NANSIG Neurology elective review

Reviewed by: Anna Hay

Destination / Neurology, Vancouver General Hospital, Canada
Time spent / 4 weeks
Supervisor / Dr Robinson
General overview / Vancouver General Hospital (VGH) is the largest tertiary hospital in British Columbia, a beautiful province on the west cost of Canada. VGH is also a teaching hospital, affiliated the University of British Columbia. This elective takes place within the Neurology department – a highly specialized 14 bed unit. The beds are roughly split between general neurology, stroke and a specialised epilepsy monitoring unit.
To do this elective you must be prepared to work within a team and to accept responsibility of your own patients. Each morning at 8.00am, after a brief description of each patient, residents and medical student would be assigned patients. That means for that day they would be under your care, you were expected to do a full neurologic exam, chase of bloods, chase any outstanding test results, laisse with other disciplines (nurses, physiotherapy, other specialties etc.), come up or continue a management plan and document it. Then at lunch time the attending (consultant in Canadian) would join and run the list again, this allows you to voice any concerns about your patients and explain what you had done that morning. The afternoon was dedicated to consulting new patients, this could either be in the Emergency Department or in other wards. You would be sent off with tendon hammer and tuning fork in hand, to go take a history and assess the patient. After having a good think about the presenting patient (if it was not an emergency) you would report back your findings to the attending who then comes to see the patient with you.
Often after the cranial nerve and peripheral nerve examination you would be quizzed where you would localise the problem to. Although quite a challenge this quickly developed my neurological examination as every sign or lack of sign was significant and second year neuroanatomy suddenly became vital. The sort of questions the attending or residents could as you about the consult include: Does this patient have a neurological condition? Is it upper or lower motor? Is it below the brain stem or above? Is it on the left or the right? How quickly did the symptoms start? Is it therefore like to be vascular/inflammatory/oncological…? How have the symptoms change with time? How do we best investigate this? What does the imaging show? (be prepared to quizzed on CT’s, MRI’s and cerebral angiograms) What are the treatment options? Is the patient likely to return to baseline? What sort of care or rehabilitation are they likely to need after discharge? You are not expected to know the answer to all these questions – but being asked completely engages you and escalates your own learning. If the patient is then admitted you can follow-up on them and if their investigations include a lumbar puncture you may get to opportunity to attempt it!
I don’t have even nearly enough space to write about all the fascinating cases I saw but I’ll quickly list a few: Guillian Bare Syndrome, Brown-Sequard Syndrome secondary to transverse myelitis, sensory ganglioapthy, parkinsons – plus syndromes, Moyamoya disease, refractory status epilepticus and every type of stroke in any location. One day in the ED, in opposite beds we had one patient with Broca’s aphasia and the other with Wernicke’s aphasia – textbook!
I chose this elective as I believed neurology to be my weakest clinical area, I had no insight into this specialty – I am now completely hooked and am even considering applying to the residency programs here in Canada! My clinical skills and decision making skills have vastly improved which has given me a lot more confidence as I soon approach becoming a qualified doctor. I would highly recommend this elective as long as your prepared to work hard!
Research opportunities / You could write a case report.
Social opportunities / Vancouver is a wonderful vibrant city, there are beaches to relax on, mountains to climb and nearby wilderness to explore at the weekends. I made friends with other elective students in the hospital.
Any other comments? / Be warned the rent in Vancouver is very expensive. Dr Robinson is the course organiser but you never meet him – you meet the other attendings who work at time you are visiting. He does however leave a very helpful concise textbook. To apply for electives in British Columbia you must go through the official UBC application process in January – so there’s no point emailing doctors. For more information about the application go to the UBC elective website.

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