Neurology - "R/o metabolic causes"

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I'm wondering how neurology programs work at other institutions. At our hospital, patient's with straight-up neuro signs and symptoms are routinely rejected by neurology as "toxic/metabolic causes" and admitted to us (medicine).

We routinely admit acute strokes, seizure disorders, etc. with no clear secondary etiology other than a "WBC of 11.5", which warrants admission to the hospitalist team for "further work-up". However, the neurology resident also recommends MRI Brain, CTA Head/Neck, etc., etc.

Why does neurology suck so much at our institution?

Originally Posted by MyNameIsOtto

I'm wondering how neurology programs work at other institutions. At our hospital, patient's with straight-up neuro signs and symptoms are routinely rejected by neurology as "toxic/metabolic causes" and admitted to us (medicine).

We routinely admit acute strokes, seizure disorders, etc. with no clear secondary etiology other than a "WBC of 11.5", which warrants admission to the hospitalist team for "further work-up". However, the neurology resident also recommends MRI Brain, CTA Head/Neck, etc., etc.

Why does neurology suck so much at our institution?

I've often asked myself, "When was the last time neurology was actually helpful?"

Originally Posted by jdh71

I've often asked myself, "When was the last time neurology was actually helpful?"

Meh...I give 'em a break most of the time. They have almost no useful therapies and basically function as organic MRI machines. I generally order an MRI brain/X-spine and call a neuro consult at the same time and let whoever gets there first make the diagnosis.

But my favorite neuro consult experience of my residency involved a patient being admitted to the MICU by a total douchecanoe of an ED attending. She had new onset seizures with no obvious etiology and was actively seizing when transported out of the ED. I got the signout as she was being rolled onto the unit. When I asked what Neuro thought of the new onset seizures, said douchebagel yelled into the phone "don't tell me how to practice medicine!" and hung up on me. 5 minutes later, the neuro resident on call showed up in the MICU while we were pushing ativan and took over management. Once the patient stopped seizing, she (the resident) rolled the patient down to the neuro ICU by herself. I got a non-apology apology page from the ED douchewad later that night saying "sorry about the miscommunication on Ms. Jones earlier."

A lot of times it's not so much that Neurology sucks, but that the ED docs are pushovers. The ED docs have power to admit to whoever they want to wherever they want. However, the moment Neuro (and surgery, and ortho, and psych, etc. etc.) says admit to Medicine, guess where the patient goes, regardless of what the ED doc thinks the REAL diagnosis is? It's the path of least resistance.

Does ortho actually admit anything from the ED these days?

Originally Posted by jdh71

Does ortho actually admit anything from the ED these days?

The occasional trauma requiring only operative bone repair without other issues. Otherwise, no. In fact, in our hospital they all go to the hospitalist service automatically.

Originally Posted by jdh71

Does ortho actually admit anything from the ED these days?

How did ortho get brought into this conversation? Ortho and neuro shouldn't even be mentioned in the same context of anything.....

Ortho fixes almost everything it touches, neuro fixes almost nothing it lays eyes on.....

That being said, back to neuro.....with my experience, this is what you get when you order a neuro consult......MRI / MRA, CTA head, EEG of course to r/o seizure, LP of course.....and then about $2 million later........the diagnosis of "toxic metabolic encephalopathy".......gee thanks neuro......

when I attended on IM wards, there were three services that I didn't want my resident to consult without talking to me:

GI (mine)
ID (painful)
Neuro (useless)

Every EEG we get - Diffuse slow waves. Cannot r/o ______ !!
They can identify the 5th branch of a particular artery that caused the stroke but in the end its always ......Aspirin, aggrenox or plavix

Oh my god the world works the same everywhere... I m a third yr IM resident in India..nd its the same here as welll.... lol neuro never takes the waste cva/stroke cases...which basically require a nurse and a physiotherapist... nd for nything we cant figure out..they cant either without like sumone said $2million investigations...hahaha @ i call an mri and neuro and let whoever comes first, make the diagnosis:-D :-D its such a relief to share the frustration....lol and true true IM is the path of least resistance... u know i have a case admitted under IM who was a diagnosed case of ckd was on maintainence HD, went in for renal transplant...during surgery suffered a cardiac arrest..hypoxic brain injury..nd seen by nephro/neuro/cardio/uro...but finally admitted under IM... :/ ;/

^^ lolwut

Originally Posted by gutonc

Meh...I give 'em a break most of the time. They have almost no useful therapies and basically function as organic MRI machines. I generally order an MRI brain/X-spine and call a neuro consult at the same time and let whoever gets there first make the diagnosis.

But my favorite neuro consult experience of my residency involved a patient being admitted to the MICU by a total douchecanoe of an ED attending. She had new onset seizures with no obvious etiology and was actively seizing when transported out of the ED. I got the signout as she was being rolled onto the unit. When I asked what Neuro thought of the new onset seizures, said douchebagel yelled into the phone "don't tell me how to practice medicine!" and hung up on me. 5 minutes later, the neuro resident on call showed up in the MICU while we were pushing ativan and took over management. Once the patient stopped seizing, she (the resident) rolled the patient down to the neuro ICU by herself. I got a non-apology apology page from the ED douchewad later that night saying "sorry about the miscommunication on Ms. Jones earlier."

Pure poetry that only raw fury at another doctor can elicit.

the most common cause of "altered mental status" in the hospital is actually toxic metabolic encephalopathy. if there are no focal signs, this is not likely to be a primary neurologic problem, and the eeg will show "slowing". now if you knew that already, why did you waste the neurology residents time? medicine residents in my experience have a poor basis of understanding of the nervous system, and are generally very confused about what neurologic signs/symtoms mean, or what the purpose of a test is. Every specialty has their own panoply of tests and wants imaging of their own organ. in medicine, it's cbc, chem7, cxr ,ekg...pretty much regardless of the chief complaint. would you dare to consult pulm without a CT first? i doubt it. also the most common diseases in internal medicine are equally incurable. I don't know about you but i've never seen anyone get cured of heart failure or copd. they degenerate and eventually die from their disease. lastly, if your hospital has a neurology ward, you probably have no idea how many "real" neuro cases are going there instead of medicine because all you see are what end up on your service.

Y u mad brah??

Originally Posted by Acherona

the most common cause of "altered mental status" in the hospital is actually toxic metabolic encephalopathy. if there are no focal signs, this is not likely to be a primary neurologic problem, and the eeg will show "slowing". now if you knew that already, why did you waste the neurology residents time? medicine residents in my experience have a poor basis of understanding of the nervous system, and are generally very confused about what neurologic signs/symtoms mean, or what the purpose of a test is. Every specialty has their own panoply of tests and wants imaging of their own organ. in medicine, it's cbc, chem7, cxr ,ekg...pretty much regardless of the chief complaint. would you dare to consult pulm without a CT first? i doubt it. also the most common diseases in internal medicine are equally incurable. I don't know about you but i've never seen anyone get cured of heart failure or copd. they degenerate and eventually die from their disease. lastly, if your hospital has a neurology ward, you probably have no idea how many "real" neuro cases are going there instead of medicine because all you see are what end up on your service.

Originally Posted by jdh71

Y u mad brah??

Originally Posted by jdh71

Does ortho actually admit anything from the ED these days?

Isolated fractures in otherwise healthy patients. Everything else goes through a hospitalist or the trauma service.


I think I've only ever called one neuro consult in two years, and I thought it was a pretty soft call in a depressed/anxious/fibromyalgia bariatric patient, but my attending wanted it.

Originally Posted by MyNameIsOtto

I'm wondering how neurology programs work at other institutions. At our hospital, patient's with straight-up neuro signs and symptoms are routinely rejected by neurology as "toxic/metabolic causes" and admitted to us (medicine).

We routinely admit acute strokes, seizure disorders, etc. with no clear secondary etiology other than a "WBC of 11.5", which warrants admission to the hospitalist team for "further work-up". However, the neurology resident also recommends MRI Brain, CTA Head/Neck, etc., etc.

Why does neurology suck so much at our institution?

yeah.....as a psych resident I recognize our service is equally useless as well, but at least we recommend lesser workups....also we occasionally function as a dispo for you guys.

also, sometimes neuro puts psych in a bind in the er. Obvious example- a psych pt comes in, but the psych person riduclously asked for a neuro consult in the er before accepting the pt. Well neuro comes by, and even though it's a psych pt recommended.....you guessed it....LP and imaging. For only god knows why. So then when psych saw that, they werent going to take the patient. After all, if neuro recommends an LP the person needs a medical workup right? So then the pt ended up being dumped on medicine for three reasons:

1) psych resident ridiculously asking for a neuro consult in er
2) neuro ridiculously recommending an LP
3) the er refusing to do the imaging and LP in the er, which required a quick dispo

what happened was the pt went to medicine of course. LP negative, imaging negative of course. Pt still psychotic as all get out. Psych comes by the next day and recommends inpatient, but there of course are no beds on psychiatry. Then psych put in their usual suggestions, mainly whatever antipsychotic was popular with that attending that month. Then the pt sat on medicine for 7 days while no bed opened up as pts coming from the ER always get preference.....then medicine finally discharged the pt when he was no longer very psychotic.......

and that bull**** happens all the time at some places. Psych is most to blame, but neuro and the er has to take some of the blame as well. And I don't see why you guys tolerate that nonsense.....stand up for yourselfs