Introduction and Orientation
Introduction
Welcome to Neurosurgery at Royal University Hospital.
This orientation guide is prepared to help you with your Neurosurgery rotation.
Neurosurgery has traditionally been challenging for most off service residents and medical students due to the emergency nature of neurosurgical pathologies, as well as, long work hours.
Residents from a number of different disciplines are required to do mandatory Neurosurgery rotations during their training, including Emergency Medicine, Orthopedic surgery, Radiology and Ophthalmology. Also residents from different disciplines, like Neurology, General Surgery, Family Medicine and even Psychiatry have a tendency to request Neurosurgery rotation to gain a better understanding of neurosurgical pathology and management.
Neurosurgery service at RUH provides patient centered care in all subspecialties of Neurosurgery with multidisciplinary team spirit. You will see the wide spectrum of pathologies in Trauma, Pediatric, Spine, Vascular, Functional, Epilepsy and Peripheral nerve surgery during your rotation. You will be communicating with all specialties and subspecialties for our patient’s multidisciplinary care, including ICU, NICU, Radiology, Rehabilitation services and also a number of different allied health care professionals.
You will have different objectives to learn, to perform and to take home with you from this rotation. Our attending physician and resident team will be happy to discuss your expectations and individual objectives before and during your rotation.
Clinical responsibilities and daily work load of residents
Morning rounds start in ICU every weekday morning at 0615, except for Fridays. Friday’s are Neurosurgery’s Academic Half Day; therefore, we start at 0600. The start time may change on a daily basis during the week depending on patient load, and the team will be notified by the chief resident in the evening rounds. You are expected to meet our team on the first day of your rotation in the ICU meeting room at 06:30.
We meet in ICU to review the new patients that are admitted overnight. Despite the fact that the ICU is a closed unit, we have a close collaborative relationship and our patient suggestions, such as imaging and blood work are almost always accommodated. Number of different drains we use for management of our patients, like EVDs, are leveled and followed in our guidance usually. You are expected to be involved in these rounds actively for examination of patients, doing hands-on procedures and charting for follow-up. essential in all multidisciplinary interactions.
When our patients are safe to be transferred from ICU, their chart is stickered by the ICU team and neurosur- gery residents write up transfer orders. You are responsible for notifying the attending neurosurgeon or a senior resident prior to writing transfer orders.
Rounds during usual regular neurosurgery weekdays continue in Pediatric ICU or NICU. We almost always have patients in 3rd floor observation unit or the ward. MRP on the pediatric observation unit or ward may be the neurosurgery attending only and there may be no other pediatric services involved in our patient’s care.
There may be emergency patients to be assessed in prior to our rounds at 06:30. We meet with our nurse coordinator daily at the front office. Here we get a daily patient list for Neurosurgery.
Rounds are led by the chief resident or the most senior neurosurgery resident. You are expected to be active- ly involved during morning rounds. Please ask your questions during rounds, provide your comments and verbalize your concerns for our patients during these rounds. Your involvement in these rounds is expected for examining patients and documenting daily patient progress notes as well as writing orders and scripts.
Most of our ward patients are followed in unit 6300. We have two observation units that we share with the neurology team.
You may come across our robot, Patrick, while he/she is doing rounds during your Neurosurgery rotation. This is designed for remote access patient care in our ward and parked in the hallway on its station and ready to be activated, especially by Dr. Mendez, and by trained staff Neurosurgeons. This robot will give you the inspiration to be ready at all times during your Neurosurgery rotation and we often say “hi” to Patrick when we walk around the ward.
Most of the critical patients are seen as a team during these rounds, while patients that are chronic may be distributed to the team to round on individually. Morning rounds need to be efficient to catch early daily operating room schedule. Patients need to be seen in holding area and patient’s chart, consent and imag- ing need to be reviewed by residents prior to surgery. Residents will be assigned to OR rooms by the chief resident every morning. It is not uncommon that a patient is waiting for fudicials to be placed for a STEALTH protocol MRI scan in the morning. Time management is critical in neurosurgery rotation and team members will be distributed to handle multiple tasks according to availability and capacity. It is essential to under- stand and organize tasks based on emergency with an efficient manner.
At around 07:45 the chief resident or designated neurosurgery resident runs the patient list on paper and heads down to operating room. Team power is distributed according to daily operating room schedule and number of patients and residents. Daily patient turn over, discharges, new admissions, transfers etc. is done in close collaboration with our clinical nurse coordinator. There is usually a quick Starbucks or coffee break during this time if possible.
In all circumstances your educational priority for your academic half-day will be accommodated. Please make sure to notify the team of these sessions early so that patient care is not disrupted.
At the end of every weekday we gather in our library for hand over. We review the imaging from the day, discuss consults, and hand over daily issues of patient care. We also discuss the next day’s schedule and workload. We may be have some kind of teaching rounds, especially if it is Wednesday, or may have some team sports activities. Please bring sports shoes and active clothing with you to play with us; if you do not, you will be provided some scrubs.
Weekly academic activity in Neurosurgery is distributed to all members by our administrative assistant called TWINS(This Week in Neurosurgery).
Fridays are our Academic Half-Day, during which residents carry their pager but even if they are on call, first call goes to attending, at least mostly. Please be considerate that the incoming page may be an urgent
patient care issue that needs to be addressed immediately. It will be well understood if you need to step out of rounds to answer your pager. Dress code for Fridays is neurology staff. Dress accordingly.
You may have an area of interest that you want to teach neurosurgery residents, and even attending physi- cians during your rotation and this is wonderful. If you do not have a topic or subject that you want to talk about, you will be provided a number of topics to choose from, likely a topic where your home program and neurosurgery intersect. Please remember that rotations are opportunities for us to learn from you as well, especially while you are here.
Code and telephone number for our library and call room will be provided to you at the beginning of your rotation. There will also be a list of telephone numbers, dictation ID numbers of attending physicians pro- vided to you, as this will increase your time management efficiency during your rotation.
Time management is essential in neurosurgery, as emphasized multiple times. At times it is the difference between survival or not. Sometimes it is more brain, spinal cord or peripheral nerve damage to a patient. It is important to be proactive; for example, if you are concerned about deterioration of a patient on the ward and ordering a STAT CT scan, you better contact one of the senior residents or attending prior to transfer of the patient, and call the CT radiology resident to facilitate the study and make sure you start some tempo- rizing ways of managing the concerning pathology, like steroids or mannitol.
Admission and assessment procedures
The admission history of the patient should include past medical, past surgical, medication list, allergy status and social history of the patient.
Medications of particular importance, such as anti-epileptics, anticoagulants and steroids may need to be addressed immediately.
Blood work in emergency admissions can be requested at arrival on the phone briefly by ordering the neuro work-up.
Physical signs must include ABCs as per ATLS protocol. External signs of trauma, cervical spine consider- ations, neurological examination with GCS (Glasgow Coma Score) is essential in all trauma patients.
Fundoscopic exam and brainstem reflexes in most cranial cases and rectal examination in most spinal cases are also essential parts of the neurological examination.
After seeing a patient in the emergency department or a consult, the resident needs to notify the attending physician on call. If patient is has high probability of a surgical pathology such as an epidural or subdural hematoma, attending physician should be contacted immediately prior to obtaining a CT scan.
ACAL patient consultations are to be directed to the attending staff.
GCS
Eye opening:
Spontaneous: 4
To verbal Stimulus: 3
To painful stimulus: 2 (Sternal rub, or distal painful stimulus)
Nil: 1
Motor:
Obeys commands: 6
Localizes: 5 (Patient will attempt to grab examiner’s hand)
Withdrawal: 4 (Limb flexes away from stimulation to avoid)
Abnormal Flexion: 3 (Elbows flex, shoulders adduct and internally rotate)
Extension: 2 (Shoulders adduct, internally rotate, arms extend and pronate)
Nil: 1
Verbal response:
Oriented: 5
Confused: 4
Inappropriate: 3 (Shouting, swearing)
Incomprehensible: 2 (Moaning, groans)
Nil:1
Orders and dosing of frequently used medications in neurosurgery
AD-DAVIDs: Admission orders.
Diet
Sips to DAT, Give IV NS@75-100cc/h, Keep NPO if OR potential or high risk for aspiration. Order SLP assessment.
Activity
AAT? Fall risk? Collar? Brace? Bed rest Flat? HOB 30 degrees? Is there a drain? Clamp? (EVD usually @ 10-15 cm open, then wean and clamp.)
Please PT/OT to assess.
Vitals
May be Q1hX4 if new trauma or post op, Then Q2-4-8-12H as /patient BP parameters? EVD settings and pa- rameters? Urine output?
Investigations
Imaging: CT, MRI, Xray, TCDs, USG
CBC, Lytes, Coags, Type and screen? X-match?
Drugs
Home Medications Filled? Need to D/C anticoagulants?
?Antiseizure: Dilantin? (1g IV loading dose, slow; Then 100 mg po/IV TID, or 300 mg PO@HS)
?Steroids? Decadron? (10 mg IV Bolus, 4 mg po/IV Q6H, tapering to stop usually)
!Ranitidine! 150 mg po BID or 50 mg IV TID
?Antibiotics? Ancef (2 g IV in OR for prophylaxis, may be 1g IV Q8H x3 doses.) Bowel care: essential! (Senna, Colace, Bisacodyl supp, lactulose, cascara, Fleet etc.) Antiemetics: (Gravol, ondansetron, Maxeran)
Analgesia: (Tylenol, Morphine, Hydomorphone, NSAIDS)
? Antihypertensives: Clonidine (0.1 mg Q1h prn, max 0.3 mg q3h), Labetolol/ Hydralazine (5-10 mg IV q1h prn)
? Nimodipine: for aneurysmal SAH! 60 mg po Q4h Zopiclone: 7.5 mg PO Qhs
SUBCUTANEOUS HEPARIN? PLEASE ASK, HIGH RISK PATIENTS BOTH FOR DVT AND FOR BLEEDING!
Immediate measures to manage high ICP:
Head of bed to 30o
Mannitol: 0.5 – 2 g/kg IV loading dose, then Q6h (comes as 20% solution, multiply by 5 to get infusion volume); order serum osmolality Q6h, and/or
3% Saline: start infusion at 25-50 ml/h; order serum lytes Q6h If intubated: hyperventilate to pCO2 25-30
If EVD: drop the level to 0.
Call room: 531
Library: 0639#
Supply room 6300: 125
Dr.Fourney: 22329
Dr.Kelly: 23534
Dr.Meguro: 22383
Dr.Peeling: 25639
Dr.Vitali: 25100
Dr.Wu: 25411
Resident Library: 844 1434
Admitting: 8008-2
CT: 2408
MRI: 2412
Angio: 0621
Triage: 1398
Emerg. Active: 1363
ERC: 6406
OR front desk: 2095
ICU: 2035
Peds ICU: 1915
Peds obs: 2092
Theatre 11: 2111
Recovery: 2122
Obs2: 1963
Obs3: 1871
Unit1: 1866
Unit2: 1867
Unit4: 1868
Unit5: 6505