Header Child Neurology

Child Neurology Residency

UW and VA Stroke Service

Introduction

This is a two-week rotation on the inpatient stroke service at the UW Hospital and the William S. Middleton Memorial VA Hospital. Residents rotate on this service during their PGY3 year. The rotation emphasizes inpatient care of acute stroke patients.

The inpatient stroke team consists of an attending neurologist who specializes in cerebrovascular disorders or neurocritical care, the neurology resident rotating on service, an advanced practice provider (nurse practitioner or physician’s assistant), several medical students, and at times the stroke program administrative coordinator. Occasionally there are neurosurgery interns, internal medicine interns, or other off-service interns pursuing elective rotations. Pharmacy interns and other observers sometimes rotate on the service as well.

Following are the goals and objectives of this rotation as they relate to the overall training program in neurology and the ACGME-defined competencies. Please refer to the separate stroke service orientation manual for more comprehensive and specific information about the UW Comprehensive Stroke Center and the acute care of stroke patients.

Schedule

During the week, the resident on the Stroke service receives sign-out from the night float resident around 7 – 7:30 am daily M-F and pre-rounds on service patients. Interdisciplinary rounds begin at 0900 each weekday except for Wednesdays, when they begin at 09:30 am due to the neuropathology conferences. These take place in the work room next to the D6/4 nursing station. Teaching rounds follow thereafter, usually ending around 11:00 am (depending on service volume).

After rounds, the resident will write notes and enter orders on current patients. The Stroke service resident is also on call for new stroke consults (including stroke codes) in the UW and VA emergency departments from 8:00 am until 4:00 pm. At 4:00 pm, the night float resident takes over the call pager and will receive in-person signout from the service resident shortly thereafter.

The Stroke service resident is expected to attend regularly scheduled educational lectures at 12:00 pm (Monday – Friday) and 8:00 am morning report (Friday) unless addressing urgent or emergent clinical issues for service patients. Resident are also expected to attend Neuropathology conferences on Wednesday mornings at 8:30 am (on the 1st, 3rd, and 5th Wednesdays of the month) and Neuroradiology conference on Wednesday morning at 7:30 am (on the 4th Wednesday of the month).

The Stroke attending covers ED and inpatient stroke codes as the primary stroke team responder from 12:00 pm to 1:00 pm to facilitate attendance at lectures.

Work Hours

The number of work hours per week is estimated to be 60-70. Residents will have at least one day off each week, free from any and all clinical responsibilities.

The resident will be responsible for tracking work hours and reporting any risk of violation immediately to their attending physician and/or Dr. Sattin.

Patient Care

Goals

  1. Develop competence at inpatient and intensive-care management for patients with acute stroke.
  2. Evaluate and treat acute stroke patient independently.

Objectives

Residents will:

  1. Develop their skills in obtaining accurate historical information from patients and caregivers, with particular emphasis on ascertaining the time of stroke onset.
  2. Be able to clearly communicate to patients and families the risks, benefits, and alternatives to intravenous and intra-arterial thrombolysis.
  3. Learn to discuss the mechanisms of stroke and hospital course with patients.
  4. Counsel patients on risk factor modification and long term outcomes.
  5. Interpret neuroimaging studies including CT, CTA, MRI, MRA, and catheter angiography, meet management decisions regarding IV tPA, IA tPA and thrombectomy.
  6. Learn the principles of post-thrombolysis care and become familiar with diagnosis and management of a variety of specific cerebrovascular conditions including intracerebral hemorrhage, arterial dissection, and venous sinus thrombosis.
  7. Become familiar with basic concepts of stroke rehabilitation, secondary stroke prevention and current research priorities in cerebrovascular diseases.

Medical Knowledge

Goals

  1. Develop self-directed learning skills essential to the maintenance of expertise in 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 stroke patients.
  3. Develop an adequate knowledge base in stroke presentation, treatment and prevention.
  4. Continue to learn how the health care system functions, especially as relevant to the patient with cerebrovascular disease.
  5. Develop adequate knowledge in diagnosis and management of a variety of specific cerebrovascular conditions including intracerebral hemorrhage, arterial dissection, and venous sinus thrombosis.
  6. Understand basic concepts in stroke rehabilitation.
  7. Develop knowledge of current evidence for secondary stroke prevention.
  8. Develop knowledge of current research priorities in cerebrovascular diseases.

Objectives

Residents will:

  1. Learn how to classify stroke into ischemic vs. hemorrhagic and their various subtypes, and about the vascular pathology underlying them. They will learn basic concepts of cerebral hemodynamics, neuroimaging, and neurointensive care.
  2. Develop their skills in lesion localization and the formulation of robust differential diagnoses that go beyond cerebral infarction.
  3. Become proficient in the interpretation of neuroimaging studies including CT and MRI, and the use of such information for clinical decision making.
  4. Learn about stroke risk factors and how these influence stroke classification and treatment.
  5. Learn the evidence supporting acute and preventive stroke treatments including tissue plasminogen activator (tPA), antiplatelet agents, anticoagulants, anti-hypertensives, and HMG-CoA reductase inhibitors.
  6. Gain knowledge on laboratory and diagnostic technologies and their appropriate uses.
  7. Learn how to access written materials including clinical practice guidelines related to patients under their care.
  8. Gain knowledge of laboratory and diagnostic studies and their appropriate uses.

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. Systematically review recent stroke cases during dedicated conferences and use the feedback generated to improve upon subsequent patients’ care.
  2. Learn to critically appraise the stroke literature, with emphasis on clinical trial design and stroke outcome measures.
  3. Become familiar with authoritative sources of stroke practice guidance, such as American Stroke Association scientific statements, and how to access these resources on-line.
  4. Maintain a patient log for tracking number and various diagnosis of patients seen during the rotation to ensure an adequate educational experience.

Interpersonal and Communication Skills

Goals

  1. Become skillful listeners, and develop specific proficiency in communicating with neurologic patients through non-verbal means.
  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.
  4. Become specifically proficient in discussing end of life care.

Objectives

Residents will:

  1. Become skillful listeners, and develop specific proficiency in communicating with aphasic stroke patients through non-verbal means.
  2. Learn to ascertain a precise time of stroke symptom. Determining onset or time the stroke patient was last known well is a crucial skill that will be developed during this rotation.
  3. Learn to communicate rapidly and efficiently with other team members in order to ensure that acute stroke therapies can be provided in a timely manner.
  4. Learn to clearly communicate neurological assessments and plans to patients, their families, and members of the multidisciplinary care team.
  5. Discuss end of life care with patients and their families.

Professionalism

Goals

  1. Learn ethical, regulatory, and legal aspects of neurologic care with emphasis on patients with cerebrovascular disease, including the difference between standard and investigational treatments.
  2. Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of cerebrovascular disease, and a compassionate approach to end of life care.
  3. Demonstrate responsiveness to patient needs that supersedes self-interest.
  4. 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.
  5. Adhere to ethical principles by respecting confidentiality of medical information.

Objectives

Residents will:

  1. Learn ethical, regulatory, and legal aspects of stroke care, including the difference between standard and investigational stroke treatments.
  2. Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of stroke, and a compassionate approach to end of life care.
  3. Adhere to ethical principles by respecting confidentiality of medical information.

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. Demonstrate the ability to work in a multidisciplinary fashion with nurses, case managers, social workers, therapists, primary care physicians, and the various medical and surgical specialties related to stroke.
  2. Learn how to triage patients and allocate resources such as intensive care unit beds and MRI scans so as to provide high quality, cost-effective care.

Become familiar with clinical practice guidelines and participate in the creation and review of stroke program policies and procedures relevant to patient care.

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