Consultant ballot in Scotland.
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Biomedical subjects
Publications and source records attributed to S Galbraith.
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This article as the series title suggests focuses our attention on decisions, both medical and ethical, which face doctors and related personnel in the medical profession daily. Many of these decisions take the form of a choice to one thing or another without being very sure of the outcome of either action. Mr Galbraith explores the pros and cons of what he calls the 'no lose' philosophy in medicine and which plays a large part in medical decision making. He concludes that possibly we may need a new philosophy rather than continuing to use more and more of our resources on care, which is perhaps being carried out as a means of avoiding making value judgements and thus possibly, prevents us from solving some of today's difficult ethical problems.
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Five cases of intracranial airgun injuries are presented. The accepted principles of treatment of a compound depressed fracture of the skull are easily overlooked in these patients because of the rarity of the injury and the apparent well-being of the patient, who is usually fully conscious with only a small scalp laceration.
Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.
A prospective study of head injury admissions to a city teaching hospital over one year has shown that most were minor. Of the 918 patients, 85% were discharged within 48 hours, only 3% required definitive neurosurgical care, and the overall mortality was 2%. Most cases came to hospital after 5.00 p.m. especially at the weekend. Head injuries accounted for almost one-third of emergency admissions to male general surgical wards.
Two neurosurgeons concerned with the emergency management of patients with head injury correctly diagnosed the presence or absence of an acute intracranial haematoma in 97 scans that were presented to them without knowledge of the patients' clinical details. There were no false-positives or false-negatives, although identification of the type of haematoma was not always possible. The impact of the EMI scan on patient management demands new approaches to the care of head injuries.
Out of 51 patients with traumatic intracranial haematoma admitted to a teaching hospital 11 (22%) died undiagnosed, and out of 307 such patients transferred to the West of Scotland Regional Neurosurgical Centre 111 (36%) had been deteriorating for more than 12 hours in another hospital. In two-thirds of these cases the delay was due to an erroneous diagnosis, either of cerebrovascular accident or of alcoholic intoxication.