I cannot empahsise how awesome the iRefer app is. This app that has been produced by the Royal College of Radiologists to explain exactly which radiological investigation is indicated in various clinical presentations. I have been able to fill in and discuss radiology request forms in seconds and never had one turned down. For example, imagine your consultant has asked for a PET-CT in a 49 year old man with biopsy proven lung cancer. The patient has already had a staging CT. Before you ask the consultant what the logic behind the PET-CT is, he has disappeared. Using the app, you can look up Cancer → Lung → Staging, where it lists the indications for the possible radiological tests. Under PET-CT, you can see the evidence is strong for a PET-CT before any radical therapy is carried out. You can then tailor your request to focus on the patient’s fitness/desire for surgery or radiotherapy as needed, and also use the information from the staging CT to show that the patient is potentially for radical treatment by TMN staging. This is also supported by the latest NICE guidance (1.3.4). Happy radiologist, happy consultant, happy patient and happy you.

The app came in handy when I was asked to review an elderly lady whose INR had come back as 6.4. No big deal I thought. Having been through an INR of 10, I felt confident that I was simply assessing her for any major bleeds, any minor bleeds and hunting for an underlying cause. I knew this patient was on warfarin for PEs and DVTs, and had an INR of 2.8 two days previously. She had been admitted two days ago with confusion following a fall, and a CT done yesterday showed no bleed or any other new problems. Her inflammatory markers were up (CRP, WCC) and a urine dipstick was positive for leukocytes. She was treated as UTI +/- LRTI, despite the lack of localizing features on history or examination.

I knew this patient quite well as a direct result of finding her difficult to bleed and taking 20 minutes to do so. I learnt about her life story. She was still mobile enough to do her shopping alone.  She liked baking apple based puddings.

She also asked me to pass her the cup, and that I could take off her watch to bleed her. She volunteered these phrases. I did not realise at the time how significant remembering this would be.

A few hours later, I was called to see her as she had a new headache that had worsened over the past few hours. In addition, I had noticed that she was different to the woman I got to know when bleeding her. She was much more drowsy, despite it being 6pm. She was not sure where we were. I asked a medical student to do a full neurological examination of the limbs, plus cranial nerve VII, pupils and higher functions.

When asked to name a pen, she said ‘penburage.’

When asked to name a bottle, she said beaker.

Was this new or old? Then I remembered our conversation earlier.

When asked to name a cup (filled with tea), she eventually said teapot.

When asked to name a watch, she just could not.

It seemed like a nominal aphasia. She had fluent sounding speech, if a little distant and drowsy. She followed instructions, but seemed generally more confused. For example, during the Babinski reflex, she denied that the shoes I was putting back on her afterwards were hers.

The Babinski showed an upgoing left plantar. Comparison with the clerking examination showed that this was new.

There were new focal neurological signs, and combined with new drowsiness and a worsening headache made me suspicious of a new bleed since yesterday’s CT head.

Convincing radiologists to re-scan a patient about 24 hours later requires a firm understanding of the guidance and precisely how this scan will change management. Were this scan to show a bleed, what would we do differently? Would we perform neurosurgery on this lady? Perhaps, perhaps not. I felt that a neurosurgeon would be in the best position to make that call armed with an understanding of the nature of the problem from a CT head. Even if the patient were not for surgical intervention, a haemorrhagic stroke is an absolute contraindication for warfarin for life, which would change management significantly.

I discussed the issue of reversing the clotting deficiency before or after the results of the CT head with my consultant. I personally felt that if the CT head could be done within 30 minutes, and there was no further reduction in GCS/evidence of raised ICP, then it made sense to wait for the results. In any case, vitamin K takes 4 hours to act. Prothrombin complex is quick and does not require ABO matching. It does however need a hematologist’s approval and he or she would usually want objective evidence of a major bleed. This is the plan we went for.

I requested an immediate CT head in line with the NICE guidance. An immediate CT is indicated if a patient is FAST/ROSIER positive and on anticoagulation. Immediate is defined in the NICE guidance as the next available slot ideally, and certainly within the hour.

We’ll have to wait till Monday to see what happened.

Edit: Monday’s CT Head was NAD.