Traumatic brain injury is the leading cause of death in young people in the UK and USA. The vast majority of these patients will be initially managed outside the teaching hospital environment and many will remain there for the duration of their treatment. As clinicians, what happens during the first hours and days after injury can have a huge influence on the patients chance of survival and also their quality of life after the injury.Results of a recent national survey have highlighted 2 main areas of major concern. Firstly, there are far too few specialist neurosurgical beds in out tertiary referral centers, which means that District General Hospital Intensive Care Units are frequently having to manage very seriously brain injured patients. Secondly, many clinicians do not know when they should be speaking to their Regional Neurosurgical Centre, do not fully understand how they should be managing these patients, do not know how to interpret the relevant physiological and radiological data, and have difficulty identifying when to escalate treatment and when the situation has become futile.Lives could therefore be saved and outcomes improved with the introduction of common treatment pathways and better defined lines of communication between referring hospitals and specialist centers.