To CT or not to CT… is pretty often the question. A friend was just concussed playing soccer, so this came to mind. At the root of the head CT dilemma again lies the “principal agent problem.” The principal is the patient who just got whacked in the head, who wants to feel better and reassured that nothing deadly may be brewing. The principal also doesn’t want brain cancer. The agent in the ER (sometimes me) wants what’s best for the principal, but also risks far more guilt and shame for missing anything deadly under the skull. No doc wants to send someone home like Natasha Richardson.

On the other hand, I’ll never feel any consequence for clicking a button that initiates a cascade of events that may one day lead my principal to brain cancer. In fact, if my hyper prudence catches even a small brain bleed or skull fracture, I’m a hero. Never mind that most of these still heal with rest and time. I’m also long gone when patients receive their bills. Even if they ask what their CT may cost, I truly have no clue. Back to being your own advocate and knowing the buzzwords. Aside from the obvious (deformed skull, unconscious, bleeding from ears), here they are…

Red Flags:

Amnesia or poor recall for the event
Persistent vomiting
Perseveration (Asking the same question over and over)
• Ataxia (Can’t walk a straight line)
• Taking blood thinners
• Loss of consciousness… “How long were you out?” “I don’t know. I was out.” (We get most hung up on “LOC”.)

Happy Words

• Eating, thinking, walking, talking properly
• Better with Tylenol (Steer away from ibuprofen or aspirin at least on day 1 to limit bleeding.)
• Good social support (Someone sober nearby who can think, dial 911 and speak.)
• Proximity (Short hop back for a CT if anything changes)

To CT is easy. Choosing no CT takes guts, observation and actual conversation (read more). Unless your bell is truly rung, you are ultimately your own best agent. Lastly, waking someone after they’ve hit their head every couple hours is just mean. Let ‘em sleep.

If you want to bounce these decisions around, or just have someone come visit for a recheck, feel free to give Pre-R a call.

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