Equipment for Neurologists

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obieards

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What equipment are must haves for neurologists? My mentor at school suggested the following:

Hammer (I have a Queen Square; how's the collapsible?)
128 tuning fork
256 tuning fork
Opthalmoscope (regular or PanOptic?)
Otoscope
OKN strip
Pinhole
Transparent red glass or lens

What (else) should I purchase, and where should I purchase? I found this site (US Neruologicals) but is it good? What equipment do you have and where do you buy YOUR equipment?

Thanks!
 
Queen Square hammer - great, collapsible usually fall apart so regular preferred
128 tuning fork - great
256 tuning fork - trash
Ophthalmoscope - highly recommend the panoptic if you have the cash
Otoscope - trash
OKN strip - trash
Pinhole - trash
Transparent red glas - trash unless going into neuroOphth

Other
Box of small safety pins
Stethoscope
NIHSS Cards (I think you can get these for free from some website)
Penlight (the welch allyn with the green switch is pretty awesome, but new ones with super bright LED's are good too)
 
Head said:
Penlight (the welch allyn with the green switch is pretty awesome, but new ones with super bright LED's are good too)
Click to expand...


Would you be kind enough to post a link for the LED light you recommend b/c I can't seem to find one from Welch Allyn. Or if anyone else could recommend a particular LED model, that'd be great. Thanks!
 
I have an Energizer brand LED flashlight that takes 2 AAA batteries. I don't know what the model number is, but I picked it up at Office Depot.
 
I use a mini-MagLite. Also, I found that an OKN strip does come in handy from time to time as a resident, and since it takes up only a modicum of space and weight, it is worth having in the ol' dork-bag. It's nice to whip out during rounds from time to time.

Don't waste money on a collapsible reflex hammer. While I definitely know people who used them throughout residency, the tried and true Queen's Square is the best for general use. A Tromner is also perfectly acceptable, and also allows for muscle percussion, but these are typically more expensive and can be quite heavy.
 
Also in my bag:
Maxalt- for those particularly stressful, headache inducing days
TPA exclusion criteria card
Copy of Plum article on predicting outcome of hypoxic-ischemic coma
Pictures of my then 2 year old daughter (now a second year med student) taking her Puffalumph's blood pressure
 
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are the old triangle-headed reflexes hammers okay or should medical students invest in the queen square ones?

EDIT- and can anyone elloborate on why 256Hz tuning forks are trash? I was thinking they might be a good compromise between 512 and 128 so i could use the same one for hearing and vibration sense testing
 
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Sensation for 128hz is not the same as sensation for 256hz, nor is hearing. So if all your colleagues have the former, and you have the latter, then you'll be comparing apples to oranges. When you re-examine patients seen by your colleagues, how will you know if the exam has changed?

I've never liked tomahawk hammers because they are just plain harder to use due to their short size and light weight. You sacrifice efficacy for portability. As a med-student, you should be using a type of hammer that allows you to get the best and most replicable reflexes possible, which is probably not the tomahawk type.
 
Raygun77 said:
are the old triangle-headed reflexes hammers okay or should medical students invest in the queen square ones?
Click to expand...
Queen Square hammers are really the best for delivering maximum wallop given the combination of mass, length, and a little flexibility. They are not practical to carry around, though. I have impaled my thigh with one sticking out of the end of my bag.

For a combination of mass and portability I like the Troemner hammer. You can get some relatively cheaply and there are some fine precision machined German stainless steel ones that are very nice.

The little tomahawk hammers are completely useless.
 
neurolddoc said:
The little tomahawk hammers are completely useless.
Click to expand...

Funny you mention that. The first day of my neuro subI as a med student, the dept chair reached into my pocket, grabbed my pharmaceutical-rep obtained reflex hammer (tomahawk-type) and tossed it in the nearest garbage can. He then handed me his Tromner and let me use it until I got one of my own. It's amazing the difference in effort and quality of reflexes elicited with a good hammer.
 
On of the pleasures of being a neurologist is reaching into your bag and pulling out exotic equipment and wielding it in authoritative fashion. Hence the market for all manner of sometimes quite expensive hammers.

One amusing anecdote about the Queen Square hammer; All through a consultation, a patient had been suspiciously eying the large QS hammer standing upright on its base on the bedside table. When I picked up the hammer during the exam, he recoiled slightly but then looked relieved after I hit his biceps tendon. "Thank God" he said, "thought that was for internal use."
 
PhakeDoc said:
Funny you mention that. The first day of my neuro subI as a med student, the dept chair reached into my pocket, grabbed my pharmaceutical-rep obtained reflex hammer (tomahawk-type) and tossed it in the nearest garbage can. He then handed me his Tromner and let me use it until I got one of my own. It's amazing the difference in effort and quality of reflexes elicited with a good hammer.
Click to expand...

I've always found the "my hammer is better than your hammer" argument to be one of the more annoying aspects of neurology. I've used many different types over the years and never found any particular difference. It's all operator dependent. Getting a "better hammer" is like expecting those fancy $100 basketball shoes to make you into Michael Jordan.
 
I think two things are important in a hammer from my limited experience as a medical student: weight and soft rubber. Heavy hammers have more momentum and softer hammers are more comfortable for both the patient and the examiner (especially when testing the biceps reflex by hitting your own finger on the patients biceps tendon).
 
I honestly would rather use my stethoscope as a reflex hammer than a tomahawk because that nice "arc" you need to get with it is ok (sometimes) when a patient is able to move, cooperate, and reposition themselves. Try getting a good exam on a coma patient with one of those :laugh:

Also RE: Pins- another option is a few long cotton swabs, broken in the middle to a point when you need them. A lot of Drs I've worked with do this and just flip the swab for sharp/dull, and if you need 2 point discrimination you can use the other broken half.
 
obieards said:
What equipment are must haves for neurologists? My mentor at school suggested the following:

Hammer (I have a Queen Square; how's the collapsible?)
128 tuning fork
256 tuning fork
Opthalmoscope (regular or PanOptic?)
Otoscope
OKN strip
Pinhole
Transparent red glass or lens
Click to expand...

The Queen's square is the easiest to use, but the non-collapsible ones are a pain to carry in a bag (much less a coat pocket). The collapsible ones break after time. I like the Troemner. You have to aim better for the tendon but it gives a better response, I think. And if fits in a bag or pocket better. Don't waste your time with the tomahawk or stethoscopes.

I have never, ever used a pinhole. Ever. Or Ishihara color plates.

I have very rarely used my OKN tape and red lens. They are cheap, fit in your bag without fanfare, and are very fun and rewarding when you do use them.

I actually use the otoscope, too. More so now that I am in Sleep Medicine and am doing more of an "ENT" exam than a "neuro" exam. I now keep a bunch of tongue depressors and a few stick q-tips, too for this reason. You'd be amazed how many office rooms lack tongue depressors these days.

A box of safety pins or paperclips is worth keeping around.

Also, a stick of cherry (or something) flavored chapstick to test olfaction. I don't like the coffee grounds.

I used the classic Welch Allyn penlight for years, but finally switched to a mini-Maglite that I much prefer. It's brighter and you can adjust the beam.

The one thing I would really, truly recommend is spending the extra cash on the PanOptic ophthalmoscope. It is worth every single cent. You might also want to carry around some dilating eye drops with you, too.

Have fun!
 
Just wanted to bump this thread and to give an accurate update, now that I am an actual neurology resident. Attention med students, this is what you will need for neuro rotation!

Given that I've been doing this for over 8 months and have developed chronic neck pain from carrying all my equipment in my white coat (in another life, I was a pediatric resident and only carried a stethoscope that I was constantly wiping grubby children's fingerprints off of), I have found some things indispensable:

1. Reflex hammer, I use a Tromner reflex hammer. Any hammer that has a nice weight to it will be able to elicit reflexes accurately. Just remember, it's all in the wrist!

2. Tuning fork at 128 Hz. This only costs a few bucks and is valuable for checking vibratory sensation. I only have this with me when I am on call though, too heavy otherwise.

3. Paper clips or tongue depressors, these are usually plentiful in the hospital. Bend them to test pinprick sensation and then dispose. Please do not litter your resident room with them.

4. Eye testing, this I find most residents are lacking the right equipment when on call and if you just had an OKN (optokinetic nystagmus) strip or red desaturation test, it could make morning report much less painful and make you look like a superstar. But then again, no one really carries these items. Instead, I just download some apps to my iPhone. I use:

http://itunes.apple.com/us/app/okn-strips/id496001751?mt=8

I am pretty sure these types of apps are available for Android, etc...and there are multiple versions. I've been able to easily assess for hysterical blindness and optic neuritis without having to waste time with the panoptic peering into the "souls" of my patients (nonetheless, I have to work on my technique).

Happy Neurology Survival! Does anyone else have other essentials they would like to add?
 
This is more to equip your mind with: learning the NIH Stroke Scale, this is most valuable on-call and it is also good to have a list of all the contraindications to giving tPA. You can certify for Stroke Scale training here and it's free:

http://learn.heart.org/ihtml/application/student/interface.heart2/nihss.html

It also has a beta program running now where you can do the certification on your iPhone (just to plug another cool iPhone app, see above post for OKN strips and red desaturation test). Takes about 1-2 hours and you can recertify every 6-12 months.

Congrats to all those who matched today!!!!!! Get your learn on!
 
can i just say no amount of hitting me where my deep tendon reflexes should be will make them come out and play...as a doctor and occasionally a patient (only when i'm desperate) i tell emerg registrars i don't have reflexes in my feet or ankles, they check and then like somehow they don't believe what they're seeing....THEY WHACK HARDER!!!!
 
I like the NIH stroke scale...bring extras and give to the ED staff so their calls can be better 😀

Also as far as references go I keep a card with the p450 enzyme classes and what drugs do what to which one in terms of metabolism. Still a lot of people on phenytoin and phenobarbital out there, and they're two repeat offenders.
 
Hmmm, that's a really good idea about p450 enzyme inducer drugs or even just common drug interactions you see. I might suggest that to add to our neuro resident booklet, thanks!

Now I'm on movement and the most helpful things so far have been the OKN strips app on iPhone for diagnosing PSP (progressive supranuclear palsy) which impressed one of my attendings and also your own two eyes. Just amazed at how you train yourself on how to observe patients and how to pick out the psychogenic ones. Knowing all the different Parkinson's meds and side effects also helps!
 
Just wanted to bump this as I am currently frustrated by the number of "fakers" we have on our service right now.

One good tip for pseudo seizures is to carry around cotton swabs with you. When the pt. breaks into a pseudo seizure, you can stick a Q-tip in their nose and it's so noxious, this will usually end the episode.

Another thing I have used for hysterical blindness is testing OKN (optokinetic nystagmus). You basically show the strips to the patient and they end up with a normal nystagmus response, you can get this app here for your iPhone, iPad or just carry around OKN tape:

http://itunes.apple.com/us/app/okn-strips/id496001751?mt=8

For numbness, which is the most subjective, I've often put ice on the same area for a long period of time, sometimes, the patient will admit that it is uncomfortable or they will try to move their extremity away. You may also force someone to move their extremity because of pain caused by icing.

Does anyone have other helpful tips for fishing out the conversion disorders? It just doesn't make sense to me that we end up wasting so much time on these patients to prove to them it is a conversion disorder!
 
Ok, so that's all my book money this year, does anyone have any suggestions on other tools or good books to buy for board review? (I know, it's a piddly amount, but at least I have free unlimited food 😀).
 
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