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A (so-called) mild head injury
  1. Charles Warlow
  1. Correspondence to Charles Warlow, 6 South Gray St, Edinburgh EH9 1TE, UK; charles.warlow{at}ed.ac.uk

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The accident

If mine were merely a mild head injury, which it was according to Scottish Intercollegiate Guidelines Network guidelines,1 I dare not think what a moderate or severe head injury must feel like. In May 2010, I was on Richard Roberts’ new sailing boat, returning from our triumph in the Scottish Islands Peaks Race, which combines sailing 140 miles with three mountain marathons (fastest monohull, third overall, top of our class). We were about to enter the Crinan Canal, the short cut from the Clyde to the west coast. It was raining, slippery on deck and there were ropes lying about. Presumably I slipped or tripped, no one is sure, but I definitely fell head first into the cockpit, hitting the left side of my head and ear, and shoulder. I was completely unconscious for about a minute, much to Richard's consternation, who thought I was dead. I came round with a sore head, a bleeding cut behind my ear and pretraumatic amnesia of seconds, comfortably above the ceiling of 15 on the Glasgow Coma Scale (GCS). I was really not too bad, able to go down into the cabin, and with help get my waterproofs and boots off, and lie down on a bunk. Within an hour I was reading the newspaper and regretting whatever stupidity had caused the fall. My left ear was a mess, bruised and bleeding from the cut inflicted by my glasses.

After motoring along the Crinan Canal for a couple of hours, we had another think. We did not need a neurologist, we had two already—me and Richard. In any event, UK neurologists know little if anything about head injury and even less about ear injury (alas, the recent “The Bare Essentials of Head Injury” in Practical Neurology was not in the ship's library).2 However, blowing my nose to cause blood to spurt out of my ear astonished—and repelled—my non-medical son Ben, and persuaded us to take action. The blood was clearly not coming just from the cut behind the ear. Of course extradural, subdural, cerebral abscess, meningitis, epilepsy, depression and bad behaviour were already in my thoughts. So we phoned the National Health Service helpline and toiled through their algorithm, which strangely rang no alarm bells on mentioning bleeding from the ear. We were told we would be phoned back in 2 h. Not good enough. Because we had local knowledge, we phoned Lochgilphead Hospital who said they could see me. The crew were glad to see the back of me as I disappeared in a taxi from a convenient road by the canal: none had fancied getting up during the night to do my neurological observations.

The local hospital

In 10 min I was in a completely empty and very modern, spick and span small emergency department. The nurses were excellent, the radiographer calm, and the general practitioner (GP) on call was firm and reassuring. Even though my skull x-ray was normal, he assumed I had a basal skull fracture because of the bleeding from my ear (I wonder how specific that sign is). He did not send me for a CT brain scan, which I thought was very reasonable—what difference would it have made to my management at that point? It was already evening, the hospital in Oban only operated their scanner 09:00–17:00 Monday to Friday, and the nearest hospital with an active scanner was in Paisley, about 2 h away by road, and without a neurosurgical department. Very strangely, the Southern General Hospital in Glasgow with a neurosurgical department is exactly the same distance—81 miles, and only 6 miles from Paisley. So why take a brain injured patient who might need surgery to the wrong sort of hospital? Maybe the neurosurgeons did not want to be cluttered up with clapped out alcoholics who have taken a tumble into the gutter.

Everyone, including the cleaners and people dishing out the surprisingly good food, was cheerful and friendly. I was to stay the night and have hourly neurological observations, plus a non-steroidal for my headache. Being woken every hour to be asked where you are is a drag for patient and nurse, only enlivened when, just for fun in the early hours, I claimed I was in London. I remained GCS 15. As ever the nurses told me to uncross my legs (but does that really prevent deep venous thrombosis?).

The hospital is run by the local general practice and how professionally satisfying that must be compared with the life of some nine-to-five, 4 days a week urban GPs ticking boxes while peering at their computer screens and counting the money. The GP did a ward round the next morning and refused point blank to let me return to the boat, despite my admittedly rather feeble protestations. But the voyage was ending anyway and that evening Richard drove me home to Edinburgh, deaf in my left ear and headachy, but otherwise OK.

Back home

The next morning when I got up I was clearly unsteady on my feet, and certainly unable to do the heel–toe test. And my head and ear hurt. I did not want to bother the neurosurgeons, and certainly not the ear, nose and throat (ENT) surgeons; in any event, physicians are the best start for everything other than dire surgical emergencies. They are generally better at taking a broad view, bringing in others where necessary, coordinating care and following up. So, together with my partner, yet another neurologist, we activated the plan that we neurologists all have in our heads. Which of our colleagues to see if we develop a neurological problem? I picked Dr X who performed a normal neurological examination of sorts (did he really learn that from me when he was my trainee?). I had a CT brain scan and was summoned to look while two consultant neuroradiologists discussed it. Very interesting. No fracture, but why were there bubbles of gas in the soft tissues deep to the temporomandibular joint (figure 1)? Where had they come from if there was no fracture? Surely not gas gangrene so soon! Plenty of fluid in the middle and outer ear, not surprisingly. Dr X consulted Mr Y the neurosurgeon and we all agreed that the best treatment was the passage of time, and everything would eventually sort itself out, or not. Later that day yet another neuroradiologist, after looking very hard, found a small fracture in my temporal bone (figure 2)—the news made me feel worse.

Figure 1

Unenhanced axial CT scan below the skull base, arrow indicating air in the soft tissues.

Figure 2

Unenhanced sagittal CT scan through the petromastoid, showing not just air, but also a fracture through the mastoid bone.

By the afternoon, back home, I was getting vertigo off and on, with various postures. Not benign paroxysmal positional vertigo (BPPV) lasting seconds with a particular head posture, but far more unpredictable and lasting a minute or so at a time. And in all sorts of directions and speeds. Surprisingly, no nausea or vomiting. I felt so much better lying in bed listening to BBC Radio 4 and reading the paper.

Early recovery, of sorts

For the next week I felt as though I had flu. Listless, poor concentration, fatigued, headachy, not wanting to do much except stay in bed and read an easy book (Patrick O'Brian) and meander through undemanding emails (leaving the ones to do with research ethics for later). I did not even want to check out the garden, and certainly not bend down and thin the lettuces. Indeed my first excursion outside, on the arm of my partner, was not until day 5, and that only round the block because of my rather unpredictable unsteadiness.

By day 6, I no longer needed the paracetamol but my left ear was very bunged up, a bit sore, more or less deaf, with horrible smelly brown stuff dribbling out of it. Although the vertigo was less, I was still unsteady enough on my feet to be careful how I moved around. My head did not seem securely attached to my shoulders, everything seemed to bounce around when I walked, or if I shook my head. But I could at least do a bit of work on the computer after reading the newspaper in bed.

By 2 weeks, I was obviously a lot better but far from normal—able to go to the theatre and walk my 9-year-old daughter to school. But I was still hellish unsteady in my head. By now I had more classical paroxysmal positional vertigo, turning on my left side in bed with impressive nystagmus—but not alarming, or nauseating, it soon stopped, maybe in 30 s. And less stuff was coming out of my ear which was still more or less deaf. Three weeks on and my fatigue and poor concentration had resolved, the positional vertigo was trivial, my hearing was returning, and I could walk much better (but not run). Maybe I was going to recover after all without any deafness, depression or postconcussional syndrome (I had no one to sue).

The residual vertigo

Slowly I returned to normal activities and, by 2 months, walking was all but normal, and I was back sailing (not a bad place to be with vertigo as one always has to have ‘one hand for the boat’). I still had paroxysmal vertigo first thing in morning turning to the left in bed, and after getting out of bed I swayed to the left, but was OK in the day. By 3 months, I was back on my bike and free of vertigo. But I was still deaf and so went off to the ENT department, first to a rather bossy audiologist who showed me my audiogram, which revealed sensorineural impairment on the left, not conductive deafness which I had hoped for. Working (I suspect) down some care pathway, she immediately offered me a hearing aid, as did the rather more empathetic ENT surgeon.

I could not be bothered with a hearing aid—the deafness was not that bad—but the vertigo remains an irritation if not really a problem. It is not quite like BPPV in the books. Certainly it comes and goes like BPPV, unpredictably, in bouts maybe over a few weeks at a time, but in between bouts I am fine. But what precipitates the vertigo with the accompanying nystagmus varies within and between bouts. Sometimes turning in bed to the left, or right or either way. Sometimes looking up, sometimes looking down which makes searching the bottom shelves in shops a problem (it would never do to pitch forward into the Puy lentils in Waitrose). Sometimes it is there just in the mornings, but not later. Sometimes I can get rid of it by looking to the left, other times to the right. It does not seem to habituate with repeated attempts to precipitate it. It can be absolutely wild and chaotic, at other times more measured. And during the bouts I am unsteady and a bit nauseated more or less all day, sometimes much more nauseated, but only once did I vomit which—strangely—got rid of the vertigo completely for several weeks. Maybe I should have seen an expert. But I was discouraged by what my mentor and friend, the late Bryan Matthews wrote: ‘There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient's complaint is one of giddiness’.3 During one particularly bad bout of vertigo I did eventually phone an expert, and the very next day I was completely better. Then the vertigo came back. By the time I got to the dizzy clinic it had gone again, not surprisingly the Hallpike's test was negative. In the next bout I promised to try Epley's manoeuvre.

So what did I learn?

  • How debilitating, and for how long, symptoms following a so-called ‘mild’ head injury can be, particularly fatigue, which is a symptom common to so many disorders from cancer to heart attacks. The mild adjective must come from the neurosurgical lexicon.

  • The modern term of ‘traumatic brain injury’ is as nonsensical as it is posey; there is much more in and around the injured head than just the brain—ears for starters.

  • I gained even more respect for GPs working in remote community hospitals; long may they and their hospitals survive.

  • As ever, I was enchanted by the professionalism, good humour and kindness of my colleagues.

  • I brushed up on the anatomy of—and around—the ear, but still find anything to do with nystagmus incomprehensible.

  • It became even clearer to me that neurologists, where they are available, are by far the best specialists to deal with head injury from the acute stage through to any short and longer term complications, of course in collaboration with neurosurgeons and others when necessary.

  • How silly the English—but not Scottish—Government is to promote competition between healthcare providers. Near the Crinan Canal there is but one hospital, in Edinburgh there is but one neurology department. That is fine by me because the service is professional and (sort of) quality assured by Health Improvement Scotland, joined up and effective.

  • The telephone is indeed incredibly useful, even on boats, for getting help, advice and summoning a taxi to the emergency unit.

Acknowledgments

Thanks to the crew of Dorothea, Dr Adrian Ward of the Mid-Argyll Community Hospital and Integrated Care Centre (think about the marvellous acronym of MACHICC), Dr X and Mr Y, and my neuroradiological friends.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.