Tuesday, March 31, 2009

Neurology Consult Service and Neurosurgery

I will be spending the next three weeks on various inpatient neurology teams: consult service this week and next week, and then inpatient neuro the last week. There is not much difference between the consult and inpatient services in terms of what we do. The main thing that distinguishes them is whether neuro is the primary team that admits the patient (inpatient), versus the secondary team that comes to see the patient at the request of the primary team (consult). Most of the consults are made by the surgery and medicine teams for patients with delirium. It's not the most interesting patient population in the world, because we had plenty of delirious patients when I was on medicine and surgery. But it's ok.

Yesterday morning, I had neurosurgery clinic, and that was a good experience for a couple of reasons. First, I got out of having to go round on the consults. Second, the patients were not seeing a surgeon for delirium! The surgeon had a cool operation planned for that afternoon, which she said I could scrub for if I wanted. I got permission from my resident to go scrub, and it was one of the most amazing things I have ever seen since I started medical school.

The patient was a teacher who began having headaches several months ago. The headaches got worse and worse, and he also started having seizures even though he had never been diagnosed with epilepsy before. An MRI of his brain showed that he had an enormous tumor. The surgeon had already operated on him once but couldn't get all of the tumor out because it was too close to vital brain structures. So the patient had come back to have a special surgery done where a neurologist would help the neurosurgeon figure out how much tumor debulking (removal) could be done without affecting the patient's mental functioning.

Although the patient had gotten local anesthetic, he was awake while the surgeon was working on removing the tumor. He had to be awake so that the neurologist could test his cognition. While the surgeon was cutting away slices of his tumor and brain, the neurologist had him doing tasks like counting, identifying pictures on notecards, reading words, and performing mathematical calculations. At one point, the patient was counting, "20, 21, 22, 22, 22, 27...." When that happened, the neurologist told the neurosurgeon not to cut any deeper. There was still tumor left, but the surgeon couldn't remove any more of it without putting the patient at risk. So at that point they starting closing the wound and the surgery was over.

One thing you may be wondering is whether the patient was in a lot of pain while the surgeon was cutting into his brain. Although all of your body's pain receptors go to the brain, there are no pain receptors in the brain itself. So once the surgeon had removed the patient's scalp, skull, and dura (the tough covering of the brain), the patient didn't feel any pain in his brain. Also, after the neurologist told the neurosurgeon to stop cutting, the anesthesiologist did put the patient to sleep so that he wouldn't have any pain while they were replacing his skull and scalp.

Today was a regular day on consult service, and as I said before, we mainly got a bunch of delirium consults. I did an H&P (history and physical) on one patient, which can be a pain sometimes if the patient is delirious. That's because they aren't the most reliable historians, and sometimes they don't want to cooperate with being examined. But I didn't have any problem with that today. Also, I don't have to preround tomorrow because I have a second morning of neurosurgery clinic. That's the last opportunity I will have to escape being on consult, unfortunately.

I should mention that I really like my senior resident, but the attending seems kind of unenthusiastic about neurology and even life in general. I'm feeling like this could be a long two weeks.


teacher said...

I am not from medical background but your post give a lot some ideas about neuro.it is so knowledgeable.

Clinton said...

Sounds like something straight out of Hannibal, from the Silence of the Lambs fame. Although perhaps more accurately, the movie did a great job portraying the buzzard phenomena of sequential degeneration of higher executive function.

Good luck with the rest of the clerkship!!

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