I read with great interest the paper by Butler and Belli [1] regarding the delays involved in the treatment of intracranial haematomas. As a trainee in the region and having been involved in the transfer of such patients, I applaud their efforts to identify and quantify the factors that cause the delays and suggest possible solutions. There can be no argument that such patients require prompt and decisive intervention and I’m sure that anyone who has been involved in the management of such patients would find any delay frustrating. However, I feel compelled to comment on a number of issues raised.

Firstly, it is unsurprising that patients who presented directly to the neurosurgical unit received their operation quicker compared with patients who presented elsewhere (median time of 3.7 h compared with 5.4 h). What is surprising is the breakdown of the individual factors and extent to which they contributed to the delay. According to their own estimates, direct presentation to the neurosurgical unit should save at least 153 min worth of ‘steps’. These mostly comprise of referral times as well as the need for inter-hospital transfer times. In fact, patients should receive definitive treatment by 2 h 34 min in the tertiary centre as there is no need for inter-hospital transfer (Figure 2 in study). This is well within the 4 h recommended [2]. It would be useful to analyse the timeline of patients who present directly to see if examples of good practice can be transferred from the neurosurgical centre to the feeder hospitals.

Secondly, I suspect that the block of time labelled as ‘to request CT’ is misleading. Clearly the patient needs to be resuscitated appropriately prior to ‘transfer’ to the CT scanner. As with most resuscitation protocols, to look after ‘D’, the A, B and Cs need to be looked after first. This may involve securing the airway with a tracheal tube, establishing appropriate invasive monitoring and IV access and the commencement of vasopressors to ensure adequate cerebral perfusion pressure.

In order to reduce delays, the authors have suggested that steps should be performed in parallel and indeed, the management of such patients require a multi-disciplinary team approach – Emergency Physicians, Anaesthetists, Intensivists, Radiologists, Neurosurgeons as well as ambulance services. I think it would be unrealistic to expect patients to be accepted for neurosurgical intervention without the appropriate imaging. The authors themselves admit that not all patients warrant an operation or a transfer and it is indeed their unit policy not to accept patients without themselves looking at the scans. Furthermore, I am unsure about the appropriateness of ‘pre-booking’ an ambulance when most ambulance services throughout the country are already stretched.

Finally, I agree with the authors that delays are not attributable to a single factor and a co-ordinated approach by both the tertiary centre and feeder hospitals is required. At the very heart of this is the patient and that should always be the driving force for change and improvement.

References
1.    Butler D, Belli A. A prospective study of the time to evacuate acute subdural and extradural haematomas. Anaesthesia 2009: 64: 277-81.
2.    The Royal College of Surgeons of England: a position paper on the acute management of patients with head injury. Annals of the Royal College of Surgeons of England 2005; 87: 323-5.