A to Z of Neurosurgery

ACDF (Anterior cervical discectomy and fusion):

 Do not need to stop aspirin pre-op
 Check op note for post-op x-ray requirement
 Most consultants request a c-spine (AP & Lateral) but check with the registrar if any
doubts as to consultant preference

Anaesthetists:
 Often found on ward 6 (neuro ICU)
 SpR (bleep 2822) can be contacted to assist if patients need input
 Will be able to help for arterial or central lines and medical issues on neuro HDU or
the wards

Anti-Coagulants/Antiplatelets:
 Always ensure senior doctors know if pre-op patients are taking aspirin, warfarin,
clopidogrel, dipyridamole etc.
 Ideally, cranial patients need to be off aspirin for 7-10 days prior to surgery as aspirin
has been associated with a significant haematoma risk post-operatively.
o For patients on clopidogrel or dipyridamole this may be extended to 14-days
off – please check with the consultant.
o Before stopping any anti-platelet therapy, check first why the patient is
taking it – for example, some patients have cardiac stents that will occlude if their
medication is stopped.
 Spinal patients do not usually need to stop aspirin pre-operatively
 Check with a senior about the timing and dose of tinzaparin post-operatively

Antimicrobials:
 Discuss with microbiology SpR (x23962) and check Trust policy on intranet
 For CNS infections discuss with our dedicated neuro consultant microbiologist Dr
Sethi (x25034) if possible
 Always document indication and duration (or review date) on drug chart & notes
 Restricted antimicrobials need a form (intranet) ± code from microbiology
 Some antimicrobials need specific charts (vancomycin, gentamycin)
 Patients who need 2 weeks or longer of abx (e.g. for ventriculitis) should be booked
for a PICC line.
 Antimicrobial prescribing is audited routinely and regularly

Audit:
 All SHOs are expected to undertake an audit during their 4/6 months with us
 These should be presented ideally towards the end of the job at a clinical
governance meeting
 We have lots of ideas if you are in need of a topic
o For audit ideas pleas speak to any registrar.
 o For mandatory audits, please speak to Soumya

Bluespier (2008 onwards):

 This is the electronic database used in neurosurgery and some other specialties
 Handover sheets, discharge summaries (EDANs) and operation notes use this system
 All clinic attendances and correspondence is available through Bluespier. From
November 2015, all clinic correspondence is available on Epro or PPM.
 The surgeons will often put post-operative instructions onto Bluespier. Please check
them and adhere to them

Clerking:
 All patients need the following charts:
o Drug chart
o VTE risk assessment
o MRSA chart
o O2 chart
o Fluid chart
 All patients should have an up-to-date FBC/U&E/Clotting/G&S as a minimum (note
bloods from other hospitals do not count)
 Make sure G&S forms and all bottles are hand-written
 Always document:
o Source of admission
o Type of admission (acute/elective)
o Responsible consultant
o Hand dominance (cranial patients)
 Inform the SpR on call (bleep 1817) when a patient has arrived & confirm the plan.
 Unless informed otherwise, keep all acute admissions NBM.
 When known patients are admitted (e.g. shunt pathway), printing off previous
discharge summaries and operation notes from Bluespier is very useful.

CSF sampling:
 You may be asked to perform CSF sampling on patients with an external ventricular
drain (EVD) or lumbar drain (LD) in situ. This is performed using aseptic technique. Please
ask a senior to show you how this is done before you undertake independently.

Discharges:
 Are very important in a tertiary centre where acute bed capacity is at a premium
 All patients being discharged need an EDAN completing on Bluespier, including
patients who are discharged with no medication
 Anticipate any discharges in advance, especially over the weekend. Discharge letters
(EDANS) for patients likely to go home over the weekend should have been written on the
Friday.
 o If EDANs are completed the day before discharge, the patient can be
discharged in the morning rather than the afternoon, making a major impact on
admissions.

Drains:
 If uncertain regarding type (e.g. subdural, extradural, subgaleal) check operation
note.
 All drain procedures, including removal of drains, should be documented in the
medical notes clearly, including whether the drain tip is intact.
 Subgaleal: can be removed on the ward (often by the nurses) and do not require a
suture.
 Subdural/extradural: should pull out once drain stitch cut and will usually require a
single, interrupted nylon suture to close the wound. Do NOT use silk to close drain sites (it
can act as a wick and encourage CSF out, and therefore infective organisms in).
 ICP monitor: should pull out once silk securing stitch cut and does not usually
require a suture (a simple dressing will suffice).
 EVD: Remove under strict aseptic technique. Will require an interrupted nylon suture
to close the wound site. Observe for CSF leak – if any CSF leak occurs, a further stitch must
be inserted IMMEDIATELY due to risk of meningitis.
 Lumbar Drain: as per EVD removal.
 Both EVDs and lumbar drains are connected to Becker external drainage systems
that allow a pressure level to be set for drainage. 0cm H2O should be placed at the level of
the tragus. The operation note will advise what pressure level the system should be set at
(usually 10 to 15 cm H2O). With this instruction, the aim of the drain is to drain as much CSF
as required to bring the intracranial pressure down to 10 to 15cm H2O. Alternatively, there
will be an instruction for targeted drainage when the pressure level is unimportant e.g drain
10 to 15ml CSF per hour. This is usually when the drain is being used to divert CSF away from
a leaking wound to allow it to heal.
 Both EVDs and lumbar drains are challenged prior to removal. This will usually
involve raising the pressure level to 20-25cm H2O for 24 hours, and then clamping the EVD
for 24 hours.
 You may be asked to review EVDs and lumbar drains that are blocked. For EVDs,
remember to firstly check the last CT head to check the drain position. The catheter may be
next to choroid plexus or intraparenchymal. Also check how much has drained - it may be
that a large amount has previously drained intra-operatively or during patient re-positioning.
The first manoeuvre is to lower the drain to see if this promotes drainage. Also check to see
if the CSF level within the drain is oscillating. Both are indicators that the drain is patent.
 Arterial line and central line tips should also be sent to microbiology when removed.
 IF YOU ARE PULLING A DRAIN/ICP MONITOR OUT AND THERE IS RESISTANCE, IT MAY
BE SUTURED IN THE WOUND OR CAUGHT ON THE BONE EDGE. DO NOT RISK FRACTURE OF
THE DRAIN; ASK A REGISTRAR TO REVIEW.

eRoster:
 This is the main system for applying for annual leave/study leave/day in lieu and
checking which on calls you are scheduled for. Rota 107 is the SHO rota and rota 109 is the
 registrar rota. Please check eRoster to ensure there is sufficient cover and that on-calls have
been swapped before requesting any leave.

Flexion/Extension Views:
 Used to assess neck stability
 Performed in X-ray
 You may need to supervise this out-of-hours.
o Go to x-ray, put on gloves & lead protection, hold neck in neutral position,
remove collar, then support head in midline as patient tries maximal tolerated
flexion followed by maximal tolerated extension, put collar back on
 Ask patient to inform you if they develop tingling or neurological deficit
o instruct them to answer ‘yes’ or ‘no’,
o discourage nodding or shaking of the head in response to questions
 Abort procedure if patient in agony or develops neurological deficit or symptoms
during procedure
 Check x-rays on screen to see if they are adequate before leaving department – if
inadequate, don’t be afraid to ask for films to be repeated

GCS:
 Learn this well, and practice examination
 When using GCS, always document the breakdown e.g. (E 4,V5,M6)
 In neurosurgery, motor scores are singularly the most useful component
 VT indicates a patient with tracheostomy
 VD indicates a patient with dysphasia

Halo Jacket:
 Used to manage c-spine fractures that do not require surgery.
 Can be applied under LA on the ward or in theatre, always with aseptic technique.
 Following discharge, patients attend the ward usually on a fortnightly basis for
tightening of pins and check x-rays. The halo remains on for at least 12 weeks.
 Use torque wrench for head pins and spanner for nuts/bolts (both supplied with
Halo and kept in the “red bag” (patient should bring these).
 Get help if in doubt – do NOT attempt to manipulate a halo if you have not been
taught how.
 Patients who present with pins that become repeatedly loose may have early pin site
infection. Do not tighten in this circumstance, and inform a senior. The majority of patients
should only require one re-tightening at 24 hours post application prior to discharge.

Handover:
 Handover notes should be kept up-to-date using PPM - update clinical details (ward
view) daily for the on-call doctor.
 No other handover sheets/systems should be used.
 They must be placed in a green bin when finished - these are confidential patient
records and must not be taken home or left lying around.
  In addition to the PPM handover, it is important to also verbally handover any
remaining jobs to the on call doctor at the end of your shift – good communication is the key
to patient safety in a shift system.
 This is particularly important on Friday - please aim to meet with the on call doctor in
the seminar room on Friday at 5pm for a verbal handover for the weekend complete with a
print out of the PPM handover.
 Morning handover commences at 0745 for the registrars in the seminar room. All
are encouraged to attend. Please arrive no later than 0800 to facilitate a comprehensive
handover to maximise efficiency and patient safety.

HDU (L7): (x27407)

 Ward round with SpRs and anaesthetic consultant daily (after the neuro ICU ward
round). Please note: the SHO assigned to HDU is required to formally present all patients on
the ward round.
 Document in “ABCD” format.
 Examine all patients and write in all notes daily, including weekends.
 Being assigned to HDU is a great opportunity to develop presentation skills, fine tune
neurological examination, learn how to site arterial and central line catheters, and develop
management skills of the critically ill neurosurgical patient.

Intrathecal (IT) antibiotics:

 Prescribe and administer with extreme care, and only after formal training.
 Strict aseptic technique.
 Always get prescription/drug/patient checked with a nurse.
 You may be asked to give these drugs on ICU/ward 52 (paeds)/PICU also.
 Sign drug chart & document in notes, including whether a CSF sample has been sent
to microbiology for analysis.
 Do not perform unsupervised until confident of correct technique.

Medical Notes:
 Trust guidelines are that notes are written in every day. Documentation in the notes
is an important task for handover and medicolegal purposes. On ward round, keep a record
of key items discussed for each patient including:
 Observations
 Examination findings
 VTE prophylaxis
 Abx treatment and duration
 Plan for imaging/sutures/drain removal/mobilisation/discharge
 Always document date/time. Sign off with your signature, name in block capitals,
grade & bleep number
 Over the weekend,
o Notes must be written in if the patient is discharged
o Notes must be written in if management is altered
o If there are no changes to management and the patient is stable, it may be
sufficient to document a brief note state this to cover the weekend period
  HDU & ITU notes must be written in every day without fail.
 In addition to ward round documentation, any assessment of sick patients or any
patient procedures should be documented in the notes eg. Stitch to a wound, drain removal.

Morning (Trauma) Meeting:

 Starts at 7:45am prompt, seminar room, G Floor, Jubilee Building
 Your official start time is 8am so only attend at 7.45 on a voluntary basis
 All referrals/admissions from previous day discussed
 Extremely useful to attend this meeting as you learn about what has been happening
on the wards
 This is where the night SHO should handover to the day doctors
 It is also a great teaching opportunity for interpretation of scans and understanding
management plans.

Nasogastric Tubes:
 These are placed frequency in neurosurgical patients and you may wish to place a
bridle with frequent flyers (ask a senior to teach you if you are unsure how to do this).
 You will need to complete an e-learning module as part of mandatory training.
 If in doubt about NGT position, always obtain a CXR before use.

Neurological Examination:
 All patients need a documented, thorough neurological examination pre-op and
post-op
 All HDU patients need a full, daily neurological examination
 All spinal injury patients need a daily neurological examination and ASIA score
 Your placement in neurosurgery is an opportunity to refine and hone your
neurological examination skill
 All patients should have a complete nervous system examination
o If they are having lumbar spine surgery, the upper limbs and cranial nerves
must still be examined and the full examination recorded.
o If you do not see lots of normal neurology how do you know what is
abnormal?
o If you do not see lots of normal fundi how will you recognise papilloedema?

OrderComms:
 All requests for investigations should be requested on OrderComms, including:
o All imaging
o All blood tests
o Micro forms
o Cerebral angiograms
 Clear clinical details should be written on the request forms, including the clinical
question.
 Attention should be paid to the urgency of the request.
 o For urgent CT scans, please call 23617 and discuss in addition to
orderComms request.
o For urgent MRI scans, please discuss with the neuroradiologist in the MRI
reporting room or on call. If the MRI is to rule out cauda equina syndrome and the
on-call spinal consultant is orthopaedic, discussion for urgent MRI during normal
working hours should be with the MSK radiologist.

PEGs:
 Many neuro patients will require long term rehab/feeding needs, often in the form
of a PEG.
 If a PEG is required, request this early as the wait can be weeks.
 Ask to speak to the gastroenterology registrar on call for PEGs to refer the patient.
 Remember to prescribe MRSA decolonisation pre-procedure.
 All patients need a full set of repeat bloods in the days prior to PEG insertion
(FBC/U&E/G&S/Clotting).
 If patients need consent form 4 filling, this is to be filled in by the person performing
the procedure, although they may ask that we confirm lack of capacity to consent on the
form.

Personal Protective Equipment (PPE):

 As per Trust guidelines and induction procedure, PPE should always be worn for any
exposure-prone procedure

Pharmacists:
 The ward pharmacists are an excellent source of information with regards to
common drugs used in neurosurgical practise – make the most of their knowledge by
discussing with them if you have any queries
 The pharmacists have also been asked to ensure that patients’ drug charts including
VTE, MRSA, oxygen etc are completed correctly; please do as they ask
 If a patient’s regular medicines were not prescribed at clerking (e.g. due to lack of
information at the time) please ensure that these are added to the chart as soon as the full
drug history is known.

PICC line:
 Patients with cerebral abscess/epidural
abscess/infection/empyema/ventriculitis/meningitis etc are likely to require IV antibiotics for
an extended duration. They need referring for insertion of a PICC line.
o There is a dedicated list for PICC line insertion on Tuesdays. Patients need to
be booked for this in theatres using a bunker form. Please complete all details in full.

Posterior Fossa Surgery:

 All patients need HDU beds post-op
  Depending on the site of surgery, it is important to check that gag reflex is intact
post-op as CN IX/X/XII may be affected by surgery
 Oral intake cannot be commenced unless the gag reflex is checked and deemed
intact

Post-Op Notes:
 Operating surgeons write post-op instructions on the operation note, found on
Bluespier and printed in the notes. This includes information about drains, post-op imaging,
steroids, and aims for discharge.
 Order post-op imaging early;
o Tumour post op scans are usually performed within 24-48 hrs to avoid
swelling-related ambiguity.
o Check with the op-note or responsible registrar as to whether CT or MRI
required.

Pre-Assessment Clinic (PAC): (x25354)

 In Brotherton wing, near medical outpatients
 Use the proforma
 Sign and document (± act upon) previous clinic’s results
 All patients must have a completed drug chart
 Visits are valid for 3 months. Patients who are admitted electively following
attending clinic need a brief overview to make sure things have not changed significantly
since PAC.
 On the day of theatre admission, patients who attended more than 3 months ago or
who did not attend clinic need a full clerking similar to an acute admission
 Please note that patients should take all of their usual medications on the morning of
surgery unless specifically told not to (patients should not be taking
anticoagulants/antiplatelets).

Registrar On-Call Phone (07979928120)

 The SpRs do 24 hours on call from 0745 through to the post on-call neuro ICU ward
round.
 Occasionally, referrals (e.g. from A&E or other hospitals) may be diverted to the SHO
bleep (x2035)
 If you receive a referral, ask the referring team if the case is life-threatening. If not,
the referring team can refer online at www.leedsneurosurgery.com . The registrar will then
respond to this referral when they are able.
 If the case is life-threatening, the most important information are patient details and
contact details for the person who has referred the case to you. Make a note of as much
information as you can get and tell the referrer that you will call them back as appropriate.
Always ask that they send any imaging electronically from their PACS system to ours.
Immediately find the registrar and discuss (the registrar may be operating in which case you
will need to change and attend theatre).

Repatriation:
  Getting people back to their local hospital is very important to keep beds available in
our unit and also for patients to be nearer to their homes and families
 In the first instance, the responsibility for accepting the patient back is with the
referring team/consultant
 If patients have been admitted from a peripheral hospital A&E, speak to the medical
registrar
 Some patients need neuro-rehabilitation and are not suitable to return to their
referring team - the therapists will inform you if this is the case and where they should be
more appropriately referred
 You then need to complete a transfer letter for the patient (using the EDAN template
on Bluespier) and inform the nurse in charge and the bed manager (phone 07786250619)
that the patient has been accepted and by which consultant
 Once identified as fit for repatriation, patients must be referred within 24 hours

Rota:
 The SHO rota (107) is overseen by Louise Steele (SpR) but managed by Sarah Pearson
from medical staffing
 A weekly rota of duties is produced by Rebecca Chave-Cox (SHO) - this will rotate you
around the various wards and also aim to give you allocated time for theatres/clinics
 All requests for leave should be made via eRoster
o Only requests with appropriately swapped on-call shifts will be accepted
o Please email all on-call swap requests to Louise and Sarah Pearson. It is your
responsibility to check your rota line on eRoster and ensure it is correct.
o All leave requests must be made with at least 6 weeks’ notice
o All study leave requests need to be accompanied with a signed study leave
form and will be approved on a priority basis.
o An absolute minimum of 3 SHOs are required for safe ward cover (ward 24,
ward 25, HDU/ward 28).

Scans (CT/MRI etc):

 Neurosurgical doctors do not need to discuss CT head requests with a radiologist;
request on OrderComms and inform the scanning room (x23617) or on-call CT radiographer
 If asked to arrange a CT head, always ask if contrast is needed. Generally speaking,
“Plain CT Head” is requested to look for hydrocephalus and bleeding and “CT Head ±
Contrast” is requested when looking for infection, tumour or post-op residuum
 CT-angiogram requests should be discussed with the neuroradiology consultants (Drs
Goddard, Patankar Warren, Currie, MacMullen-Price, and Craven) and it should be
documented on the OrderComms request that they are aware.
 MRI scan requests must be discussed with a consultant neuroradiologist. Inpatient
requests must be discussed in person… we have a good relationship with the team and they
are amenable, provided you know the indication for MRI and the clinical details
 All OrderComms requests must be filled out thoroughly - demographics, brief history,
indication for scan, consultant responsible and dates/type/location of previous relevant
imaging
Shunt Care Pathway:
 Patients with shunts have direct access to neurosurgery.
 They know to phone the ward if they have a problem, and may be advised by senior
nursing staff or doctors that they need to attend ward 24/25 for investigation of a shunt
malfunction.
 Recognise which type of shunt is in (ventriculoperitoneal, ventriculoatrial,
lumboperitoneal, ventriculopleural)
 These patients need a full history and examination, previous Bluespier documents
printing if available, a CT head, shunt series (X-rays of skull, neck, chest and abdomen) as well
as bloods: FBC/U&E/CRP/G&S/Cultures (if febrile) – they will also need discussion with the
on-call SpR
o If you feel that CT scan and shunt series may not be required please check
with the on-call SpR prior to ordering
o LP shunts only require AP/lateral X-rays of abdomen
o VA shunts only require skull, neck, chest x-rays

Sodium:
 Important to differentiate between SIADH (water retention) and CSW (cerebral salt
wasting) in hyponatraemic patients
 Diagnosis requires: U&S, serum/urine osmolality, spot urine U&E, 24hr urine U&E
 SIADH – needs endocrine review, fluid restriction
 CSW – in mild cases can be treated with oral sodium (Slow Sodium up to 4 tablets
QDS), dioralyte (5 sachets in 1 litre water over 24 hours) ± fludrocortisone 50 micrograms BD
(starting dose)
 More severe cases may require 1.8% IV sodium chloride (aka “double strength” or
“sticky saline”). This can only be administered on HDU or ICU.
 Hypernatraemia may be due to diabetes insipidus and may require IV fluids and
DDAVP (desmopressin) treatment, pending endocrine review
 Do not diagnose aetiology or initiate management of hyponatraemia unless
discussed with a senior - correcting sodium too quickly or incorrect diagnosis/management
can have life threatening consequences

Steroids:
 Patients with brain tumours will usually require 16mg Dexamethasone on admission
then 16mg OD am daily prior to surgery, patients also need gastric protection (e.g.
lansoprazole 30mg PO OD)
 Following surgery, steroids will need to be reduced either to maintenance level or to
stop (this is usually dependent on the histological grade of the tumour). Please check with
the registrar for the desired plan and rate of weaning.
 Before prescribing dexamethasone as an EDAN please check with the registrar what
dose and duration are required
o Some patients have ended up on steroids for 3 months when they should
have been stopped on discharge!
 Departmental prescription charts are available for hydrocortisone, which is the
preferred steroid for pituitary cases.
Subarachnoid Haemorrhage:
 All patients require minimum HDU bed
 All need arterial line
 Some patients need central lines as clinically indicated
 All require nimodipine 60mg 4-hourly (02:00, 06:00, 10:00, 14:00, 18:00, 22:00) for
21 days to help prevent delayed ischaemic neurological deficit secondary to vasospasm
 If BP drops with 4-hourly nimodipine, amend to 30mg 2-hourly, but only after
speaking to the registrar
 Keep well-filled with IV fluids - a minimum of 3 litres of normal saline per 24 hours
should be prescribed
 Need a CT-angiogram if not already performed
 Keep on bed rest until aneurysm secured
 Generous laxative use (to avoid straining)
 Monitor sodium daily
 If high urine output/abnormal U&Es – need daily serum & urine osmolality and urine
U&Es
 Careful use of analgesia (these patients are at high risk of developing hydrocephalus,
so overuse of sedative analgesics such as morphine can confuse interpretation of neuro obs)

Teaching:
 Neurooncology MDT & neuroradiology meeting (optional) – Wednesday 09:30 after
ward round, radiology academy, B floor
 Weekly academic teaching (compulsory) – Wednesdays 11:30, usually in Littlewood
Hall, Postgraduate Centre, LGI
 Mr Tyagi’s SHO teaching – Usually Thursday after morning trauma meeting

Theatres:
 Are based on C floor (Jubilee Wing)
 Changing rooms and scrubs are on D floor
 All SHOs are welcome to attend theatres, but ward work takes a priority.
 Introduce yourself to the consultant
 Try to see the patient pre-operatively as this will help with your understanding of the
surgery
 Scrub hats and masks should be worn. You may be encouraged to scrub to assist
with the case.

Trigeminal Surgery:
 Always check corneal reflexes post-op
 If corneal reflex is absent, need discussion/review by ophthalmology

Vasospasm (Delayed ischaemic neurological deficit (DIND) Post-Subarachnoid Haemorrhage):

 May present with reduced conscious level or new neurological deficit.
 High morbidity and mortality
  If aneurysm secured, treat with “Triple H” (Hypertensive-hypervolemic-
haemodilution therapy) – aim for CVP 10-12 and MAP of 110-120
 Urgent neurovascular intervention may be required (stenting or intra-arterial
nimodipine)
 Diagnosed with CT angiogram or formal cerebral angiogram
 ALWAYS ALERT A SENIOR ASAP IF A PATIENT DEVELOPS DIND

Venflons/Cannulae:
 Strict aseptic technique and PPE must always be used, as per trust induction
 Fill in cannula documentation and file accordingly

Ward 28:
 If you are on for ward 28, your working day is 07:00-16:00
 From 07:00-07:30 complete EDANs on ward 24/25
 At 07:30, go to ward 28 to check patients are ready for theatre
 Most ward attendees will also be directed to ward 28
 You are also required to attend the pre-operative assessment clinic to clerk patients
sent from clinic. Pre-operative assessment should history and examination, drug chart, VTE
assessment, and requesting further investigations/referring to anaesthetics should there be
any pre-operative medical concerns e.g. echo, CXR, pulmonary function tests.

Ward Rounds:
 Ward rounds happen immediately after the handover meeting in the seminar room,
which aims to finish at 0815. Usually cranial round will commence on ward 24 and spinal
round on ward 25.
 SHOs should present the patients on rounds and be the leader for the round.
 The on-call registrar and the post on-call registrar commence the ICU round
immediately after handover. The HDU round follows this, and the SHO needs to be ready to
present all patients to the neurosurgeons and neuroanaesthetists on the ward round.
 Check with the night staff and nurse in charge for any new issues since yesterday’s
rounds when you arrive on the ward in the morning.
 Make sure you know the latest blood and microbiology results for all of the patients,
especially Na levels for SAH and head injury patients.

Weekends:
 We do ward rounds of all the patients on Saturday and Sunday mornings. Registrar
handover is at 0830 in the seminar room, so night/day SHO handover should commence at
0815. The exact ward round times will vary according to on call referrals and operations, but
usually take the form of L6, L7, and then the wards.
 Make sure you hand over about all unwell or high risk patients to the on call doctor
for the weekend, together with any jobs that need doing or scans that need checking,
preferably on the Bluespier handover sheets and verbally. Aim to meet on Friday at 5pm in
the seminar room for a formal verbal handover with the weekend on-call doctor.
 The weekends can be very, very busy; please try to anticipate discharges, drug charts
to transcribe, and required bloods etc on a Friday to ease the burden for your colleagues. All
anticipated bloods for the weekend should have forms put out on Friday. (Remember, all
SAH patients and most head injury patients require daily Na check.)