Thursday, March 17, 2011

Secrets of the Jedi Masters




Today I am going to reveal one of the deep, dark secrets of neurology. A secret so carefully hidden that this post could result in my excommunication from the neurobrotherhood.

Most doctors, in some way, are snobs. Some are money snobs (a malady not limited to medicine), others about where they went to med school, still others about their clientele, others about research.

And what are neurologists snobs about?

We are snobs about...

(looks around furtively and whispers)


Reflex hammers.

Yes, reflex hammers. The little rubber triangular thing your internist uses to tap on your knees.

But we're NEUROLOGISTS, damnit! We did 3 years of training to learn how to properly use a reflex hammer! Plus, while your internist will only tap on your knees, we have a bunch of other reflexes we check.

I mean, we have to do SOMETHING to make it worth your higher co-pay to see a specialist. Would Harry Potter carry around just any old wand? No! Reflex hammers are to neurologists as lightsabers are to Jedi.

This is what your internist likely uses:





It's called a Taylor hammer. Or Tomahawk. They give you one in med school. No self-respecting neurologist would EVER be seen holding one. It's like a toy to us, and we are specially trained to look down our noses at them with a "you call THAT a reflex hammer!" look.

Someone once pointed out to me that this was one of the very first types of reflex hammer specially designed for this purpose. My answer to that is that the Wright brother's plane was the first one built, but I don't see anyone catching one to Chicago these days, either.

The only thing (in the eyes of a neurologist) lower than a Taylor hammer is this bizarre contraption:




Yes, it's a sad attempt to combine a Taylor hammer and a tuning fork (another item commonly used by neurologists). In the Bible they called things like this "abominations unto the Lord" (or, in our case, abominations unto Charcot).

It's like a sofa-bed: when you combine 2 things, you often get something that isn't quite as good as either one alone. When I was in med school I thought these things looked cool and practical (it took up less pocket space in that stupid looking short white coat). Now that I'm a neurologist, I realize how worthless they are. If you ever have a neurologist use one on you, ask them how many box tops they had to exchange for their medical degree.

The only thing worse than either of the above is using the head of your stethoscope to check reflexes. Might as well put on a shirt that says "Beware! Greenhorn on rounds!"

Next up, and maybe a notch or 2 above the Taylor hammer:

This is a Buck hammer.



The Buck is a few notches above the Taylor. It means that you're somewhat serious about checking reflexes. It's often carried by neurologists on hospital rounds, because it's convenient to toss in your bag.

A word of warning- the top piece on most Buck's unscrews to reveal a sharp pin. This is a throwback to the pre-AIDS era when you could freely jab multiple patients with the same sharp object and not worry about spreading disease. If your doctor pulls one out of his hammer and tries to jab you with it, RUN AWAY. You don't know where it's been.

A few rungs up, and we get the Trömner hammer (or Troemner, depending on where you trained).



Now THIS is a good hammer. It's what I carry in my hospital bag. The picture alone can't convey what it feels like to hold one. Although it looks somewhat like a Buck hammer, in reality it's larger and heavier. It has a solid, reassuring, feel to it, like if the patient suddenly lunges, you can beat the crap out of him with it. No other reflex hammer gives you that sense of security.

For my pharmacy readers, my faithful Trömner actually was a gift from a Naprosyn rep. Which says more about me than I want to admit.

This is a Berliner hammer. I've never used this type.



It looks, somewhat reassuringly, like an axe (to keep the Haldol deprived at bay until the orderlies arrive).

Now we come to the royalty of reflex testing, the Queen Square hammer.



As simple as it looks, this is THE HAMMER for the serious neurologist. It's what I (and most) keep in our offices. It's nicely weighted and allows you to swing it easily from several directions to test reflexes in different limbs, without having to reposition yourself or the patient too much. It's not as solid as the Trömner, but if the patient attacks you can stun them with it (it breaks after 1 solid hit, don't ask how I know this) as you draw your other hammer.

But neurologists sometimes have to round at the hospital, and the Queen Square, with it's long stalk, doesn't conveniently fit in a black bag. So, if you don't like the Trömner or Buck, there's the Babinski hammer.



This is basically the smaller handle of a Buck hammer with the Queen Square head. The head usually tilts to the side and the handle telescopes to a smaller size so you can put it in your bag.

It has the bizarre history of having been introduced to the U.S. by neurologist Abraham Rabiner, who received his personally from the great Dr. Babinski himself. This was as a peace offering after the 2 of them had physically beaten the shit out of each other (REALLY!) during a debate over a neurophysiology question at a Vienna black-tie dinner (Hey, we neuro Jedi take this shit seriously).

There are a handful of other hammer types out there (Krauss, Wintrich, Ebstein, and Wintle to name a few), mostly variants of the above. Some of them, like Ebstein and Wintrich, are of mostly historical interest and no longer used.

That's reflex hammers in a nutshell. Now you have something to talk about when you want to see a neurologist, or pretend to be a neurologist, or want to score points on your neurology rotation, or end up on Jeopardy saying "I'll take 'Reflex Hammers' for $500, Alex."

And know, ye of lesser hammers, why those of us who wield a Trömner or Queen Square look down on you as unwashed heathens. And appropriately so.

88 comments:

Becca said...

I am not a doctor, but us non-medics can have moments of snobbishness too you know. In that vein I will now tell you that I am British, which as everyone knows is far superior to being from any other country. To support this assertion, I note that the Queen Square hammer is the standard reflex hammer in the UK, found everywhere including GP surgeries. This may have something to do with its clearly British origins - the National Hospital for Neurology & Neurosurgery is based in Queens Square, London (and the hospital itself is often just referred to as Queens Square).

Old MD Girl said...

The Babinski hammer is a piece of crap. The threading on the head gave out on mine after the first week of use and then the head kept falling off when I tapped people. So embarrassing!

CrownedwithVictory said...

This is a really cool post! I had no idea there were more than 2 kinds...the first one you showed, and the ancient chicken shaped one our pediatrician uses.

BGDino said...

The Queen Square is also the standard here in Sydney although that might have something to do with the fact that it's the cheapest one for sale at the medical school shop.

Randomly I did see a neurology senior registrar who had a Queen Square with a head about 50% bigger than normal. Apparently it got reflexes every time.

Grumpy, M.D. said...

It's not the size of the hammer's head that matters. It's how you use it.

WarmSocks said...

This is great!

Doris said...

AH HA! Queen's Square Hammer!

My internist had one of these puppies sticking out of his bag the first time I saw him.

I knew it was a reflex hammer, but now I know that it holds a certain cachet among the elite.

>:)

Packer said...

Man read that and enjoyed one of the best naps I've had in months. Thanks.

Anonymous said...

@Becca: Yes, the Queen Square is the only type of hammer I have been assailed with in the UK over the past 50+ years.And I still hate the spike on the end being dragged over the sole of my foot.

apotential said...

DUDE. Our med school class was advised to get Taylors, but I went with a Troemner.

And now I feel like I have the Grumpy Stamp of Approval to secretly feel a little superior. Awesome.

Jacqueline said...

That was...awesome!!!

Anonymous said...

Lowly neuro resident reporting in.

http://www.aan.com/storefront/New_Taylor_Hammer_P522C28.cfm

I'm carrying one of these around to, in the common internet parlance, troll the crap out of my fellow neurologists. It's not as heavy as a Troemner but it is sleeker and fits better in a coat pocket.

The common reaction when I offer the hammer is a condescending look followed by "I don't need that hammer" followed by "Hey, this is actually pretty heavy, where'd you get that?"

I've also heard that Dr. Lanska is working on a Queen Square revision.

Moose said...

Today on Dr Grumpy's Blog --

STOP! HAMMER TIME!



(Can't believe nobody else has done this yet...)

Anonymous said...

All Hail Thor! May his hammer smite all foes!

Kyla said...

You nailed it. My kid's near is the only one with the Queen Square.

Anonymous said...

Sorry for doubleposting.

Lately our students have been carrying around even cheaper Taylors than before. The metal body is lighter and the head is no longer made of rubber, but some cheaper soft plasticky goop. In fact I could swear my OG Taylor from med school (five years ago) was heavier. They're $2 at the local bookstore and weigh less than my phone.

That's right, my smartphone elicits stronger reflexes than a standard Taylor hammer.

Sandra said...

OMG what is wrong with me... I read this entire post and could care less about hammers. LOL

As to snobs..well, my sister and her husband are embarrassingly so.
I often want to hit them in the head...can I borrow your hammer?

redgirl said...

I LOVE this post!

If someone ever beat the crap out of me, I would accept a good reflex hammer as an appropriate apology gift.

And come ON Dr. Grumpy, we *have* to hear the story of how you would know about the defense capabilities of the Queen Spare Hammer. Just a leeetle hint?

EDNurseasauras said...

Bang! Bang! Grumpy's silver hammer came down upon his head,
Bang! Bang! Grumpy's silver hammer....oh, sorry, got carried away.

Anonymous said...

What about the giraffe hammer? What does this say about the neurologist?

Jen in Cincinnati said...

nerd.

Queen of the Road said...

I feel so deprived. My specialty doesn't have any nifty gadgets. Maybe that's why I'm a shoe snob.

pharmacy chick said...

you have your hammer, and I have my spatula..I think I have the beginnings of a new post....better grab my camera...

I am assuming you had no patients today???LOL

C said...

Do the fancier hammers make it easier to elicit the reflexes? I cannot, for the life of me, elicit the biceps one...

Anonymous said...

Is it really about the hammer or is it the skill of the doctor who uses it? HAHAHA. I have a Taylors, but now I want a Queen's one. I have to figure out my professions ego-item. It might be the stethoscope.

Grumpy, M.D. said...

What's a stethoscope?

Anonymous said...

Does the Queen Square hammer make that humming noise when you use it? Can you get a double-headed one like Darth Maul?

Anonymous said...

Queen Square? How delightfully non-U! Nothing but SW1 for me...

Anonymous said...

5 minutes of my life I will never get back. ;-)

Hammers... who knew? I think everyone within their specialty or expertise, has some they are snobbish about.

M2 said...

We all use the Queen Square type at my school.

However, in answer to your question "What's a stethescope?" It's a heavyish flat round thing on the end of a flexible tubing which primary care doctors use to test reflexes.

sara said...

At one point I think I had the cheap ass tomahawk one. But now I really do use the stethoscope.

a.generic doc said...

What about the ball peen hammer and the sledge hammer.

Er, wait... Nevermind.... those are orthopedic hammers

Not House said...

" If you ever have a neurologist use one on you, ask them how many box tops they had to exchange for their medical degree."

Bwahahaha. Thanks for the best laugh I've had in a while.

"The only thing worse than either of the above is using the head of your stethoscope to check reflexes. Might as well put on a shirt that says "Beware! Greenhorn on rounds!"

Or an orthopod, who might try and judo chop your knee too (happened to me).

Ben S said...

I don't really get the Square being circular, but more importantly, what the heck is a tuning fork used to diagnose?

Grumpy, M.D. said...

Ben:

1. It's named after Queen Square, where it was invented. NOT after the shape of the hammer.

2. Sensory damage.

Rachel said...

I'm a med student in Australia, and the only tendon hammer I've ever used in the Queen Square. It came with the neurology kit that I bought, and if you're lucky enough to find a hammer on the wards of the hospital, it will be a Queen Square. I've seen some people with a Babinski hammer, but Queen Square definitely predominates. Maybe it's just a North American thing that the crappier hammers are available?

On another note, I am now pleased to know that I would not be looked down upon by neurologists for my tendon hammer.

Now if you'll excuse me, I have a paediatrics exam in two hours...

Anonymous said...

Babinski hammer, as in the Babinsky reflex (wherein the toes curl up, or down, or something)? Can you use the pointy end of the hammer to elicit the Babinsky reflex?
Regarding names of instruments, and the people for whom they are named, I recently found out that the Snook hook (used in spaying animals) was named for Dr. James Snook, a member of the 1920 U.S. Olympic pistol-shooting team who later was executed for murdering his girlfriend. To quote the Wikipedia article on him:
I don't know if he's the most interesting person for whom a medical implement has been named, but he's got to be up there.
"The trial was considered shocking for the sexual activities discussed, including fellatio"

laughingdaughter said...

Actually, from my person experience, I have found that the Queen Hammer can handle AT LEAST two serious wacks. You just need to learn how to hit them right. If you want, I can tutor you in the art of Hammer Hitting. But I'm usually hitting doctors, not patients...

Anonymous said...

Just to prove that veterinarians are superior in every way to those who can only treat one (1) primate species, in most practices I ahve worked in, we eschewed poncey hammers for a nice big set of clamps, reversed so as to hit the patellar tendon (or whatever) with one of the round bits made to put your finger in.
Actually it could be a reflection not of our superiority, but of how crappy our incomes are compared to yours...sigh...which is why I quit being a veterinarian.

Doctor Blondie said...

I'm about a Internal Medicine resident and I own a Babinski and a Berliner.
And yes, the Queen Square is found everywhere in the UK, where nobody seems to own their own hammers.

The Berliner I might add is also great fun to put in your hand luggage when travelling by air. Especially when going through security. Bonus points for flying over London Heathrow where you have to go through 2 security points. I am now able to re-pack my entire hand luggage in less than 1 minute.

gabbiana said...

I use the end of my stethoscope. Well, of *course* I do; I'm ER. (Plus, after losing two Tomahawks in medical school, I figured I was done.)

ERP said...

I like reflex hammers but honestly, find them almost useless since my newly aquired skills at getting reflexes with the fingers. We do have a stash of Queen Squares and a Troemner in a drawer in the ER.

SuFu said...

now i know how people feel when i start talking about the differences between microtomes. very interesting though

08armydoc said...

It's only for this quote, "It has a solid, reassuring, feel to it, like if the patient suddenly lunges, you can beat the crap out of him with it." That has enticed me to go find a Tromner and keep it with me at all times.

Who knew that neurologists could be useful?

Watercolor said...

I have fancy colored pencils.....

Dragonfly said...

I have a Babinski that a friend gave me in 3rd year medicine. I still have it, though it spent 3 months away from me last year after a long code before one of the ICU team noticed my name on it and gave it back to me. The more pliable and cumbersome queens square is the model to be found lying around in all Australian hospitals Ive worked in (or...not lying around, hence the need to carry a babinski in my handbag).

carol b. said...

All this hammer talk aside, Doc Grumpy, you sound awesome!!
I'm a lowly ward clerk in an O.R., and if our docs were half as funny as you, my days would be great!

I wonder if, meeting you face to face, we'd recognize you as the author of this blog?? Are you really this cool in person too?

Li'l Azathoth said...

Never mind the Jedi; I want to know what kind of hammers the Sith Lords use.

shrtstormtrooper said...

I bet your Hammer can't touch this.

Dr. J said...

Dr. Grumpy, I feel ignored as you didn't even lower yourself to make fun of us emerg docs and our penchant for testing reflexes by finger percussion or with our stethoscopes!
I also have a big old Queen Square with a label reading FOR SEDATION ONLY that I use for the times I really care about reflexes...
Dr. J

Anonymous said...

i love my new babinsky hammer. i just finished my neurology rotation, and succumbed to the nerdiness, i mean, the greatness of the "real" reflex hammer.

....and Im going into pediatrics (I just matched today!!!!)

rxgirl said...

Sounds like something you should have used on the spider :)

That Lady Druggist said...

Holy Cow! (complete with halos and wings)

We have a Babinski hammer at our pharmacy. It lives in the big ugly purple Vantin pen-holder with several scissors and spare spatulas. How we came to have one, I have no idea. My former boss probably picked it up at one of the many pharmacy conventions he went to. It has some drug company's name on it, but I don't remember which one.

Now we have a proper name for it besides "that weird reflex-hammer looking thingy!"

Anonymous said...

Okay, I'm a long-time reader of your column and happen to be an aspiring veterinary neurologist. I'm one of the few students in the teaching hospital who actually carries a hammer around, though it is the lowly Taylor. It makes ME twitch to see our surgeons using the handle of a pair of hemostats--or even worse, bandage scissors!--to check reflexes--aaggghhh! I would love a Troemner, though I'm afraid the Chihuahuas and kitties might suffer undue harm with its use. Will have to check out the feasibility of the Queen's Square. :) Thanks for satisfying this neuro geek!

Doctor Doom said...

I had a Buck hammer when I was in med school. If I remember correctly the bottom unscrews to reveal a little brush.

Ladybug said...

I noticed our AO using "The Hammer" as a hole punch. A creative use for sure but there are more effective tools for that job. I asked her if she knew what it was. Not a clue.

Apparently it had been missing for several months. No one, oddly enough, had thought to look on the AO's desk,

Anonymous said...

lil az- ask an orthopod.

Anonymous said...

and the apod is backwards today

Anonymous said...

oh *sharp intake of breath* I am strangely pleased to see that New Zealand medical students and junior medical staff only ever use the Queen Square Hammer! I have many memories as a junior (before I jumped ship to anaesthesia) swinging and hitting poor elderly patients with the above instrument and feeling slightly important if not a little uncoordinated :)

Mr Mobius said...

Great primer on the tendon hammer. In the UK, my med school pretends that the Queen Square is the only tendon hammer around. Was once given the Taylor by a drug rep in a nice case. They have a rubbish feel as can't get a good swing on them to elicit a reflex.

Every ward that might need a tendon hammer has Queen Squares lying around. Just back from an A&E placement where the consultant had an obsession over the health risk of pointy tendon hammers lying around everywhere.

CholeraJoe said...

The horror! The horror! As a pulmonologist/critical care doc I would NEVER use my fancy Littman Cardiology stethoscope (complete with built-in S4 gallop) to test reflexes.

I had a Buck in residency, but it got stolen. A Taylor is just fine for what I need it for.

Jonquil said...

Heh. I once had a conversation one of my neuros (yeah, yeah, migraineur) about all the different reflex hammers I have known.

He uses a Queen Square, too.

Abe said...

Craftsman ball pein is the way to go.

Anonymous said...

I personally only use the Queen square tendon hammer, but I have a modified version: the "sawed-off tendon hammer". I took a hacksaw and a file and removed approximately three inches or so, off the pointy end. Now my sawed-off Queen square hammer conveniently fits in all of my bags that I tote around the wards and will not accidentally stab someone with the long point on the end. (also qualifies as a concealed weapon, though I haven't needed it yet....)

terri c said...

My neuro has a heap of things lying in the exam room that look like implements of torture. Now that I know what the Queen Square hammer is I feel grateful that I never asked her what the flimsy-looking thing with the point on it was. I always thought it looked cheap.

Captain Crab said...

Thank God my neurologist uses a Hammer

RxKerBer said...

I had no idea the complexities of reflex hammers. I'll have to pay attention to the neuro my hubby is going to see at Mayo.

RxKerBer said...

And now I've been thinking this all night "By Grabthar's hammer..........."
Alan Rickman, Galaxy Quest

Anonymous said...

When I was in med school, I went to my daughter's first grade class to give a "career" talk. I took several small flashlights and all the reflex hammers I could find lying around loose-- 3 or 4 Taylors, a Buck and a Queen Square I kept for myself to demonstrate with. It seemed the easiest to use, so I made a couple of spares out of Tinkertoys and sent the kids into the dark cloakroom (yes, it was an old building) to try eliciting ocular and tendon reflexes. WHAT was I thinking?! 15 six year olds in the dark with flashlights and weapons--mayhem ensued, but actual injury was narrowly averted. Later, though, I heard mine had been the most exciting career talk...must have been my dynamic speaking.

Anonymous said...

Awesome post...however I must say I'm way more interested in the tuning forks you neurologists use. Since I am a cellist and have one myself. Do you use different pitches?

Melissa

Grumpy, M.D. said...

128K tuning fork is the standard.

512K is rarely used. I have one, but haven't used it in over 10 years.

I'm sure some academic person is horrified to hear that, but in a practical, general neurology practice, the 128K is all you ever use.

They're used to test vibration sense in the hands and feet. Less commonly for hearing testing (look up Weber test and Rinne test on wikipedia).

Anonymous said...

If any neurologist came at me with a Berliner, I think I would run away. As for the last two pix, is the point at the other end for testing the pain withdrawal reflex, silently menacing the patient with risk of pain, or just for ruining the lining of your bag?
For that matter, the nether end of the Taylor, the Tromner and the Berliner all look good for getting under the ring tab of a Diet Coke, thus sparing your fingernails.

Tee said...

Dang, now the first thing my eyes will go to is to see what kind of reflex hammer my doctors are using. Thanks for that!

And you know I have to ask how you found out about the pressure that poor hammer can withstand.

Anonymous said...

I'm a surgery resident. We don't use reflex hammers!

Anonymous said...

I'm an ob-gyn, and I eschew hammers altogether. The lovely 4+ reflexes we get with our pre-eclamptic pat
ients don't require any subtlety.

RxKerBer said...

Follow up : Mayo neurologist used a Tromner. And tuning fork, cotton ball, stick pin, and some plastic long pin thing. Hubby failed at all his test. Just amazing to watch him get poked by that pin starting at the toes and not say ouch until the thigh

Historically Crazy said...

I just watched Peter Frampton's "Sgt Pepper's Lonely Hearts Club Band" and noticed that Dr Maxwell Edison uses a Taylor hammer to change people's appearances... If you don't know what I'm talking about, look up Maxwell's Silver Hammer Steve Martin. It was pretty amusing to read this article then see one of the reflex hammers in a movie that had nothing to do with reflex hammers!

Ishie said...

I was given a Babinski hammer in my early medical student days as a gift.

I got sick of the extra weight in my (short white coat) pocket so went straight to whacking patients with the bell of my stethoscope, thinking I'd found a cool doctor-trick.

Sigh. Off to pathology I go.

Maritfuglen said...

Been reading up on your blog the last days, and it´s keeping me busy at work trying not to fall off my chair laughing!
I work at a chiropractors clinic in Norway, where they actually use the Queens square head hammer on the pasients.

MD said...

It's not snobbishness. Only neurologists can understand the importance of a Queen square hammer with the big rubbery end. If you can't get any reflex out of that, it's truly absent and patient probably has Guillaine Barre which is can be life threatening. That's why we take it seriously.
MD

Whitney said...

I have multiple neuros (an expensive little hobby I have thanks to a very dear brain tumor) and I've never noticed their hammers before - definitely going to be paying more attention!

Anonymous said...

It's Guillain-Barré. My neurologist told me neuros used to be recognizable because they wore a hat pin in their coat with which they stuck their patients. Nowadays, it's safety pins, which afterwards go in the sharps disposal. I was impressed with the low-tech simplicity of the neuro's art — then they trotted out their electrodiagnostic machines ...

Gary in Oakland

Anonymous said...

I don't recall if the neurologist that saw my son even used a hammer, but i do suddenly have everything i need to interpret the look the woman gave me as she held her stethoscope...to his skull.

Just begging for me to ask what the hell she was doing. I was not aware that the extra training to hear blood flow with the silly heart monitor device could lend itself to snobbishness...but that's exactly what i know (now) that i was looking at.

Kat said...

I watched someone use their pager to check reflexes once. I still laugh.

It'sAllGoneToTheDogs said...

In regards to the Taylor hammer: it may seem like a silly reflex hammer, but it's very valuable in veterinary medicine when doing comprehensive exams that test hearing sensitivity. As a vet tech student, part of my exam includes using this to test reflexes, then whapping the tuning fork end on the sole of my shoe and holding to either side of the patient's head to see if they can hear the tone. So - in the words of my four year old nephew - nyah! =P

Jayesh Vira said...

I am a big fan of the Queen Square. I haven't yet mastered it and have broken them on more than one occasion. But the ease and quality of reflexes elicited with the Queen Square makes me feel that the Taylor should be relegated to the museum.

Anonymous said...

I rather like the new Lanska edition of the Taylor hammer!

But this one is my favorite:
http://www.babinski.de/diagnostik/reflexhaemmer/KaWe-Colorflex-Hammer::1190.html

It has about the right weight, size and it's very soft on my fingers.

Anonymous said...

Dejerine for PM&R's!

 
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