This issue of CMScript focuses on head injuries as a prescribed minimum benefit (PMB) condition, from the slight bump to the serious brain injury.
What is a head injury?
Head injuries include any trauma, minor or serious, to the scalp, skull or brain. They can be closed or open (penetrating). A closed head injury means that the skull did not break (fracture); an open head injury means that the skull and a foreign object (such as skull bone) entered the brain.
What are the causes of head injuries?
Common causes of head injuries include traffic accidents, falls, physical assault, accidents at home and work, outdoor activities and sports injuries.
Symptoms of head injuries
The symptoms of a head injury can set in immediately or develop slowly over several hours or even days. Even if the skull is not damaged, the brain can hit against the inside of the skull and be bruised; the head may look fine on the outside, but complications could result from bleeding or swelling inside the skull.
What is covered in the prescribed minimum benefits?
All head injuries are medical emergencies and all medical emergencies are PMBs. A head injury, however insignificant it may seem, is thus a PMB condition until the diagnosis determines whether it remains a PMB condition or whether it changes to a non-PMB condition.
The PMB Code of Conduct states that where a medical emergency is diagnosed provisionally and not confirmed by additional medical evidence, the medical scheme must treat the medical emergency as a PMB and cover in full the costs for the diagnosis, treatment and care of the condition up to the point where a PMB condition has been excluded.
For example: Phumzile, a show-jumping competitor, falls from her horse and hits her head against the ground, cutting it open. She is unconscious but regains consciousness on the way to the hospital. At the hospital her doctor orders an X-ray and determines that there is no skull fracture. Based on firm clinical grounds, a Computed Tomography (CT) scan is also performed to ensure that there are no serious internal injuries to the head. The CT scan results are normal and Phumzile displays no further symptoms or signs of a brain injury. Right up until the CT scan results show everything to be normal, the case must be treated as an emergency (a PMB condition) and must be covered in full. Once treatment of the non-PMB condition starts, it will not be covered under PMBs.
PMBs cover the following head injuries:
• skull fractures;
• difficulty in breathing, eating, swallowing and bowel/bladder control due to a non-progressive neurological (including spinal) condition or injury;
•severe or moderate head injury: hematoma (bleeding which results in localised collection of blood within the brain) or oedema (swelling but no bleeding) with loss of consciousness;
• subarachnoid bleeding (between skull and brain);
• intracranial bleeding (in the skull);
• hematoma (bleeding in brain);
• compression of brain; and
• injury to major blood vessels.
Diagnosing PMB conditions
Depending on the clinical situation, the following diagnostic tests may be necessary and must be covered (in full) to determine the seriousness of your head injury and whether it remains a PMB condition:
• skull X-rays: to detect fractures and bone fragments;
• CT or Magnetic Resonance Imaging (MRI) scans, or an angiography: to detect swelling between the brain cover and the brain or within the brain tissue, and a shift or distortion in the brain chambers;
• electroencephalography (EEG): to detect the shift of the brain past its centre line;
• cisternography: to detect tears in the brain cover; and
• cerebrospinal fluid (CSF) sampling (called lumbar puncture): to detect whether there is increased pressure and blood in the CSF.
Treatment, care and rehabilitation
PMBs include the medical and surgical management of all head injuries. People with serious head injuries are always admitted to hospital for observation.
The Regulations in the Medical Schemes Act do not restrict the setting in which head injuries may be treated. Relevant treatment and care may be provided on an outpatient basis (in a hospital or clinic but where no hospitalisation is required) or in a setting other than a hospital, whichever is most appropriate clinically. Serious injuries may require that the patient be admitted to an intensive care unit and placed on a ventilator to assist with breathing. Ventilation, if required, is included in the medical management of head injuries.
The medical management and care of people with head injuries often includes rehabilitation. Rehabilitative services include but are not limited to physiotherapy, occupational and speech therapy, and psychological and social support.
Once it becomes clear that the patient will not regain further bodily functionality, the medical scheme is not obliged to pay for further rehabilitation services. The scheme can ask to see the initial assessment findings and weekly progress reports to determine whether you are making progress in regaining your functionality to be self-sufficient.
When a head injury has occurred, NEVER:
• Wash a head wound that is deep or bleeding.
• Remove any object that is sticking out of a head wound.
• Move the person (unless it is absolutely necessary).
• Shake the person if s/he seems confused.
• Remove the helmet if you suspect a serious head injury.
• Pick up a fallen person with any sign of a head injury.
• Drink alcohol within 48 hours of a serious head injury.
U.S. National Library of Medicine (www.nlm.nih.gov/medlineplus/ency/article/000028.htm)
KwaZulu-Natal Provincial Health Department (www.kznhealth.gov.za/headinjury.htm)
The Communications Unit would like to thank Ronelle Smit, Dr Selaelo Mametja and Dr Boshoff Steenekamp for making this edition of CMScript possible.
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