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Neurosurgery Rundown

General

  • 0700 weekdays: paper round – in meeting room on ward 83

  • 0730 weekends: paper round – in the HO room

During the paper round, ask for follow up plans for any patients who are expected to be discharged. This will save the hassle of asking during the ward round/texting afterwards and not getting a reply. Check timing of outpatient follow up clinic, whether the patient needs a scan prior to clinic, whether they need to continue anti-epileptic medication, and plan for the steroid dose. Check when sutures will need to be removed.

Suggested triaging of jobs:

  1. Booking scans – Neurosurgery is extremely imaging dependent. Take a photo of the scheduled operations on PIMs for the next day and ask the registrars if pre-op scans are necessary. The vast majority of patients will need an updated MRI or CT. Always ask if contrast is necessary. Always ask if a STEALTH sequence is necessary (a STEALTH sequence is used for operative planning). Clarify both these points in your radiology request. Non-contrast CT heads do not need to be discussed.

  2. Getting patients accepted for transfer to different Districts. Because neurosurgery is a regional service, once any active neurosurgical issues are dealt with, they need to be transferred to their domicile DHBs. The accepting doctor will usually be general medicine. Once you have an accepting doctor’s name, give it to the charge nurse so they can arrange transport.

  3. Calling other services for advice/review.

  4. Discharge summaries. The turnover can be very fast in neurosurgery. However, do NOT neglect the above jobs in favour of a discharge summary. The toilet code near the elevators is 2208. There is a red folder in the HO room with guidelines for managing common problems in Neurosurg

There is a red folder in the HO room with guidelines for managing common problems in Neurosurgery.

Minimum neurosurgery house officer staffing is 5x HOs on Mon‐Thurs and 4x HOs on Friday. Make sure to apply for cross cover if there is any less.

Neurosurgery specific house officer jobs: Ward review for shunt resets; drain removal (incl. EVD, subdural drain, subgaleal drains); troubleshooting blocked EVDs. All of the above should be taught by a registrar at the beginning of the run, BEFORE doing it yourself.

Patient list

Have the list ready for the paper round each morning. Ensure the room order is correct and the HDU west (i.e. patients who are in room HDU 3x) bloods are updated. This is particularly vital for subarachnoid patients as the registrars will ask about Na+ during the ward round. Don’t worry about East i.e. HDU 6x.

For DCCM patients, it may not always be obvious if they need to be on the list. Ask the overnight registrar regarding this.

Admissions

Elective admissions come in some time in the afternoon. As with all surgical patients they will need “pre op bloods” (FBC, U+Es, coagulation screen, and a G+H). For pituitary patients they will need a “pituitary panel” (IGF1, prolactin, FSH, LH, testosterone/oestrogen, TSH + T4, and cortisol) You can send them to Level 6 with necessary forms, or nurses can sometimes help you out. If they need a pre-op scan make sure you have a time on RCP, or call the technicians to ask.

Acute admissions should be seen by a Registrar. But sometimes you will be the first person to see them down in CDU if the registrar is held up. Make sure you do the admission note and medication chart, then check the plan with them. Ask are if they are on anti-coag/platelet therapy (and why), smoking status, hand dominance, and baseline function.

On call evenings and nights

After hours, you will cover Neurosurgery patients; from 10PM you cover Neurosurgery & ORL patients. Every night on call you need to do a ‘midnight’ round of bloods on the HDU WEST patients. Note: nurses can take bloods from people who have arterial, central venous or PICC lines. It is also your responsibility to update the list for the morning team.

Neurosurgery clinical tips

Patients may ask about their driving. It is not always clear cut even with rigorous perusing of the NZ transport guidelines. For patients who have had open surgery, you can reasonably tell them to cease driving until their next clinic appointment.

Do NOT chart prophylactic anti-coagulation unless specifically requested by a registrar/SMO. Stay away from clexane. If needed it will always be heparin 5000IU SC BD/TDS.

Do NOT chart tramadol for patients with intracranial issues. It lowers seizure threshold.

Remember dexamethasone demarginates neutrophils and if patients are on it for long enough they will start developing leukocytosis. Always chart omeprazole for gastric protection whilst on dexamethasone.

Do not chart fluids other than the NaCl variety. Stick with 0.9% for all “maintenance” needs +/- electrolytes as needed for replacement. Other types of IV fluid (eg PL148, dextrose etc) supposedly increases risk of cerebral oedema so it is not used.

Scopoderm patches can cause pupils to dilate if a patient has rubbed their eye.