Guide for Residents, Interns, and Students
Neurosurgical Service
Massachusetts General Hospital

This document is intended primarily for the internal use of students, interns, and residents rotating on the MGH neurosurgical service. Others are welcome to browse with knowledge of that fact.

THE NEUROSURGERY RESIDENCY PROGRAM AT MASSACHUSETTS GENERAL HOSPITAL

I. DESCRIPTION

    The length of the Training Program is six years. This includes five years of residency and 12-18 months of expanded training. Six to twelve months of the expanded training year is spent in research and six months in
clinical activity as Assistant in Neurosurgery at the MGH. The five years of Residency Training include seven six-month clinical rotations and 18 months of laboratory research. The mandatory research period is a single
time block between the Senior clinical rotations. There is an additional six months of research, either coincident with that time block or just before the first clinical rotation. There are no clinical responsibilities during the research period.

    We accept two Residents per year. The clinical rotations start on a staggered basis, every six months (January 1 and July 1). The Resident who begins on January 1, spends the six months from July to December in research. With the exception of a three-month rotation at Boston Children's Hospital at the Junior Resident level, all clinical assignments are at the MGH. The sequence of rotations is designed to provide the trainee with clinical experience of graded and increasing complexity with responsibilities appropriate to their level of training. In addition to their responsibilities for in-patient and Emergency Ward care, all residents on clinical rotations participate in the Neurosurgical Outpatient Clinic one day a week. The in-hospital night call schedule is every third night. This is shared by all residents on clinical rotations.

    For purposes of coordinating Neurosurgical Service activities Visiting Staff members are assigned to a clinical team (East or West). The order of resident assignments is such that he/she rotates through all Service teams, thus coming under the supervision of every member of the Visiting Staff. In the final six months of the Chief Resident year, the trainee is directly supervised by the Chief of Service, Dr. Zervas. Thereafter, the graduating Resident completes his/her six months of extended clinical training with a Staff appointment at the MGH. During that period, he/she is in charge of the North neurosurgical team.

II. DESCRIPTION OF CLINICAL ROTATIONS

    In the following sequence, only one resident is assigned to each position at a given time.

1. NEUROLOGY (MGH, 6 months): The trainee shares clinical responsibilities with MGH Neurology residents at the Junior level, taking part in the activities and conferences of that service. This includes familiarization with EEG and other electrodiagnostic techniques.

2. NORTH TEAM JR. (MGH 6 months): This rotation is the trainee's initial exposure to clinical neurosurgery. He/she assists the recently graduated Junior Staff neurosurgeon (during the latter's period of extended training), learning fundamental diagnostic and operative skills and taking part in the daily care of patients assigned to this team. Clinical responsibilities, including Emergency Ward coverage, are carried out under
the supervision of the Junior Attending neurosurgeon and other MGH Staff including Sr. Residents.

3. EAST TEAM JR. (MGH 6 months): The trainee shares clinical responsibilities with the East Senior Resident caring for patients under the direct supervision of the responsible Staff neurosurgeon.

4. CHILDREN'S HOSPITAL ROTATION (3 months): The MGH participates in an exchange with the Children's Hospital Medical Center whereby our Year 2 trainees spend three months at that institution as junior resident.

5. SPINE/EMERGENCY WARD SR. (MGH 6 months): This rotation provides the trainee with concentrated, systematic exposure to the management of spinal disorders. He/she is under the supervision of our senior spine specialist, Dr. Borges, assisting in the operative and outpatient care of his patients. The resident also supervises Emergency Ward coverage during the day and shares in other routine patient care responsibilities. During this rotation, the trainee participates in the activities of the MGH Neuropathology Department, attending teaching conferences and performing dissections.

6. EAST SR. (MGH, 6 months): The trainee is now able to assume a larger role in operative and non-operative management of more complex clinical problems under the supervision of Visiting Staff neurosurgeons on the East Team. The trainee works closely with his/her East Jr. counterpart, overseeing their work and doing clinical teaching. The operative experience is extensive with a special emphasis on vascular problems such as aneurysms, arteriovenous malformations, and occlusive cerebrovascular disease.

7. WEST CHIEF RESIDENT (MGH, 6 months): The responsibilities of this rotation are similar to those of the East Sr. resident except that they work with members of the Visiting Staff. There is an emphasis on technically difficult tumors of the skull base, working under the guidance of Dr. Ojemann, the associate Chief of Service. The operative cases are typically of a complex and sophisticated nature, commensurate with the resident's level of progress. At this level and beyond, there is important responsibility for teaching other residents and supervising their clinical work.

8. CHIEF RESIDENT FOR THE CHIEF OF SERVICE (MGH 6 months): The resident now works under the supervision of the Chief of Service, Dr. Zervas, assisting in the care of his patients.

9. NORTH ATTENDING (ASSISTANT IN NEUROSURGERY MGH) (6 months): During this interval of expanded clinical experience, the trainee has an appointment as a member of the hospital staff and is responsible for the comprehensive care of patients on the North Team. This period allows the finishing Resident to expand their clinical experience in a relatively autonomous setting, while providing for oversight and instruction by more senior staff neurosurgeons. Formal supervision is provided by the Neurosurgical Visiting Staff who hold teaching rounds on a weekly basis. These rounds are regularly attended by members of the Resident Staff and rotating medical students. In addition to these formal rounds, the North Attending and his assistants meet frequently on an informal basis with Visiting Staff members for case management and teaching discussions.


III. TRAINING IN NEUROSCIENCES

    The initial rotation in Neurology introduces the trainee to the fundamentals of EEG and clinical neurophysiology. This provides a basis for later exposure to the neurophysiologic techniques used intraoperatively (e.g. cortical mapping; epilepsy localization; peripheral nerve/spinal cord/cerebral monitoring). We also encourage our residents to attend the intensive two week Neuroscience Course held yearly at The Woods Hole Oceanographic Institute.

    During the Spine/EW rotation, the trainee regularly attends neuropathology conferences, reviews pathologic specimens, and performs anatomic dissections under the supervision of a staff neuropathologist. Throughout
the residency, there is an emphasis on gaining proficiency in neuroradiology. The resident is expected to be familiar with the radiographs of patients, in whose care he/she is involved, and to attend clinical conferences at which x-rays are read and reviewed. There is also the opportunity to attend regularly scheduled conferences in the MGH Neuroradiology Department.

IV. TEACHING CONFERENCES

    The following is a list of the regular teaching sessions and neurosurgical conferences.

• Luncheon Conference with Chief of Service. Problem cases and those of particular teaching value presented. Current resident issues also discussed.
  
• Morbidity and Mortality Conference. Weekly 1-1½ hrs.
  
• Journal Club. Weekly ½ hr. required.
  
• Neurooncology Conference. Weekly 1 hr.
  
• Chief of Service Breakfast Meeting. Weekly 3/4 hr. Discussion of resident and Service affairs and problems.
  
• Neurosurgical Grand Rounds. Weekly 1 hr. Neurology Grand Rounds. Weekly 1 hr.
  
• Neuropathology Conference. Weekly 1 hr. Residents review teaching material and weekly pathology specimens with a staff neuropathologist.
  
• Neuroradiology Teaching Conference. Weekly 1 hr. Review of neuroradiology teaching material with senior staff neuroradiologist.
  
• North Service Visit Rounds. Weekly 1-1½ hrs. North Attending and Visiting Staff member meet to review selected cases under the care of the North Team.
  
• Vascular Conference. Weekly 2 hrs.
  
• Problem Case Review Conference. Monthly 2 hr. Held at MGH and attended by New England Area neurosurgeons for discussion of problematic or interesting clinical problems.

V. UNDERGRADUATE TEACHING

    The Neurosurgical Service at Massachusetts General Hospital, in affiliation with Harvard Medical School, offers clerkships to qualified medical students by individual arrangement. Students considered are generally fourth year medical students and have already had formal exposure to clinical neurology and/or related subjects. In addition, some experience in general surgery is useful, though not required. The duration of the clerkship is for four weeks only.
   
    The Neurosurgical Service, with 1500 admissions and 850-900 outpatient visits a year, has an average daily census of 40-50 patients. One hundred to one hundred thirty surgical procedures are performed each month. This gives the student ample exposure to a wide variety of clinical problems. The student is actively involved in the daily care of neurosurgical patients under direct supervision of the Attending and Senior Resident Staff. This includes participating in daily rounds, assessing selected instructive cases, assisting in or observing operative procedures, and attending the Neurosurgical Outpatient Clinic. The student learns to manage emergency problems through exposure in the very active Emergency Ward. Finally, he or she attends the formal teaching conferences, which are held on a regular basis. The principal purpose of the clerkship is to acquaint the student with common neurosurgical problems, including their appropriate assessment and management. Students who have an interest in some particular aspect of neurosurgery, such as brain tumors, cerebrovascular disorders, functional neurosurgery, spinal problems, or pediatric neurosurgery can arrange to concentrate in these or other areas.

    Interested students should apply in writing to David Berti, Exchange Clerk Program, Registrar's Office, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115. Housing accommodation and parking is not routinely available, and must be arranged by the individual.

VI. MAJOR RESEARCH PROJECTS

    Trainees within the Neurosurgical Service have access to any of the laboratories within the Harvard University System. These include all of the major current areas of research in neurobiology, as well as cell and
molecular biology.

    Within the Department of Neurosurgery itself, the research activities can be grouped in 5 major areas:

    Cerebral Blood Vessels

    Blood vessels are being studied from several perspectives. A major research program concerns the biology of cerebral stroke. Research in this area includes studies on imaging of cerebral blood flow with a variety of
modern imaging techniques. A basic laboratory program studies in vitro systems toward the goal of learning what might protect nervous tissue from interruptions of its supply of glucose and oxygen. Neuroprotective agents such as cooling and neurotransmitter antagonists are currently under study. In addition, laboratory studies aimed at extending the in vitro studies to the in vivo situation are carried out. Commonly ischemia is caused in a neural region, and agents that might reduce the severity of the infarct are tested. These studies have led to introduction of certain therapeutic maneuvers in the operating room, notably mild cooling in patients whose cerebral circulation must be interrupted for surgical reasons.

    A major research area concerns the biology of headache. In the laboratory, the innervation of the blood vessels has been intensively studied. The sequence of events attending migraine have been delineated
using extravasation of tracers as a marker. A new series of anti-migraine drugs is being developed and tested both in vitro and in vivo.

    A major laboratory studies cerebral vasospasm. In the laboratory, isolated dog arteries are perfused in vitro and the factors that constrict and relax them are studied. In vivo, vasospasm may be experimentally induced in dogs by subarachnoid injection of blood. This provides a model in which to test potential maneuvers aimed at reducing the spasm. Recently, a major collaboration with the MGH Laser Laboratories has resulted in a potential new therapeutic invention. High intensity laser pulses are applied at the site of spasm. In dogs, these succeed in relaxing the vessel. Phase 1 trials of this intervention are being planned.

Neural Growth and Regeneration

    A major long-term goal for Neurosurgery is the restoration of damage of function that has been lost due to damage to the nervous system. Two research areas aim toward that goal.

    Work carried out in collaboration with the Department of Neurology involves the attempt to implant cultured neurons into the brains of animals following experimentally induced brain damage. The basal ganglia are the
focus of this work and dopamine-releasing neurons are being implanted into the brain following experimental lesions of the dopamine-containing brain neurons. Similar strategies can be applied to other brain models.

    On the more fundamental level, we are trying to learn the factors that promote the growth of neurons. This is being carried out using cultured cells. A new factor released by immortalized cultured glia has been discovered. It promotes a neurite outgrowth from a variety of projection neurons. Current studies are aimed at identifying and cloning the factor.

Brain Tumors

    The natural history of brain tumors is being studied in collaboration with the Department of Pathology. This work focuses on the mutation or series of mutations that occur in glioblastomas. This work concentrates on the
use of PPCR methodologies to amplify the DNA of biopsy specimens and of archival neuropathology slides. The latter are particularly useful since the outcome is known. A series of mutations have been found to occur in
naturally occurring brain tumors. Many tumors have a mutation of the p53 gene. Another common mutation is amplification of the EGFR (epidermal growth factor receptor) gene.

    A second area of brain tumor research is the use of retroviral therapy against glioblastomas. The goal is to use retroviruses to introduce into the tumors genes that would either kill the tumor cells, later their pattern of growth, or sensitize them to chemotherapeutic agents. One such trial involves the introduction of a gene for thymidine kinase. A number of analogous manipulations are being tested both vitro and in rats.

Intraoperative Monitoring and Imaging

    A major area of clinical research concerns surgery for epilepsy. Candidates for epilepsy surgery are intensively studied by electrophysiological and imaging techniques. Electrophysiologically, implanted electrodes are used to monitor seizure activity in awake patients. PET imaging is used to localize motor and language areas. New technology allows superimposition of the PET images with MRI scans, providing sharply defined landmarks during surgery. A further area of exploration is the use of virtual imaging in the operating room.

Cellular Neurobiology

    Within the Department of Neurosurgery there are also laboratories of fundamental neurobiology. These are concerned with various aspects of neuroanatomy and neurophysiology.

    One area of focus is the cell biology of the retina. The retina is used as a model system for studies of how small neural networks operate computationally upon their inputs. This laboratory uses anatomical methods and combined anatomy/physiology studies of in vitro retinas.

    Another area of research concerns the biology of membrane proteins, particularly the Na,K-ATPase. These studies are aimed at understanding the heterogeneity of the Na,K-ATPases in the brain and their regulation.

Services

• Primary areas of neurosurgery (very roughly)
  • North (general neurosurgery, trauma, spine, pediatrics, emergency ward)
  • East (vascular, stereotactic, functional, epilepsy, and trigeminal neuralgia)
  • West (brain tumors, skull base, spine)
  • South (pituitary adenomas, pediatrics)
  • Conferences
• Coverage Responsibilites (and procedures)
• Referrals
• Trauma Evaluation
• Subarachnoid Hemorrhage Evaluation
• Pre- and post-operative Routines
• Procedures
• Note on the organization of the Service

I. North:

Attending (secretary 6-3776):

Junior:

Intern:

• General Surgery Rotator (page operator will know as the "North Neurosurgery Intern")

II. East: :

Visit Staff:

Resident Staff:

Senior Resident:

Junior:

III. West:

Visit Staff:

Resident Staff:

Chief:

Junior:

• Neurology Rotator (page operator will know as the "West Neurosurgery Junior Resident")

IV. South:

(covered by East Service for call purposes unless South Resident is on call)

Visit Staff:

Resident Staff:

Chief:

V. Teaching Senior Resident (Spine /Neuropathology):

Conferences

Monday

9:00 AM Cox one conference room, Brain Tumor Board Conference (no pathology)
2:00 PM White-12 Library Movement disorders pre-surgical Conference
4:00 PM WACC-7 Endocrine conference room Neuroendocrine/Pituitary Rounds

Tuesday

11:30 AM MEEI third floor conference room, Brain Tumor Board Conference

Wednesday

7:15 AM Basement Cafeteria Chief's breakfast (once a month)
12:30 PM Mixter Library (Edwards-4), lunch with Dr. Zervas , case presentations
5 PM Ellison-12 conference room joint orthopedic/neurosurgical Spine Conference (biweekly, confirm with Dr. Borges's office, 726-6156)

Thursday

7:00 AM Quality Assurance Conference, Ether Dome, Bulfinch-4
8 AM Ether Dome, Grand Rounds.
9:00 AM Mixter Library (Edwards-4), Journal Club.
10:00-12:30, WACC-835 NORTH SERVICE CLINIC: REQUIRED !!!
5 PM Ellison 12 Conference Room, Visit Rounds, case presentations.
6 PM Blake-1 Auditorium Skull Base Surgery Rounds with otolaryngology, (first and third Thursdays of each month--confirm with Dr. Barker's office (726-3801).

Friday

7:00 AM White-2 reading room, Vascular conference, case presentaions

Saturday

10:00 AM Blake-1 Auditorium Interesting Case Conference on the first Saturday of each month during the academic year. Area neurosurgeons are encouraged to present cases for discussion at this conference.

Coverage Responsibilites

EMERGENCY WARD COVERAGE Head CT 6-6760

The neurology resident rotating on the West service will cover the emergency room from 5pm to 6:30am on a rotating basis with the junior neurosurgical residents. Coverage from 6:30am to 5pm is by the North junior. However, if he/she is in the OR then the person on call that night covers. If that person is also in the OR then the neurology rotating resident will cover. If, however, the neurology rotator is post-call or in clinic then the neuropathology resident covers. The types of EW evaluations are: TRAUMA, consults, and direct referrals from an outside hospital to either a specific staff member or to the North Service (if no other attending has been arranged in advance).

There is currently an EW beeper, which is to be passed to the person covering the EW.

The EW resident who sees the patient is responsible for the complete admission note and orders. The resident to whose service the patient is being admitted should be called and filled in once this is completed.

GATA (Pre-admission) work-ups are done by the residents on the service of the admitting physician. This includes junior and senior/chief residents. If these residents are in the O.R. then the person covering the emergency room is responsible. As always, any resident out of the O.R. may be recruited by this person as necessary (preferably in order of increasing seniority). Our pride and reputation as a service hinge remarkably on an enthusiatic availability to answer EW and GATA calls.

House Service Consults (in-patient) are performed by the North Junior and should be referred to him or her. At night the Senior resident on call is responsible for all in-patient consults.

Referrals

1) Always accept outside emergency referrals of a neurosurgical nature, with the exception of multi-trauma (which is referred to the Surgical Senior Resident in the Emergency Ward--they also accept all referrals) and as noted below- Obtain the patient's name and pertinent info, hospital name and number, referring physician's name, estimated time of departure. Remember to request the FILMS!

Our instructions from Dr. Zervas are to accept all neurosurgical pateints regardless of bed availablity in the ICUs or the EW, without giving the referring physician any runaround. For primary intracranial hemorrhages it is often appropriate to discuss matters with neurology or if the hemorrhage is supratentorial and small to arrange for them to come directly to neurology. (Ideally just accept the patient, then make arrangements.)

For trauma they will ask you about mannitol, dilantin, steroids, etc. In general, do not use steroids in trauma (except spinal cord injury which requires the methylprednisolone protocol). Do administer mannitol (50-100 gm i.e. 1gm/kg bolus) and hyperventilate (pCO2 27-32) in cases with mass effect/global neurologic deficits, only if this will not significantly delay the transfer (i.e. sometimes it will take an hour to intubate the patient ). Dilantin (1g iv over 30-60") is given in cases with supratentorial contusions and/or SAH, but again this should not delay transfer. Specifically ask that sedation and muscle relaxants be withheld when possible. For helicopter rides they will need these, however, as the transport may not be safely done without total control of the patient. In this case recommend dilantin load strongly.

Spine trauma patients with para- or quadra-paresis need a foley and a nasogastric tube immediately.

Acute spine trauma (or question of stability) without a neuro deficit goes to orthopedics (by long tradition) [unless an MGH neurosurgery attending has already accepted the patient].

Back/neck pain referrals alternate between orthopedics and neuro-med. The EW front desk (4-4100) knows who is on as should the page operator.

-For subarachnoid hemorrhage (SAH) refer to later section.

2) Call EW triage 4-4141 with the info for transfer.

3) If it sounds like the patient will need ICU care, you may call the Neuro ICU charge nurse "just to let them know" at 6-8071 and see if a bed in the ICU or intermediate will be available depending on your suspicion on what the patient will need, i.e. arterial line, ventriculostomy, etc. require ICU; If no neuro ICU bed is available and the patient needs ICU care try the GRACU (6-8905), then the RICU (6-8975) (The fellow in these units usually doles out the beds, but you may start with the charge nurse or the resident).

4) Notify the Senior Resident about the expected transfer. If needed, also notify the visit. [After going over the case with the Senior resident the visit will decide if the patient is to be admitted.]

5) In cases of multi-trauma the referring EW will usually contact the General Surgeon in the EW. Make sure that they are informed about and involved in any transfer involving trauma.

Trauma Evaluation

The initial neuro exam is done immediately and the time of the exam should be noted. The key features of the exam include:

1) General Findings: palpation of the head for lacerations and fractures, inspection of ears and nose for blood or CSF, examine fundi/discs, note presence/absence of Racoon's eyes or battle signs (denoting basilar skull fracture), palpate the neck and back for tenderness, hematoma etc., listen to carotids for bruit, extremity trauma as well as general state hemodynamic stability, temperature etc. should be noted briefly.

2) Neuro Findings:

A. Mental Status should be noted to the extent possible, e.g. comatose, obtunded, somnolent, confused, agitated, cooperative, orientation, speech, comprehension.

B. Cranial Nerve exam, which in a comatose patient is limited to only pupils, oculocephalics (once C-spine is cleared) or calorics (once TM's are cleared), corneals, facial grimace to supra-orbital compression, gag and cough.

C. Motor/ Sensory/Cerebellar exams in an awake patient.

D. In the more likely setting for a trauma eval. the only form of motor and sensory exam will amount to a Glasgow Coma Scale:

Eyes Opening	Spontaneous	4	
To verbal command	3	
To pain		2	
No response	1
Best Motor Response	Obeys verbal command	6	
Localizes pain		5	
Flexion-withdrawal	4	
Flexion-abnormal	3	
Extension	2	
No response	1
Best Verbal Response	Oriented, converses	5	
Disoriented, converses	4	
Inappropriate words	3	
Incomprehensible	2	
No response	1
Total		3-15

E. Reflexes: deep tendon & Babinski, Note in spine trauma: Hoffman, abdominal, cremasteric, bulbocavernosus & clonus.

Subarachnoid Hemorrhage (SAH)

Often times the patient will be referred to a private attending and will be known to have a SAH prior to your evaluation and may even come with an angiogram demonstrating the anuerysm(s). Other times you will be the one taking the referral from an outside hospital. In any case, always question the assessment made at the outside institution until you have confirmed it to your own satisfaction, e.g. headaches are not usually evaluated most efficiently by the neurosurgical service. But always try to get the referring physician in touch with the appropriate service.

The neurosurgical attending on call should be informed of all SAH admissions, for unassigned patients this is usually taken care of by the North Service attending. If Drs. Cosgrove, Chapman, Borges, or Ojemann are on call the vascular attending (Dr. Ogilvy) may be consulted directly.

Grading of SAH (Hunt-Hess Classification)

Grade Description

     0		unruptured aneurysm
     1		asymptomatic or mild HA and nuchal rigidity
     2		moderate to severe HA, nuchal rigidity, +/- cranial nerve palsy (eg. III, IV, VI),
     3		mild focal deficit, lethargy or confusion
     4		stupor, moderate to severe hemiparesis, early decerebrate rigidity
     5		deep coma, decerebrate rigidity, moribund appearance

The initial evalualtion of a SAH patient is similar to the trauma neuro-evaluation. Another feature with these patients is that they often have cardiac problems, either associated with the SAH or prior history. They will frequently be hypertensive and one of the first therapeutic moves is to place an arterial line and control their blood pressure with nipride or TNG. All patients are treated with Nimodipine 60 mg. po q4 hrs. x 21 days. Central lines are also needed for i.v. b.p. meds.

If airway protection is an issue make it so that it is no longer an issue; that is, intubate once the baseline exam is obtained and make sure RICU knows to carefully control the BP during intubation. The other measures include: dilantin load (1 gm IV routinely); mannitol, if the scan shows hydrocephalus and the patient is obtunded, to temporize before a ventriculostomy can be placed; decadron (4-10 mg IV) for headache and pre-op preparation.

All Grade I through III patients should have 4-vessel cerebral angiograms as soon as possible, if they are stable. This can be arranged through Neuroradiology (6-8320) during the day and by paging the fellow on-call at nights (6-1818). Before this stage you should have reviewed the case with the attending on the case to make the decision regarding going ahead with an angio. In addition, he may want to perform a ventriculostomy or repeat CT etc. before commiting the patient to a long procedure.

Those patients who are Grade IV + may be good candidates for EVD (external ventricular drainage) if the CT demonstrates hydrocephalus. If the grade improves to Grade III or better then an urgent angiogram is still indicated as surgery would be done urgently. If there is no improvement then the angiogram can be done in a less urgent manner and the specifics of timing must be addressed with the attending.

Pre-Op and Post-Op Routines

Write a pre-op note in the chart with the following sort of format as a checklist:

• Labs (lytes, BUN, Cr, CBC, plts, PT/PTT, and anticonvulsant level)
• UA
• EKG
• CXR
• T+C 2 units (for big vascular cases 4 units)
• Consent
• Orders

Write pre-op orders:

• NPO after midnight
• thigh high TEDS and airboots on call to OR (for ambulatory patients).
• Void on call to OR
• Pre-op meds such as steroids (e.g. 10 mg p.o. at night--10 mg i.v. on call), cimetidine (e.g. 400 mg p.o. at night--300 mg i.v. on call), anticonvulsants, sleep med, antibiotic on call (e.g. 1 gm Ancef or Vancomycin on call, i.v.)
• IVF if scheduled as second case

Write a post-op check on every patient, with a format similar to a progress note. Include:

• Subjective/Events
• VS and I/O's
• Wound check, general exam
• Neuro exam
• Labs
• A/P

Procedures

1. All procedures (arterial line, lumbar puncture, central line, lumbar drain, ventriculostomy, bolt, etc.) should be documented in red ink. Signed consent is required (except in cases of emregency when patient unconscious/incompetent and no N.O.K. available-document your attempt to contact them). In the case of central venous lines & Swan-Ganz catheters, CXR results should also be noted in the chart.
2. The senior resident is available to instruct and/or oversee any procedure.

Note

The neurosurgical service is organized in a heirarchical fashion. Residents are encouraged to utilize this chain of command (which is occassionally followed to the chief of the service) for questions or supervision whenever needed. Use of these resources allows us to acheive our combined goals of optimal patient care and education.

Also see the MGH History of Neurosurgery Homepage
or the MGH Neurosurgery Alumni Homepage
or the Guide for Intern, Residents, and Medical Students
or Neurosurgical Education Links
or Other WWW Resources of Neurosurgical Interest.