Clerkship Survival Guide

It is difficult to make generalizations when caring for neurosurgical patients, so the following is simply a guideline to help you during your rotation on Neurosurgery. Manage each patient as an individual and always ask for help when you are unsure.

All daytime consults/admissions should be seen by the most junior resident who is free (i.e. not first assisting in surgery). When the housestaff on-call is busy in the operating room, it is his/her responsibility to ensure that the consult/admission is seen in a timely manner by someone else. For stable patients, preference is given to the medical students to do the admission. This should be followed by an opportunity for the medical student to review the case with a resident or staffman. Surgical cases will be assigned to the residents by the chief resident on the day prior to surgery. Depending on circumstances, it may be expected that off-call housestaff check in on Sunday afternoons to help with any “elective” admissions to their team.

General advice

  • With a deteriorating neurosurgical patient
(e.g. head trauma, hemorrhage), act quickly because TIME is BRAIN!
  • With an unstable/unwell patient, the CT head scan needs to be organized and done STAT (it is the diagnostic rate-limiting step and you’re the only one to push the process along).
  • Be familiar with process of obtaining urgent CT head scans.
  • When it’s just you at night, ensure that the staffman is informed of deteriorating patients early (he may want to be present to review the CT head scan as it is being done).
  • Neurosurgical patients in general are very ill and prompt management decisions are required – always err on being safe and NEVER be afraid to ASK someone more senior for help when you’re unsure.
  • Neurosurgery is a demanding yet exciting specialty with much to offer you regardless of where your career path takes you.
  • In addition to being committed to helping our patients, we are committed to helping you get the most out of your rotation on neurosurgery.

Material to be familiar with while on service

  • Trauma – assessment in the ER, GCS, various bleeds, contusions, DAI, brain herniation
  • Tumours – features of raised ICP, meningiomas, tumours
  • Cervical and lumbar degenerative spine disease – neurological assessment for radiculopathy, myelopathy, neurogenic claudication
  • Spontaneous hemorrhages – clinical features of SAH, aneurysms (Hunt and Hess classification), vascular malformations; ICH due to hypertension, amyloid angiopathy
  • Functional surgery – assessment of temporal lobe seizures, epilepsy surgery; Parkinson’s disease, trigeminal neuralgia, hemifacial spasm

Rounds

  • Morning NICU & ward rounds are work rounds and need to be completed in a timely fashion in order to be punctual for surgery.
  • Discussions/questions should be focused on only patient care issues.
  • Medical students are encouraged to save questions & residents will make time to go over patients and scenarios towards the end of the day.
  • The most senior resident on either team is responsible for the ward rounds on the patients on his/her particular team.
  • Medical students should follow and write progress notes on patients belonging to their specific preceptor.
  • The most senior resident on either team is responsible for supervising the medical students during ward rounds.
  • On weekends, 2 housestaff members agree to a meeting time in the NICU (typically between 0700h and 0800h) in order to make rounds.
  • Following NICU rounds, the housestaff members split up to round on their assigned teams on the ward.
  • The resident who sees a patient admitted to another service is the one responsible for rounding on that patient and updating the relevant neurosurgical staffman.  The same resident is responsible for making the weekend on-call team aware of any pertinent issues concerning these patients.

On the ward

  • Be problems-focussed (usually lots of problems)
  • ACTIVELY look-out for small problems that can become big, life-threatening problems:
    • Signs of neurologic deterioration
    • 6 W’s of fever (water, wind, wound, walking, “weins”, wonder drugs)
    • Meningitis
    • Hyponatremia/SIADH (esp. head inj., SAH), DI (post-pituitary surgery)
    • Constipation (use neurobowel protocol)
  • Check the problem list.
  • Avoid unnecessary lines, Foley catheters (cause infection).
  • Staples out POD 7 if wound healing well.
  • Be accountable – If you order a test, you are responsible for knowing the results of that test.
  • Ensure that requested tasks are seen to completion.
  • Make a list of things to do/check.
  • Avoid unnecessary consults (ask senior resident/staff prior to consulting another service).
  • Utilize the ward allied health professionals
    • OT’s: swallowing ax, splints, cognitive ax
    • PT’s: mobilization issues
    • Dieticians: feeds
    • Social workers: d/c planning
    • Speech pathologists: language, speech problems

Admissions

  • Complete history, physical and orders required.
  • If a head CT scan is required urgently, this needs to be organized by the Neurosurgery resident ASAP.
  • Ensure that the staffman and chief/senior resident are aware of the patient.
  • If surgery is required, the operating room needs to be notified (Resident’s responsibility)
  • Admissions from the ER (in addition to above). Call emergency admitting (62238), Inform neurosurgery ward charge nurse when admission made to the ward/NICU at 604.872.9855 and If ICU is required, the ICU resident on-call needs to be notified.
  • Requests for patient transfer to VGH need to go through staffman. Spine consults need to be referred to the Spine service.
  • In general, avoid unnecessary sedation of patients with intracranial pathology.
  • View a guide for writing an admission order

Pre-OP

View a sample pre-op checklist

Post-OP