body contact.

Step 6: Game play

Please remember: these steps do not correspond to days! It may take many days to progress through one step, especially if the concussion is severe. As soon as symptoms appear, the player should return to the previous step and wait at least one more day before attempting any activity. The only way to heal a brain is to rest it. Never return to play if symptoms persist! A player who returns to active play before full recovery from the first concussion is at high risk of sustaining another concussion, with symptoms that may be increased and prolonged.

Homelessness at minus 20 C - Is this not an Emergency?

On many a night shift I have witnessed the ambulance bringing in yet another intoxicated homeless person. Sadly, the vast majority are aboriginal as well. In the summer months, like in most ERs in the south, my goal is to rule out a serious medical emergency, treat any superficial injuries and come up with a disposition. This is challenging sometimes but mostly it is fairly obvious what to do. Some people end up sleeping it off in the RCMP drunk tank and the more sober ones either end up at one of the shelters in town or just walking out the door.

But what to do on a cold winter's night?

Often, the temperature around here in Yellowknife dips below - 20C. Some of the homeless sleep at the shelters, others have tents that are set up in some of the wooded areas around town. Unfortunately, some are banned from the shelters for inappropriate or violent behavior. Others still look for a warm place where ever they can (indoor bank machine rooms, unlocked doors, etc.).

Is there an ethical duty to provide a place for someone to stay who has no safe place to go? I would argue that there is. I am not sure though that this duty falls to the emergency department. The fact that waiting times are too long and bed availability is often a factor makes this a dilemma. I figure with no other options, it becomes our obligation to house these individuals until we identify another location.

So in a sense homelessness is a real emergency and not just a chronic (and therefore not an ER) problem. But is it not really everyone's problem? Shouldn't the hospital as a whole have a plan for providing a place to sleep for the homeless? Maybe we need to start by asking them!

Life in the ER