There is a full induction session on your first day, which usually covers the following:

1. A welcome to the neurosciences placement by Mr Mannion

2. The rota

3. Neurosurgical emergencies including how to assess GCS and why you should place most emphasis on the motor score

4. Neuroradiology

5. Ward work flow

6. Services offered including: - Neuro-oncology - Trauma - Spine - Paediatrics - Vascular - Skull base

Ensure you can do a slick GCS Assessment + management of the sick patient.

Get access to ORION (NRS - neurosurgical referral system). Ask SpR Alexis Joannides. This is useful when on call as you will know who is coming in and what the plan is for the patient (especially if SpR busy in theatre) Also, get access to TRAD (which will allow you to see scans performed at other hospitals) by phoning the PACS office.

A weekly rota will be sent out sometime during the preceding weekend allocating you to one of the following ward areas:

1. A3 + adult outliers

2. A4 + paediatric outliers

3. A5

4. D6 / J2

SHOs are therefore ward-based and not firm-based such that you will need to liaise with numerous consultant-led teams within the department throughout your shift.

Most paediatric outliers will be on wards D2, C2, C3, G3 or D10.

There are a number of consultants who work within the neurosurgical department. Between them they cover each of the main sub-specialities e.g. vascular.

Each consultant has their own allocated registrar and a clinical nurse practitioner (CNP). The clinical nurse practitioners have a wealth of knowledge and are incredibly helpful for sorting out any and all issues that may arise during a normal working day. They even do discharge summaries!

Rotation between different wards as mentioned above.

1-2 sets of nights per rotation (a set of nights includes an initial 4 nights on call followed by 3 nights on call with 6-7 days off in between).

An average of 1 weekend a month, which is one of the following shifts:

- Long days weekend on call (the toughest shift you will do on this placement!)

- Short days weekend on call (leave at 12:30 pm)

- NCCU weekend (leave at 4 pm)

9 Days annual leave per placement as for other placements in the FY2 year.

Ward work.

Ward work.

Ward work.

Theatre / clinic time if you finish your ward work.

During nights you will get the opportunity to spend time in theatre and learn a few procedures e.g. burr holes (only if you are interested - you will not be forced to do this otherwise!).

Brief handover from night SHO at 8am in the SHO office. Go to ward. Teams visit at unpredictable times throughout the day from 8 am to 6 / 7pm. Do your own ward round. Arrange tests requested by team. Manage ward throughout day. Hand over to on call SHO at 6pm who carries bleep until 8pm when they then hand over themselves to the night SHO. It is then a good idea for the night SHO to catch up with the night SpR who will be receiving hand over in the SpR office from the day SpR. This is very useful as they will then know what to expect throughout the night in terms of admissions. It will then also be possible to discuss what management will be required for these patients.

Airway management

At least once during this rotation, you are likely to be required to manage a patient who has dropped their GCS and is no longer managing to protect their airway. This can be scary at first, as it is a scenario that is not encountered as frequently outside of neurology and neurosurgery. The key is to be methodical and to be overly cautious in your approach. If the GCS is 8 or less, is not maintaining their oxygen saturations or the patient is snoring / has audible stridor, you should be concerned the airway is not protected. Have a low threshold for inserting a Guedel airway - if you are unable to do so, insert a nasopharyngeal airway. Ensure you are familiar with how to size and insert these adjuncts prior to starting the placement (it may have been a while since you did ALS!). Airway adjuncts can usually be found in ward stores, however if there is any delay ask the nursing staff to open the crash trolley where they will definitely be present. Ask a member of the nursing staff to call the rapid response nurse - in these situations, they are often extremely helpful as they attend promptly, are probably more experienced than you with basic airway management and are the best way to get an anaesthetist to attend promptly if appropriate. Asking the NCCU clinical fellows can occasionally be helpful, however not all of them are happy to review patients on the ward in this manner. If you think the patient is deteriorating too quickly or help is not coming as quickly as you would like, do not hesitate to put out a cardiac arrest call - it is a sure fire way to get you an anaesthetist quickly.

Once you think you have an airway secured, inform the neurosurgical registrar. Whether the patient has dropped their GCS postoperatively or while in transit from a local hospital, they are likely to require a CT head (which you will likely have to accompany the patient to scanner for) +/- surgical intervention (for example, a re-do craniotomy after an evacuation of a chronic subdural haematoma or an EVD for a patient with obstructive hydrocephalus secondary to posterior fossa haemorrhage).

Seizures

Again, seizing patients are encountered much more frequently on the neurological and neurosurgical wards than on general medical and surgical firms and new SHOs often feel uncomfortable in their management at first. Have an ABCDE approach - do not be tempted to jump straight in with lorazepam / diazepam! Begin first with their airway (see above). You may need a Yankauer suction catheter to remove blood or vomit from the mouth. Get the patient turned on their side. Ask someone to start timing. Obtain IV access and send off bloods (FBC, U+Es, CRP, Mg, Ca). Get a BM (hypoglycaemia is a common cause of seizures). If the seizure lasts for a few minutes without self-terminating, administer either IV lorazepam (2-4mg IV) or PR diazepam 5mg). Unless you are very confident in the management of seizures, I would call for senior help (neurosurgical SpR, RRT, NCCU clinical fellows, crash call if desperate) if it has been going on several minutes and hasn't been terminated by a dose of IV lorazepam (most episodes are). Inform the neurosurgical registrar when the seizure is terminated - they may need a CT head urgently. Depending on the situation (for example, following severe TBI), it may be appropriate to load the patient on levetiracetam or phenytoin after 1 seizure (if they are already on one, consider re-loading or load on the other). If they have 2 or more seizures, you should definitely load with one of the above. Bear in mind the patient is likely to be significantly drowsy and/or confused following the seizure (the post-ictal period - including, for example, persistently tolerating a Guedel airway) - this will often improve over the course of 5-20 minutes; if it does not, arrange senior help.

Common cases

Subarachnoid haemorrhage (SAH):

Patients admitted with SAH get placed on the aneurysmnal SAH protocol. This involves the following:

1. 3 L of fluid / day (depending on GCS this could be PO or IV)

2. Nimodipine 60mg 4 hourly for 21days (assists in prevention of vasoconstriction during the 21 day period in which there is increased risk of further bleed and rupture)

3. Analgesia & anti-emetics (SAH is extremely painful and nausea-inducing; vomiting can increase risk of aneurysm rupture)

4. Bed rest (reduce the risk of aneurysmal rupture)

5. Laxatives (straining at stool can increase the risk of aneurysmal rupture)

6. Regular neural obs (to assess for drops in GCS or changes in pupil size, which might indicate re-bleeds or hydrocephalus)

SAH patients will be transferred from other hospitals for further imaging - CT angiography or DSA (cerebral angiogram). Once the cause of the bleed is identified they are discussed at the vascular MDT and plans are made for either coiling (interventional radiology) or clipping. Coiling is the preferred treatment. Once stable and monitored for a period we try to repatriate to the patient's local hospital for ongoing rehab as necessary.

SAH/intracerebral haemorrhage with interventriclar extension and acute hydrocephalus - these often go directly to theatre or via NCCU to theatre to have an external ventricular drain (EVD) inserted. You will see them once they are 'stepped down' to the ward. The EVD then gets challenged over a period of days as the patients symptoms resolve with close monitoring of GCS. If well-tolerated the EVD can then be removed - measure the opening pressure, taken a final sample, cut the stitch, pull the drain out, single vertical mattress suture. Local anaesthetic is usually not required.

Early repatriation referrals are key to patient turnover here. Be guided by the registrars and consultants.

Brain Tumours:

These patients usually arrive on an elective basis and as such you will usually first meet the patient 1 day 'post-craniotomy & -tumour resection'. They often stay for 1-3 days after which they are discharged on reducing regimens of dexamethasone following their being cleared by physiotherapy (PT). A complication to be aware of in these patients is extradural haematomas, which are sly and can jump up up unannounced with rapid deterioration of GCS.

Spinal decompressions:

Again, these patients are mostly seen post-operatively. Day 1 they will have a PT assessment. They may have a drain requiring removal. Otherwise pain is to be expected. The large majority of patients will be discharged the same day before consultant review. Review the wound, ensure dressing clean and dry and make a note in discharge letter of suture material used and when they should review with GP. We standardly arrange for patient review with GP 1 week later to review wound.

Post-cauda equina - patient may take slightly longer to be back on their feet, but still just a few days. Once again they are safe to be discharged once PT / occupational therapy (OT) are happy and the patient is passing urine (PUing).

Advice spinal decompression patients to avoid heavy lifting and bending over for a minimum 4 weeks. Also advise them not to drive until they feel comfortable that they could perform an emergency stop without hesitation.

Trauma - Skull # + SDH / extra-dural haematoma (EDH):

The main management for these patients is surgical. Most SDHs & EDHs are evacuated overnight and you will get the chance to assist with these if time permits and you are keen. Careful GCS monitoring and reversal of any anticoagualtion is key.

Discuss with the on call haematologist RE the following:

1. Warfarin reversal: beriplex or vitamin K

2. Aspirin reversal: peri-operative platelet transfusion

Drains for SDH / EDH are removed after 48 hours - use an aseptic technique, cut the stitches holding the drain, pull the drain out slowly and steadily and then place a single vertical mattress stitch. No local anaesthetic usually required. Ensure the stitch is removed in 7-10 days.

Abscess & wound infection:

Antibiotics +/- the early involvement of microbiology and/or the infectious disease team.

Common medical issues

Deranged sodium:

DO NOT presume this is SIADH and fluid restrict the patient. Especially in the case of SAH in which deranged sodium is more likely to be cerebral salt wasting and fluid restriction may precipitate vasospasm.

Seizures and status

AKI

AF

Pain management

N.B. always consider medical causes for a deteriorating GCS.

Admissions: elective or emergency (via our A&E or as transfers from another hospital). Emergency transfers can be for further investigation (typically ?cauda equina for out-of-hours MRI spines or intracerebral bleeds for r/o underlying vascular abnormalities) in addition to assessment/work up for surgery. Details of referral/plan on assessments can usually be accessed via NRS.

Discharge: Once medically stable + not requiring further neurosurgical intervention, patients are likely to be repatriated to local hospitals for further rehab +/- institution of package of care if required. To arrange this, phone the medical registrar (via switch) at the intended hospital and give them relevant details (name, age, nsgical problem/intervention, ongoing needs). Remember to document the name of the registrar you have spoken to as well as the admitting consultant on the day (and tell the ward clerk that you've done this) Patients who are local to Cambridge or have specific neuro-rehab needs may be transferred to J2 /Lewin for further rehab.

CT heads: these do not need to be discussed with the on call neuroradiology SpR/consultant. Simply call the CT co-ordinator on 3219 or 3208 (in hours) or 2779 (out of hours).

CT angiograms & CT brain perfusions: the first CT angiogram & first CT brain perfusion do not need to be discussed with the on call neuroradiology SpR/consultant. Simply call the CT co-ordinator on the aforementioned numbers.

Post-op MRIs: these do not need to be discussed with the on call radiology SpR. Simply call MRI reception on 6363 to ensure they have received the request and to find out when the scan will likely take place.

Other head imaging - discuss with neuroradiologist on 2458 (neuroradiology reporting room).

DSA (digital subtraction angiography i.e. cerebral angiogram; done for patients with SAH after their CT angiogram): EPIC request, discuss with interventional neuroradiologist (usually by phoning the angiography suite on 2405 and catching them between cases / leaving a message) and consent the patient yourself (this will be explained at induction). If a patient cannot consent themselves you will need to complete a form 4 consent form (consent form for those who cannot consent), which will require a discussion with the next of kin.

Senior support is variable. Registrars are often in theatre and can be very difficult to contact. Most of them are very friendly, but busy. You can easily check who is in theatre on EPIC and if you need to speak to the SpR or Consultant, just go up to theatres and talk to them (neurotheatres are Neuro 1,2,3 and very often theatre 20 in main theatres - N.B. as of 16/4/16 the neurotheatres are being refurbished so theatre 22 in main theatres is the main neurosurgical theatre). Alternatively, just go to the SpR room and ask for help - you can ask registrars from other neurosurgical teams for help - no one will mind. Outreach team and medical registars are useful when you are dealing with sick patients and have no senior support due to their being unavailable.

You rarely need to bleep the neurosurgical registrars - checking the registrars office and popping into level 6 theatres is the easiest and quickest way to get a senior opinion.

You will be expected to manage medical problems alone so ensure you liase with more senior members of other teams and be careful to document the advice you receive.

There are three hand over periods during the day. One in the morning (8 am) in which the night SHO hands over to the day SHOs, one in the early evening (6 pm) when the day SHOs each contact the evening SHO to hand over any outstanding day jobs, and finally one in the late evening (8 pm) when the evening SHO hands over to the night SHO.

Out of hours can be hectic due to the unstable nature of the patients under our care. Additionally, the number of patients you will be responsible for adds to the difficulty - you will be covering neurosurgery and neurology.

NCCU is the ICU for neurosurgery and neurology patients. NCCU is comprised of a main unit with approximately 18 beds, and an HDU with approximately 6 beds. If your patient needs an escalation of care you can discuss this with the NCCU clinical fellows who are incredibly helpful and very experienced. However, if you wish to refer a patient to NCCU, be that the main unit or their HDU, you must discuss this with the on call NCCU consultant. It is only the NCCU consultant who can accept patients onto NCCU. They are very, very helpful - will tell you what to do in the meantime and will make sure a bed is available for the patient.

Neuroradiology Cons / SpR: 2458, or via switch if out of hours

CT coordinator: 3219, or 2779 if out of hours

Neuroangiography suite: 2405

MRI: 6363

Inpatient X-ray: 2387, or 3121 if out of hours

NSGY SpR on-call: 156-0358

NSGY SHO On-call: 152-357

Rehab SpR: 156-2101

NSGY SpR room telephone: 56167

Neurosurgical theatre reception: 2579

Neuro theatre 1: 2001 Neuro theatre 2: 2002 Neuro theatre 3: 2003

Blood bank: 3130

SDH - subdural haematoma

SAH - subarachnoid haemorrhage

SAH protocol - generally includes the following elements: nimodipine 60 mg 4 hourly, 3 L fluids / day, analgesia & anti-emetics, laxatives, bed rest & neuro observations

CTA - CT angiogram

DSA - digital subtraction angiography

You will start this rotation absolutely hating it. Give it time. Give it a chance. And at the very least, in hindsight, it will have been a great experience.

The skills you learn in neurosurgery are transferable to all other departments. You will be used to assessing GCS without a thought, looking at CT scans with pathology on them, clear as day, managing rapdily deteriorating patients - not only from their neurosurgical pathology (seizures, status, GCS drops, blown pupils etc), but also from repiratory, cardiac and diabetic fronts. You get to perform actual clinical skills beyond simple venepuncture - lumber punctures, shunts taps, infusion studies, drain removal, suturing (so nothing will ever leak again), EVD management & intrathecal antibiotic administration (vancomycin & gentamicin).

This is all in all a great rotation even if you have no interest in doing surgery (I second this comment as another person reviewing the wiki who has done this placement!).

The CNPs are an excellent resource. They will be able to help with any of the patients that they are looking after.

Becky Legge 154-173 ext 2189 - Covers: Mr Travedi (vascular not spines), Miss Fernandes, Mr Crawford, Mr Hay

Eva Nabbanja 152-423 ext 4492 - Covers: Mr Garnett, Mr Morris

Indu Badahur 154-175 ext 2189 - Covers: Mr MacFarlane, Mr Mannion

Mikky Asbey 152-165 ext - Covers: Mr Kirkpatrick, Mr Kirollos

Kristine Harkin 154-174 ext 2127- Covers: Prof Hutchinson, Mr Timofeev, Mr Helmey

Gemma Bullen - 152 090 Ext 56246 - Covers: Mr Price, Mr Watts & Mr Santarius

Jane Easton - 152 350 Ext 4492 - Covers: Mr Vergara & Mr Laing