Pediatric Epilepsy Monitoring Unit

Introduction

The PEMU rotation is focused on providing intensive clinical experience in pediatric epilepsy, with an emphasis on developing a systematic approach to reviewing electroencephalography (EEG) and applying that knowledge to the practice of pediatric neurology.  Rotators will be expected to arrive at 8 AM.  Morning duties include review of ongoing continuous EEG studies (EEG’s running on non-elective/hospitalized patients), review of preassigned PEMU patient EEGs, and prerounding on EMU patients with the nurse practitioner to learn about relevant overnight events.  The resident will then staff EEGs with the attending pediatric epileptologist and discuss findings and the clinical implications of those findings.  Throughout the day, outpatient EEGs will become available for the resident to review.  These will be assigned by the attending responsible for those studies.  New continuous EEGs will also become available to review, at the discretion of the attending pediatric epileptologist.  Residents will write reports on studies that are assigned to them by the attending pediatric epileptologist.  In addition, residents are expected to attend Friday morning Epilepsy conference though they are not expected to present.

Patient Care

Goals

1. Develop the skills necessary to evaluate, treat, and counsel all pediatric patients and families with epileptic disorders.
2. Gather essential and accurate information necessary to provide comprehensive care to pediatric patients with epileptic disorders.
3. Demonstrate effective and appropriate clinical problem solving skills using evidence-based medical knowledge and sound clinical judgment.
4. Recognize the ethical, personal and social implications of the diagnosis of epilepsy as well as the issues surrounding predictive testing and interventions for individuals with severe disabilities.

Objectives

Residents will:

1. Obtain accurate and sufficient histories to characterize seizures and to define risk factors for developing epilepsy.
2. Evaluate patients for specific epilepsy syndromes, epileptic encephalopathies, or electrical status epilepticus of sleep.
3. Demonstrate communication skills to educate patients and families regarding epilepsy diagnosis and treatment.
4. Review electrophysiological studies and apply findings to care for patients with epilepsy.
5. Formulate patient management plans regarding appropriate diagnostic and therapeutic interventions
6. Identify patients who would benefit from epilepsy surgery.
7. Identify which patients would benefit from Ketogenic diet or vagal nerve stimulator
8. Determine from the history and physical the likelihood that a patient has focal or generalized onset seizures
9. Determine which medication choices may benefit a patient

Medical Knowledge

Goals

1. Develop self-directed learning skills essential to the maintenance of expertise in Child Neurology.
2. Use internet and printed resources including primary and secondary literature, relevant texts and published databases to acquire, critically evaluate, and use current knowledge regarding diagnostic test availability and applicability, natural history, and management of pediatric epilepsy.
3. Develop an adequate knowledge base in epileptology.
4. Learn how the health care system functions, especially as relevant to the patient with epilepsy.

Objectives

Residents will:

1. Recognize and recommend appropriate treatment of status epilepticus
2. Describe the importance of neuroimaging in the evaluation of patients with epilepsy.
3. Be able to classify seizure types and epileptic syndromes.
4. Explain the utility of epilepsy monitoring and the evaluation of intractable epilepsy, especially the use of surgical treatment of epilepsy.
5. Describe the principles of EEG generation and recording.
6. Achieve an orderly approach to the interpretation of EEG studies.
7. Identify normal and abnormal EEG patterns in children and neonates, including
   1. Normal and abnormal background findings
   2. Benign variants

• Interictal epileptiform abnormalities

1. Patterns of encephalopathy in critically ill patients

8. Describe the developmental features of EEG from birth through childhood, including;
   1. Common waveforms seen in neonates.
   2. Evolution of normal background.
9. Recognize abnormal EEG findings and correlate EEG findings with clinical epilepsy syndrome and seizure types in neonates, infancy, and childhood.
10. Achieve skills in creating EEG reports.
11. Identify seizure patterns on EEG in neonates, infants and children and in different epilepsy syndromes.
12. Correlate video recordings of seizures with EEG tracing.
13. Identify common and uncommon EEG artifacts.
14. Understand the meaning of electrocerebral silence and the use of EEG as an ancillary test for brain death determination.
15. Describe the principles of Wada testing.

Practice-Based Learning and Improvement

Goals

1. Use skills acquired during primary residency training as an initial foundation for medical and ethical decision making
2. Identify opportunities for improvement in the delivery of quality of patient care.

Objectives

Residents will:

1. Appraise literature to better understand pediatric epilepsy syndromes and their etiology and clinical presentation.
2. Assess studies that evaluate treatment options for specific seizure types and epilepsy syndromes.
3. Apply and use the International League Against Epilepsy (ILEA) website that aids in understanding epilepsy syndromes and seizure management.

Interpersonal and Communication Skills

Goals

1. Become skillful listeners, and develop specific proficiency in communicating with patients with epilepsy and their families.
2. Learn to communicate rapidly and efficiently with other team members in order to ensure that proper therapies can be provided in a timely manner.
3. Learn to clearly communicate neurological assessments and plans to patients, their families, and members of the multidisciplinary care team.

Objectives

Residents will:

1. Develop techniques to obtain accurate history from patients, and gain the patients’ confidence and trust.
2. Describe rationale for new EEG studies to the EEG technician.
3. Create reports that accurately convey EEG findings and relate these findings to the clinical setting.
4. Interact effectively with other members caring for patients including nursing and technical staff.

Professionalism

Goals

1. Demonstrate continuing commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity.
2. Learn ethical, regulatory, and legal aspects of care for pediatric patients with epilepsy, including the difference between standard and investigational treatments.
3. Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ and parents’/caregivers’ medical decisions in the context of neurologic disease.
4. Demonstrate responsiveness to patient needs that supersedes self-interest.
5. Demonstrate compassion, integrity, accountability and respect in all interactions with patients from diverse backgrounds in gender, age, culture, race, religion, physical and cognitive ability and sexual orientation.
6. Adhere to ethical principles by respecting confidentiality of medical information.

Objectives

Residents will:

1. Show respect, compassion, integrity and ongoing professional development.
2. Verbalize ethical principles with adherence to confidentiality, HIPAA principles, and appropriate informed consent.
3. Determine psychosocial issues that complicate care, especially as it relates to the possibility of patient history of physical or sexual abuse and the diagnosis of nonepileptic seizures.
4. Be punctual and appropriately attired.
5. Complete EEG reports in a timely manner.

Systems Based Practice

Goals

The resident recognizes that he/she is part of a large and intricate health system that has implications for his/her ability to care for patients and impacts upon his/her patients’ human needs and financial resources.

Objectives

Residents will:

1. Identify the importance for proper diagnosis and treatment of epilepsy as to the effect of diagnosis on insurability and driving privileges.
2. Assess efficiencies of the AFCH and UW systems regarding patients referred from other centers, and develop management plans that are effective and not redundant or wasteful of medical resources.
3. Make decisions regarding the cost considerations of choosing appropriate antiepileptic drug therapy.