So family med this time is without residents, its just me and the doc, which is totally different. I have a lot more responsibility. I basically get to be the doc for the first fifteen minutes with each patient. I have to recommend a plan and have differentials. And its way harder than I thought. I feel like i'm constantly stumbling around.
The doc is female and about 36 or so. She's only 7 years out of residency and basically super chill. I like her because she often forces me to make a decision which is good, but she also doesn't care all that much about times and whatnot. I do stuff to help like vaccinations and ear wax removal (yay...). She is in a practice with 3 other docs and their practice is amazingly functional. Not to mention, that they have drug reps come give us lunch everyday but wednesdays. And i don't find them to be as pushy as everyone says. Most of the time we don't even talk about the drug they're representing.
By the end of the week, I started getting things right. And again I end up with that feeling-- i like family medicine. But the thing is, I can't give up my ER dreams. So I started looking into ER/FM dual residencies. Decided against it because they seem to be more research based (i want to do clinical medicine not lab medicine). But I have to say Family med is now my second choice, if i couldn't pick ER.
Currently, there is immense pressure right about for getting audition rotations, it seems everything is filling up. And I'm kinda freakin out a bit.
Wednesday, February 29, 2012
Wednesday, February 22, 2012
Neuro: HA protocol and eyes
SO we always seem to get these consults about patients with headaches. Its not that nobody else can handle it, its that this neurologist get great rates of fixing them and he can figure out who is faking and who isn't. But his method isn't exactly kosher. He simply judges their 'crediblity' with a series of rapid fire questions that have right and wrong answers but you don't realize them.
The best combo he recommends: Doxepin (an alzheimer drug), Pentobarbitol(anti epilepsy), Fluids, and sometimes involving ambien to help sleep. And these patients always always wake up refreshed with at least a severely diminished headache and a better outlook.
On other notes, many of these intubated, severely brain dead patients present with an odd physical finding that I found worth mentioning-- chimosis. Its swelling of the whites of your eyes (the mucus membrane part). Some patients have more of this than others and of course its possible to be reverable, but you know when you see it: this patient is really really sick.
The best combo he recommends: Doxepin (an alzheimer drug), Pentobarbitol(anti epilepsy), Fluids, and sometimes involving ambien to help sleep. And these patients always always wake up refreshed with at least a severely diminished headache and a better outlook.
On other notes, many of these intubated, severely brain dead patients present with an odd physical finding that I found worth mentioning-- chimosis. Its swelling of the whites of your eyes (the mucus membrane part). Some patients have more of this than others and of course its possible to be reverable, but you know when you see it: this patient is really really sick.
In this picture, it looks more yellowed than usual and it does not extend into the white part of the eye toward the nose. This is because this patient is in a medically induced coma, which means he's unresponsive for a reason, in this case because he had a heart attack. The patients that exhibit less chimosis have a better prognosis. This is not a medical definition just something i have noticed and when brought to the neurologist's attention, he agreed. NEAT!
Tuesday, February 14, 2012
Neuro: Another tragic story
So a VERY cute 16 year old boy came in to the ER today, and we got called for a consult. As usual, I was not informed why and instead of looking at the chart, I just barge into the room and start asking questions (i really gotta learn better).
Turns out the kid hasn't been himself over the last several days. He's been more tired and sleeping for literally days at time. His mom hasn't been able to wake him up without considerable effort. He has said he doesn't feel well about a week ago. And he has even missed school over the last several days. Upon exam, I can only wake him when I get mean and cause pain. He only rouses enough to tell me to get away and answer maybe 2 questions. Oh and I also discover he was diagnosed with leukemia a year and a half ago and has been doing chemo.
I come out completely baffled and the resident pulls me aside. Yes, I knew he has leukemia. No, he wasn't really okay on exam. No, I haven't seen the MRI. Apparently, many kids who are on chemo for leukemia can get a weird problem. Its not really a side effect but we don't really know why it happens, only that is more common than we want it to be. Its a brain tumor, sometimes filled with blood sometimes just dead brain tissue, it grows for about a week. Everyone looks around all somber-like.
They show me his MRI.
This doesn't get better, they tell the parents. And the mom nods, as if she knew all along that her son was dying. We can keep him in the hospital if you want, but there is nothing we can do for him but keep him comfortable. No, the mom says, we'll take him home. He's not having any pain.
I walk out of the room, flabberghasted. 16 and dying? He didn't look like he was dying. But he also didn't really do anything at all. And now all I can think is, he would have been a real-heartbreaker if he'd had the chance to grow up. Happy Valentines.
Turns out the kid hasn't been himself over the last several days. He's been more tired and sleeping for literally days at time. His mom hasn't been able to wake him up without considerable effort. He has said he doesn't feel well about a week ago. And he has even missed school over the last several days. Upon exam, I can only wake him when I get mean and cause pain. He only rouses enough to tell me to get away and answer maybe 2 questions. Oh and I also discover he was diagnosed with leukemia a year and a half ago and has been doing chemo.
I come out completely baffled and the resident pulls me aside. Yes, I knew he has leukemia. No, he wasn't really okay on exam. No, I haven't seen the MRI. Apparently, many kids who are on chemo for leukemia can get a weird problem. Its not really a side effect but we don't really know why it happens, only that is more common than we want it to be. Its a brain tumor, sometimes filled with blood sometimes just dead brain tissue, it grows for about a week. Everyone looks around all somber-like.
They show me his MRI.
I walk out of the room, flabberghasted. 16 and dying? He didn't look like he was dying. But he also didn't really do anything at all. And now all I can think is, he would have been a real-heartbreaker if he'd had the chance to grow up. Happy Valentines.
Thursday, February 9, 2012
Neuro: Big heads
So today saw a baby with hydrocephalus, an increase in the fluid around the brain. In adults, this condition is life threatening because if there is too much pressure... the brain gets pushed out the holes in your skull (called herniation). This means you will die if not treated. But in a baby, the skull is not yet solid, so the fluid just stretches the skin around it and makes them look like they have a really really big head. I've included the CT and I'm sure you can imagine the rest....
Another interesting case, was a post-concussion syndrome. The theories on how to deal with a concussion have changed drastically in the last decade or so as we understand more about how the brain deals with injury. They used to say keep your patients awake for the next 24hours because the were scared of brain bleeds. Then they decided as long as the patient could wake up every 2 hours over the next 2 days then they were fine... and now we say... let them sleep, as long as the CT in the ER is clean.
But some people exhibit symptoms beyond what the CT shows. One guy 26y.o. M who had fallen off a roof a week ago and the chimney (which he was tied to) fell on him! He was miraculously ok, but went to the ER and told to go home after an extensive workup. He was able to sleep but he was constantly dizzy and being macho didn't admit it to anyone. He ended up falling down the stairs hitting his head AGAIN on cement. When i saw him he had a personality change, he was more dull (showing no emotion on his face). He couldn't concentrate enough to count to 10, made lewd comments at me and he was very very angry for essentially no reason. Also the MRI of his brain was clean. This is called post-concussion syndrome. The brain sustained too many bruising injuries and decided to rearrange things to allow other parts to heal (as the neurologist explained). While this happens he will be this way, it can take up to 3 months to get back to normal. And he will always be more prone to falling injuries (once you get one concussion you're more likely to get another). The more concussions he gets the more problems his brain will have. Interesting tho, right?
Another interesting case, was a post-concussion syndrome. The theories on how to deal with a concussion have changed drastically in the last decade or so as we understand more about how the brain deals with injury. They used to say keep your patients awake for the next 24hours because the were scared of brain bleeds. Then they decided as long as the patient could wake up every 2 hours over the next 2 days then they were fine... and now we say... let them sleep, as long as the CT in the ER is clean.
But some people exhibit symptoms beyond what the CT shows. One guy 26y.o. M who had fallen off a roof a week ago and the chimney (which he was tied to) fell on him! He was miraculously ok, but went to the ER and told to go home after an extensive workup. He was able to sleep but he was constantly dizzy and being macho didn't admit it to anyone. He ended up falling down the stairs hitting his head AGAIN on cement. When i saw him he had a personality change, he was more dull (showing no emotion on his face). He couldn't concentrate enough to count to 10, made lewd comments at me and he was very very angry for essentially no reason. Also the MRI of his brain was clean. This is called post-concussion syndrome. The brain sustained too many bruising injuries and decided to rearrange things to allow other parts to heal (as the neurologist explained). While this happens he will be this way, it can take up to 3 months to get back to normal. And he will always be more prone to falling injuries (once you get one concussion you're more likely to get another). The more concussions he gets the more problems his brain will have. Interesting tho, right?
Tuesday, February 7, 2012
Neuro: Brain Death and Organ Donation
Today was a crazy day of extreme ups and extreme downs. As it seems all days on Neuro are. In some ways it is well-balanced that way.
I feel like I must address brain death and organ donation since there are a TON of myths out there about it. For example, if you are an organ donor.... nobody knows it until you are already declared brain dead. So that myth about the doctors not trying to revive you as hard if you have organ donor status, is ridiculous. Trust me, nobody has time to riffle through your pants pockets to decide how hard they are going to work that day... they are busy trying to keep your heart beating.
The organ donation banks are totally separate from the hospital or the doctors. And legally, the doctors aren't allowed to bring it up or discuss it with the family in any way. So the doctors aren't after your organs, we promise.
Also people think 'brain death' is like it is on the movies. A doc walks in looks at a bunch of tests on the chart and says 'he's dead, let's go tell the family' therefore some docs don't give the patient an opportunity to wake up out of a coma. This is not the case. Brain death is made in a period of 48 hours with extensive testing and multiple doctors have to all agree on the same conclusion without talking to each other. Its very complicated and the chances of waking up after meeting the criteria for brain death is absolutely zero Miracles can happen, but not after brain death. Noone has ever woken up after being declared brain dead. You are getting 'brain dead' mixed up with 'coma' totally different.
The neurologist is usually one of the doctors called to assess brain death, since he is after all an expert on the brain. The idea is we are trying to determine "if they are still in there" as the neurologist says. The criteria for brain death is very long and convoluted and I can promise you'd be bored if i went over it, not to mention i'd be bored typing it. But the basic idea is to test the instinctual part of the brain to see if there is any response at all. These are called cerebellar reflexes that are so basic we don't even think about it: pulling away from pain, blinking, moving your eyes when exposed to cold, pupil dilation, etc. We also you use fancy technology like EEGs (Electroencephalograms) to figure out if your electrical activity in your brain is active, sleeping, or not present (there are other options but i don't want to get into that now). There are other ways we can evaluate you including a multidude of testing that has to be done to rule out causes that could be keeping you from responding, like drugs, electrolyte imbalances, toxins, temperature, etc etc.
As I said above, people who are 'brain dead' are fairly simple to ascertain. And they are the easy cases. It's the people who don't quite fit all the criteria and who do have some basic reflexes or some brain activity on EEGs that are complicated. Prognosis is hard to say with those patients.
We had two recently.
The first was an older lady, 88, who we think tried to commit suicide by driving her truck at 70mph off an overpass. She broke at least 3 major bones in every limb of her body and was not conscious. She was intubated, and tho her heart was beating on its own, without medication her heart would not beat fast enough to perfuse her brain or body. She was completely dependent on medical intervention. She did have some electrical activity on EEG and she exhibited some spontaneous movement of her legs that were questionable reflexes vs. seizures vs. voluntary of some nature. So do we recommend that she be unpluged? What are her chances for recovery? These are things the family wants to know. And honestly, we have no definitive answers. Eventually, after much discussion we told the family what we know and left the hard decisions up to them. Do they want to unplug or put her in a nursing home like this and see if she ever wakes up? The chances of people waking up from this sort of thing is essentially none, but her chances of living in a coma or vegetable state is fairly good. So how do you decide what life is worth? In these cases, usually the experts discuss 'quality of life' rather than actual living. Sure her body would get blood and make urine and twitch and blink. But would she ever be able to move, talk, understand, think with purpose? Probably not. So we told them the simple things, the things we could for sure tell them. Her kidneys were dying. her heart needed a constant infusion of medicine and her brain while not dead, will never be in control of her faculties like it was before..... And after a long while, I got paged to the bedside and they decided to unplug her.
On an opposite but equally confusing case, We had a 58 year old man who came in unresponsive. He had no reflexes and no pain withdrawl and no movement. He had a heart attack and was under hypothermia protocol. This is a protocol we utilize when someone has not woken up after being recussitated (CPR) after a heart arrest. The idea is if the body is kept in a lower temperature the oxygen demand of the organs goes down (they need less blood) this gives your brain more time to heal. However, most people have SOME reflexes when on hypothermia protocol. This man did not. We ordered an EEG when they warmed him up (can't declare brain death if they are at a low temp) expecting to declare him brain dead. But we got a call at noon the next day that he was warmed up. We walk in the room and the guy is TALKING. It was as close to a miracle as I've seen yet.
I think its important to note that being unresponsive from a heart attack is very different from trauma is very different from any other brain injuries. The brain is still at least 45% of a mystery, even to the neurologists.And its just as frustrating for us medical professionals as it is for the patients.
Also to end this discussion, the hospital gave me a really expensive parking ticket... say what!
I feel like I must address brain death and organ donation since there are a TON of myths out there about it. For example, if you are an organ donor.... nobody knows it until you are already declared brain dead. So that myth about the doctors not trying to revive you as hard if you have organ donor status, is ridiculous. Trust me, nobody has time to riffle through your pants pockets to decide how hard they are going to work that day... they are busy trying to keep your heart beating.
The organ donation banks are totally separate from the hospital or the doctors. And legally, the doctors aren't allowed to bring it up or discuss it with the family in any way. So the doctors aren't after your organs, we promise.
Also people think 'brain death' is like it is on the movies. A doc walks in looks at a bunch of tests on the chart and says 'he's dead, let's go tell the family' therefore some docs don't give the patient an opportunity to wake up out of a coma. This is not the case. Brain death is made in a period of 48 hours with extensive testing and multiple doctors have to all agree on the same conclusion without talking to each other. Its very complicated and the chances of waking up after meeting the criteria for brain death is absolutely zero Miracles can happen, but not after brain death. Noone has ever woken up after being declared brain dead. You are getting 'brain dead' mixed up with 'coma' totally different.
The neurologist is usually one of the doctors called to assess brain death, since he is after all an expert on the brain. The idea is we are trying to determine "if they are still in there" as the neurologist says. The criteria for brain death is very long and convoluted and I can promise you'd be bored if i went over it, not to mention i'd be bored typing it. But the basic idea is to test the instinctual part of the brain to see if there is any response at all. These are called cerebellar reflexes that are so basic we don't even think about it: pulling away from pain, blinking, moving your eyes when exposed to cold, pupil dilation, etc. We also you use fancy technology like EEGs (Electroencephalograms) to figure out if your electrical activity in your brain is active, sleeping, or not present (there are other options but i don't want to get into that now). There are other ways we can evaluate you including a multidude of testing that has to be done to rule out causes that could be keeping you from responding, like drugs, electrolyte imbalances, toxins, temperature, etc etc.
As I said above, people who are 'brain dead' are fairly simple to ascertain. And they are the easy cases. It's the people who don't quite fit all the criteria and who do have some basic reflexes or some brain activity on EEGs that are complicated. Prognosis is hard to say with those patients.
We had two recently.
The first was an older lady, 88, who we think tried to commit suicide by driving her truck at 70mph off an overpass. She broke at least 3 major bones in every limb of her body and was not conscious. She was intubated, and tho her heart was beating on its own, without medication her heart would not beat fast enough to perfuse her brain or body. She was completely dependent on medical intervention. She did have some electrical activity on EEG and she exhibited some spontaneous movement of her legs that were questionable reflexes vs. seizures vs. voluntary of some nature. So do we recommend that she be unpluged? What are her chances for recovery? These are things the family wants to know. And honestly, we have no definitive answers. Eventually, after much discussion we told the family what we know and left the hard decisions up to them. Do they want to unplug or put her in a nursing home like this and see if she ever wakes up? The chances of people waking up from this sort of thing is essentially none, but her chances of living in a coma or vegetable state is fairly good. So how do you decide what life is worth? In these cases, usually the experts discuss 'quality of life' rather than actual living. Sure her body would get blood and make urine and twitch and blink. But would she ever be able to move, talk, understand, think with purpose? Probably not. So we told them the simple things, the things we could for sure tell them. Her kidneys were dying. her heart needed a constant infusion of medicine and her brain while not dead, will never be in control of her faculties like it was before..... And after a long while, I got paged to the bedside and they decided to unplug her.
On an opposite but equally confusing case, We had a 58 year old man who came in unresponsive. He had no reflexes and no pain withdrawl and no movement. He had a heart attack and was under hypothermia protocol. This is a protocol we utilize when someone has not woken up after being recussitated (CPR) after a heart arrest. The idea is if the body is kept in a lower temperature the oxygen demand of the organs goes down (they need less blood) this gives your brain more time to heal. However, most people have SOME reflexes when on hypothermia protocol. This man did not. We ordered an EEG when they warmed him up (can't declare brain death if they are at a low temp) expecting to declare him brain dead. But we got a call at noon the next day that he was warmed up. We walk in the room and the guy is TALKING. It was as close to a miracle as I've seen yet.
I think its important to note that being unresponsive from a heart attack is very different from trauma is very different from any other brain injuries. The brain is still at least 45% of a mystery, even to the neurologists.And its just as frustrating for us medical professionals as it is for the patients.
Also to end this discussion, the hospital gave me a really expensive parking ticket... say what!
Friday, February 3, 2012
Neuro: the Fly-By
The majority of our patients thus far have been Strokes. Stroke is brain injury due to a burst brain vessel (hemorrhagic) or due to a tiny clot that blogs the vessel that causes the brain to die (ischemic). Such a tiny little cause with so much damage. People actually do come in with text book weakness of a limb, drooping one side of their face, or can't quite talk to you even tho they are trying (aphasia). I read about these in school and spent two solid miserable months trying to learn what lesion went where. But i still feel like i have no idea what is going on. I have no idea why things in text is so much easier to think through than when the patient is staring at you. Maybe because their deficits are just so devastatinig. We use CTs and MRIs to show them the area of the brain that is damaged and usually its something tiny. But the desperation in their eyes says all they want to hear is if it will get better. And again its something we can't answer. So we tell everyone, the rule of 3's : 3 hours to know the extent of the brain damage, 3 days to know if it will start to resolve, and 3 months until symptoms start to stabilize.
One of my patients is 50y.o. F whose name is Bonnie (fake name). She seems fine and talks fine. But when you ask her her name, She responds as such "umehmehmeh. No. That's not right. My name is Umehemeh. Umehemeh! Shit. I know my own damn name. I swear I know it." She goes on like this for quite awhile. Its heart breaking and oddly unbelievable. Its like she's messing with me (maybe too many hours spent in the ER), but she really isn't. And I should clarify it isn't just a certain sound that she can't say, because she can sometimes say her name, the problem in the part of the brain that retrieves thoughts and makes them words. So any question that she has to THINK about (which is probably half of what you say) she can only babble. Talk about frustrating! After spending even 5 minutes alone with her, I began to get uncomfortable, even angry. Not that I acted on it or showed her that. The patience required to be Bonnie is now higher than my threshold and the patience required to be her husband.... I can't even imagine. I get a tiny glimpse of what it means when he said "for better or worse" in his vows.
Speaking of which, one of the residents (did i mention all the neuro residents are ER residents doing their month of neuro?) anyway he discovered that I was not married. Apparently, he had assumed I was and was offended. So he decided that his goal this month would be to try to get me a boyfriend in the hospital. I thought this was hysterical. I've never had guys try to set up a girl before. So I went along with it during out lunch discussion answering a bunch of questions not really thinking he was all that serious. Then he conferred with another couple of residents and they decided on the first candidate, this ortho resident. And they wanted me to 'assess' him so they took me on a 'Fly -by' which consisted of walking past him in the ER about a million times and then finally going up to talk to him and introducing me as a "very single med student." (not obvious at all). It was a funny joke and i went along with it good natured-ly. But then this guy comes up to me the next day and asks what i'm doing this weekend and if I want to hang out. Say what? O.O Crazy Crazy. Since when did the hospital become a dating scene? (please don't say grey's anatomy)
We had one patient who honestly told the neurologist he thought someone was stalking him. Every time he turns around he can see someone try to hide. He was legitimately afraid. I thought, man this guy is crazy, but the neurologist just laughed. Turns out it was his own arm he couldn't get away from. It was so bizzare that i couldn't actually believe it. Probably one of top three weirdest things I've seen yet.
Also on that list. Get called down for a neurosurg consult and we get there and there is a 2 year old boy sitting on the bed looking at us with a NAIL in his brain. Just sticking out. He's just sitting there. Very disturbing. Apparently, he had pulled on a blanket in the garage with paint cans and nails. I guess the nail and the paint can fell just right.... sounds unlikely right? We called child protective services no worries. We pulled the nail out, there in the ER. It was also disturbing. There was no surgery to be done, but the kid hasn't used his left arm since. But we are confident that his brain, as young as it is, will compensate. We hope.
One of my patients is 50y.o. F whose name is Bonnie (fake name). She seems fine and talks fine. But when you ask her her name, She responds as such "umehmehmeh. No. That's not right. My name is Umehemeh. Umehemeh! Shit. I know my own damn name. I swear I know it." She goes on like this for quite awhile. Its heart breaking and oddly unbelievable. Its like she's messing with me (maybe too many hours spent in the ER), but she really isn't. And I should clarify it isn't just a certain sound that she can't say, because she can sometimes say her name, the problem in the part of the brain that retrieves thoughts and makes them words. So any question that she has to THINK about (which is probably half of what you say) she can only babble. Talk about frustrating! After spending even 5 minutes alone with her, I began to get uncomfortable, even angry. Not that I acted on it or showed her that. The patience required to be Bonnie is now higher than my threshold and the patience required to be her husband.... I can't even imagine. I get a tiny glimpse of what it means when he said "for better or worse" in his vows.
Speaking of which, one of the residents (did i mention all the neuro residents are ER residents doing their month of neuro?) anyway he discovered that I was not married. Apparently, he had assumed I was and was offended. So he decided that his goal this month would be to try to get me a boyfriend in the hospital. I thought this was hysterical. I've never had guys try to set up a girl before. So I went along with it during out lunch discussion answering a bunch of questions not really thinking he was all that serious. Then he conferred with another couple of residents and they decided on the first candidate, this ortho resident. And they wanted me to 'assess' him so they took me on a 'Fly -by' which consisted of walking past him in the ER about a million times and then finally going up to talk to him and introducing me as a "very single med student." (not obvious at all). It was a funny joke and i went along with it good natured-ly. But then this guy comes up to me the next day and asks what i'm doing this weekend and if I want to hang out. Say what? O.O Crazy Crazy. Since when did the hospital become a dating scene? (please don't say grey's anatomy)
Wednesday, February 1, 2012
Neuro: the basics
Before I get into all the exciting crazy stories, I should talk about the basics of the rotation first. I am on Neurology. This is different than Neurosurgery. Neurology is about opinions. Neurosurgery is about actions. Seizures, strokes, tremors, think brain and nerve problems. They are chronic and acute, but they are long lasting. Neurons are among 8 types of cells that do not replicate they can't heal. Once a neuron dies, there are only two outcomes. That function is lost forever or another neuron takes over its job. That's the bottom line. If it can be fixed or is temporary, it goes to neurosurgery. If it can be covered up, last forever, or linger in that unknown state where we don't know which way it'll go that's a case neurology. And the million dollar question is always 'will it get better?' That is what neurologists spend their career learning. Most of their job is helping people manage horrible dysfunction. I've always wondered why someone would chose that field. And I did get that answer. There is amazement left to be had with the weird cases that defy logic. There is also those few cases that you witness are miracle recoveries. And those cases are what the neurologists live for.
So at our hospital there is only one resident on each service, Neuro and Neurology. Since you can't work a trauma 1 hospital without a Neurology and Neurosurgery resident in house, the residents of each service would theoretically have to stay in the hospital 24/7 for the whole month. This is illegal and ridiculous. So each resident takes a 24 hours shift taking both pagers with the next day off. This means at any one time there is only 1 person responsible for both Neurology and Neurosurgery. I am with that resident.
The reason this is important is because i'm with that resident during the day. So many of my experiences are those you don't see on a regular neurology rotation. So this is a disclaimer.
Edit: Also all the residents on neuro and neurosurg are ER residents. At least at our hospital there is no residency for neuro.
So at our hospital there is only one resident on each service, Neuro and Neurology. Since you can't work a trauma 1 hospital without a Neurology and Neurosurgery resident in house, the residents of each service would theoretically have to stay in the hospital 24/7 for the whole month. This is illegal and ridiculous. So each resident takes a 24 hours shift taking both pagers with the next day off. This means at any one time there is only 1 person responsible for both Neurology and Neurosurgery. I am with that resident.
The reason this is important is because i'm with that resident during the day. So many of my experiences are those you don't see on a regular neurology rotation. So this is a disclaimer.
Edit: Also all the residents on neuro and neurosurg are ER residents. At least at our hospital there is no residency for neuro.
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