First of all, thank you all so much for your support while I blog intermittently though residency- all your nice comments mean SO much to me!!!
Now, onto Neurology! (Mayo just ranked #1 in the country for neurology! It also ranked #1 for 8 other specialties I think… it’s a pretty great place!)
My intern year at Mayo consists of 12 months of different rotations. I get 3 months of electives (I chose research, neuro-radiology, and ophthalmology clinic) and 1 month of float which means I sit at home until I get called in to cover for another intern who’s sick, has an emergency, has a baby, that kind of thing. The 8 other months are required rotations and include: Neurology, GI, Cardiology, Hematology/Oncology, Emergency Department, ICU, and 3 months of regular medicine. I started with Neurology and I am SOOOOOO glad because it’s a very relaxed month with a small patient load. It has allowed me time to learn the system and figure things out without having to juggle 8 patients at once while working 80 hours a week and being exhausted. I’ve only been working about 60 hours a week (sometimes a little less) and it’s glorious.
The neurology service is divided into 3 different teams: the consult service, the general neurology service, and the stroke service. This month, I spend 1 week on consults, 2 weeks on general neuro, and 2 weeks on stroke.
I started on consults.
Consults happen when a patient is in the hospital for a non-neurology reason, but happen to have a neurology problem. For example, the patient might be in the hospital for a heart attack, and it is later discovered that they had a stroke during the bypass surgery. Or, maybe they are in the hospital for a blood stream infection and they happen to have a history of epilepsy. The regular medicine service might consult neurology to come see the patient and make sure they are on the right anti-seizure medications. Stuff like that.
Consults were a great place for me to start because I got to practice the neurologic exam. When we do a full neuro exam we go from head to toe and test everything. We start with mental status and ask a patient who they are, where they are, what the date is, who the president is, etc. We can do a more thorough mental status exam if needed. That might include things like testing for attention, “I’m going to tell you 6 numbers and I want you to say them back to me” or recall, “I’m going to tell you 3 words and I want you to remember them. Apple, penny, table.” Then 5 minutes later we ask them if they remember those 3 words.
We also can test mental status by having a patient draw a clock or copy a cube. If a patient has a lesion on one side of the brain, they may “neglect” the opposite side of their world. There isn’t anything wrong with their eyes, but they don’t see things on the left side of the world anymore. I stood at the left of my patient and realized they were facing right and never once looked over at me. Once I moved to the right of the bed, they looked me in the eye. When I asked them to draw a clock, it looked something like this:
I had also asked them to copy the cube I drew on the left of the paper, and you can see their drawing. Isn’t that facinating? I think the brain is such a mystery, and the neurologic exam lets us see so much of how it works.
After testing mental status, I test cranial nerves by testing vision, muscles in the face, the tongue, hearing, sensation in the face, and strength in the shoulders. I test strength and sensation in the arms and legs. I test reflexes in the arms and legs as well. Reflexes are super cool. If you have a lesion in your brain or spine, or upper motor neurons, your reflexes will be increased or hyperreflexic. If you have a lesion in your peripheral nervous system, or lower motor neurons, your reflexes will be diminished. All kinds of things can influcence reflexes and they can also help us locate the lesion causing the symptoms. Lastly, reflexes are more objective than other neurologic exam findings (in my opinion) and are good to document to help follow patient progression.
After my week on consults I switched to the general neurology service. Day shifts are either long call (7am-8pm), night call (7pm-11am), or a normal day (7am- 5 or 6 pm). I generally get to the hospital around 6:30 to see my patients and start writing their notes. Our daily tasks are written on a big white board in our team room so we don’t forget:
Then we round as a group which lasts until around noon. The other interns and I escape for noon conference and lunch, and then get back to work around 1pm. We take new admissions, follow-up with things our patients need, go to afternoon lectures, read, and work on discharging our current patients. I’ve found that the most time consuming things are coordinating care between other facilities. I had one patient whom I discharged needing follow-up with three different medical specialties. I spent all day calling different doctors trying to set up appointments for my patient. If I didn’t set up those appointments, the patient would have left the hospital and gone to their nursing home and then never had follow-up with the surgerons and medical specialists this person needed to see. You have to make sure your patient will be okay once they leave your service- it’s too easy for them to fall through the cracks.
If I’m not on long call, I’m generally out of the hospital before 5 or shortly after. Mayo lets you set up a remote system at home so you can log in and check on your patients while you’re at home. I LOVE this because I can go home and a few hours later see if their labs came back. Or, I can read a note a consultant left on my patient and look things up to read for the next day. It’s pretty great. I can also keep an eye on the service as a whole. If we get 5 new admissions at night, I know to come in early the next day. If there are only 2 patients on the entire service, I know I can come right on time and don’t have to stress about it.
On general neurology I’ve seen lots of patients with seizures, some organic and some non-organic (it’s not uncommon for seizures to be a manifestation of a psychiatric condition not a neurologic problem), I’ve seen multiple patients with brain tumors, I’ve seen patients with big infections in their brain, auto-immune conditions attacking their nervous system, parkinson’s, dementia, and more. I’ve learned SO much. I’ve learned simple things like the normal dosing range of seizure medications, how to give fluid boluses, how to call consults, how to order acid reflux medications, and how to order blood thinners. I’ve also learned not simple things, like how to tell someone their cancer is back, or that they aren’t going to leave the hospital any time soon.
Neurology can be a heartbreaking specialty, because often there isn’t anything you can do for a patient. But, it’s also miraculous and uplifting at times. I had a patient who I saw every day for over a week. This patient had cancer and had an infection in their brain. When they came to the hospital, this person was completely paralyzed on one side and could hardly speak. One morning, I went in to see this patient and asked them to squeeze my fingers, as I had asked every day for a week. To my complete surprize, I felt their fingers grip mine with minimal but unmistakable strength. My eyes met the patients, and they smiled a child-like smile. “I did it!” they said. It was a beautiful moment of pure joy that I got to share with this person. The first bit of movement back into paralyzed fingers- and hopefully just the beginning of a successful recovery.
So, I’m enjoying every bit of my days on neurology, and learning more than I could have imagined!
**Side note- I LOVED my neurology rotation in medical school and wrote about it here. I also talked about how I studied for the exam if you happen to be a medical student interested in that 🙂