A day in the life of a neurology registrar is varied and exciting. Neurologists are interested in conditions of the brain, spinal cord, peripheral nerves and muscle. We see a range of pathology from the common to the extremely rare and are involved in the management of both acute and chronic disease. Indeed, a unique attraction of the specialty resides in the challenge of diagnosis and the vast array of conditions we consider with every presentation. This means we regularly get to use all the letters in our mnemonic for our diagnostic sieve. Due to the rapidity of advancement in understanding of neurological disease, there is never a day in which I don’t learn something new.
An average day on the ward involves meeting the team at 8am. After a handover from the on-call registrar overnight, we start the round. Given that the majority of neurology inpatients are related to vascular events, it typically involves a comprehensive tour of the acute stroke unit. We check the telemetry, blood results and imaging. The rest of the ward rounds involves seeing patients with a variety of neurological conditions including; meningitis, multiple sclerosis, movement disorders and epilepsy. Neurology patients often recover rapidly from their acute flares. This means they are frequently discharged in a timely manner from hospital. After the ward round, we have an opportunity for a team coffee and a chance to discuss the interesting cases from the ward.
A day in the life of a neurology registrar would not be complete without a code stroke. I get a call from my consultant. Mr JH is being sent down by helicopter from Dubbo. He is a 70-year-old right-handed cattle farmer who collapsed while repairing his tractor this morning and has a left large middle cerebral artery stroke. We halt our discussion of cases and notify the relevant teams including anaesthetics, intensive care and emergency. It’s not long before hearing the rumble of the chopper approaching in the distance.
The stroke team and I head up to the roof to greet the paramedics and receive handover on the helipad. We quickly assess and grade his deficits on the way to the angiography suite. Mr JH has a severe mixed dysphasia, right-sided weakness and neglect confirming the occlusion. With all the teams on standby, Mr JH undergoes expedient endovascular thombectomy and is successfully recannalised. At the end of the procedure he is already moving his right side and speaking. When we visit him the next day in the intensive care department his only residual deficit is a very mild arm weakness…
Less than a decade ago, a recovery story like that of JH would have been the exception. But over the last few years, many therapeutic options have arisen for acute stroke management and this sort of result is becoming the norm. There are now emergency thrombectomies, thrombolysis and agents for rapid reversal of anticoagulation. Expedited imaging is a cornerstone of management involving advanced modalities such as perfusion maps and fast magnetic resonance imaging.
An attraction of acute stroke care is the comprehensive multidisciplinary environment in which you get to work. It typically involves interacting with multiple specialties including emergency medicine, radiology, anaesthetics and intensive care. If you work at a centre offering hyper acute therapies, you will be involved in coordinating transfer of patients from far-reaching areas of the state. A highlight of the job is working with the wide variety of health professions in both a challenging but also exhilarating environment.
In contrast to acute stroke, the vast majority of neurology patients are stable and managed as an outpatient. Seeing patients in clinic forms a large proportion of my job. Clinics encompass an array of subspecialties including cognitive neurology, hearing and balance, epilepsy, vascular neurology, neuroimmunology and neuromuscular disorders to name just a few. On a typical day; I may see patients spin and twist on an Omniax machine (a device which looks more suited to a carnival than a hospital), assess suitability for epilepsy surgery or monitor recovery from the first clinical bout of multiple sclerosis.
The field of neurology is rapidly changing. In Australia, neurophysiology is a core feature of training. It involves the qualitative and quantitative measurement of the components of the entire neuro-axis. This is the hands-on part of neurology. Using a range of electrodes and stimulators we are able to diagnose and monitor a multitude of conditions. Common tests which we perform or interpret include nerve conduction studies, electromyography and electroencephalograms.
For those who like procedures, there are a variety of other diagnostic tests and treatments performed by neurologists. These procedures include lumbar punctures, local nerve blocks and botulinum toxin injections. Indeed, with the ever-expanding range of sub-specialties; there are now interventional neurologists. These doctors spend a considerable proportion of their week in the angiography lab performing emergency clot retrievals, vessel stenting and treating aneurysms.
There is an old Chinese curse which says “may you live in interesting times”. It suggests that during times of greatest change also exists the potential for greatest uncertainty. Neurology encompasses both ends of this spectrum. While traditionally considered a diagnostic specialty, rapid developments have led to new technologies and advanced therapeutics. Conversely, there is a lot unknown and undiscovered regarding neurological disease. This lends neurology as a specialty to ample opportunities to be involved in basic scientific or clinical and translational research.
With improvements in neuroscience; new conditions, investigations and treatments are being discovered seemingly on a daily basis. I’m certain that the future holds great leaps forward for medicine and neurology. We certainly live in interesting times. There has never been a better time than now to be a doctor, especially a neurologist!
Please note names and details have been changed to protect patients’ privacy.