Neuroscience Clerkship

CLEVELAND CLINIC NEUROLOGY SERVICE
 

The Cleveland Clinic Foundation

DEPARTMENT OF NEUROLOGY

The Neurology Module is a 28-day experience which will require a moderate amount of work and a large amount of learning. Don't be concerned that you will be left out on a limb with any of the patients assigned to you. There is a Senior Neurology resident on call at all times to help, and each patient you have will also have a resident assigned who will have ultimate responsibility for writing orders, etc. Your ward senior will guide you as necessary and refine your skills to make you more efficient and comfortable with the in-patient care and investigation of neurological disease.

Ms. Tripepi will meet with you and provide with you with a brief orientation on the first day of the module.  After this you will be introduced to the Senior resident on your service who will assign you to a Junior Neurology resident who will in turn act as your mentor for the rotation.

General

You are not expected to know a large amount of neurology before the rotation begins. However, you will be expected to study and learn throughout the rotation. You will often be given brief assignments to discuss the next day, and later in the rotation you may be requested to present a patient at the Thursday noon conference, where attendance is compulsory for everyone on service.

Daily Patient Care

Daily patient care is of utmost importance. You are expected to see (and write your daily notes on) every primary patient and any "active" consults before the staff rounds with us in the morning. This will mean that you may have to arrive at the hospital before morning conference begins (see conference schedule attached).

Order Writing

Medical students are required to have any order countersigned by a Resident or Staff physician before it is processed.

Daily Notes

Daily notes should reflect active and prophylactic issues. Re-examine each patient daily -- looking for any significant change in his/her condition.

Pay attention to: decubitus ulcer formation, urinary symptoms and function, fluid ins and outs, DVT formation, oral intake, activity level, progress in PT, blood sugar....especially if on steroids.

Some Guidelines on Patient Care

A) Write the current medications and dosages in the margin (green sheet) of EVERY primary patient Monday, Wednesday, and Friday, and before any day you will be off. This is to be sure we keep up with medications that were ordered by others, to minimize medications when possible, to streamline on-call coverage problem management, and to standardize care on the weekends.

B) When the team is doing "card rounds", be ready to talk about your patients (i.e. have your cards out in front of you and stay awake -- keep petit mals to a minimum). When the team is seeing your patient on rounds, let someone know the room number immediately upon arrival to the floor (so they can get the chart). Take control (you know who and where the patient is, hopefully). Be the first one in the room, introduce Staff to the patient, pay attention to the patient, you may be the only friend or familiar face they have in the room (scary, eh?!).

C)  On your last day on service, write a Handover Summary of all salient issues, pending tests with a brief mention of the history, hospital course, and pertinent physical exam findings.

D) Consider (on every patient): PT/OT/alternate site coordinator/rehab, social services, PAS stockings or subcutaneous Heparin, H2 blocker, incentive spirometry, skin care, and DNR status or living will.

Neuro-Intensive Care (NICU)

Patients in the NICU are under the care of Dr. Mike DeGeorgia and his Fellows. If medical students are assigned to these patients, it will only occur in the context of close cooperation with a resident who will be involved in all aspects of patient care. These patients require a lot of work and attention but please take it as a compliment if you are assigned in the NICU!

These patients take priority and should be seen first in the morning and last in the evening. There are a few simple but very important rules:

1. See these patients first in the morning and be available to round with the NICU team whenever necessary.

2. Answer all calls to the unit without delay, it could be important.

3. Discuss any treatment plans with Dr. DeGeorgia, your attending, and your Senior.

Outpatient Clinic

In addition to hospital consults and admissions, you may also go to the outpatient neurology clinic of one of the junior neurology residents on hospital service. Your Senior resident will let you know the afternoon. This is an excellent opportunity to see general outpatient neurology.

Sign-Out

Each night you will give a sign-out of your patients in writing to the person on-call. Your Senior may provide you with a typed list so you may fill in the issues each night, but it is your responsibility. Do not leave the hospital without calling the on-call house officer or seeing them if you have time.

Attitude

Please don't be lulled into a false sense of security. At times, the service can be quite relaxed and you will have plenty of reading time and no new patients. However, other times, business will be quite heavy and you may see 1-2 new patients in a day requiring you to see new patients or consults in the evening after X-ray rounds.

On-Call

Medical students are expected to stay in house on-call until at least 10:00 p.m. one night per week, and to have a patient to present on rounds the next day. You may arrange to be on-call with a resident with whom you have worked closely during the day, if you wish.

Please feel free to contact the on-call resident on any given night if you want to get more experience, just make sure you don't crowd another student who may be on-call that night.

Strokes On-Call

We have thrombolysis protocols for acute hemispheric infarcts. While many problems require very prompt attention, this problem is especially acute. To be entered into the intra-arterial study, patients need to have a head CT and be in the angiography suite within less than 6 hours. For IV thrombolysis, the tPA infusion needs to be initiated within 3 hours of the onset of symptoms. In this situation, you will have an ideal opportunity to see acute neurological care.

Neurology In-Patient Services

HOSPITAL SERVICE I

Service base on H61 with one Neurology senior and several Neurology residents and interns. this is also referred to as the "Stroke" service. Patients suffering from vascular-related neurological disease are preferentially admitted to this service, if possible, but other acute admissions and in-house consultations will ensure a broad exposure.

HOSPITAL SERVICE II

Service based on H61 with one Neurology senior and several Neurology residents and interns. This is referred to as the "Multispecialty" service. Most of these patients suffer from non-vascular neurological disease, but the frequency of cerebrovascular disease among emergency admissions and consultations provides a broad experience on this service as well.

PEDIATRIC NEUROLOGY SERVICE

Service based on M30 and M33 with one Pediatric Neurology Senior and one Neurology Junior. These are pediatric patients with neurological disease. Medical students do not typically rotate on this service.

EPILEPSY SERVICE

Two services (Adult Epilepsy and Pediatric Epilepsy) with one Neurology resident and one Epilepsy fellow who alternate calls. These patients are based on M53 (EMU Epilepsy Monitoring Unit), M35 (PEMU Pediatric Epilepsy Monitory Unit), and scattered on the Pediatric and Adult Neurology floors. Medical students do not typically rotate on this service.

MELLEN CENTER

Service of ill multiple sclerosis patients or multiple sclerosis protocol patients. These patients are usually on the H61 floor and are cared for by the Multispecialty Service.

Cross Coverage/Weekends

Medical students are generally allowed one full weekend off per module and can take off  one of the two days during each of the other weekends, exactly the same rules as apply to residents. If/when you have a day off, your patients will be covered by one of the junior residents or interns on the team. It is your responsibility to assign your patients to the "chosen" resident, and to provide an adequate summary of the current issues. This usually means that you will need to take them by to see your patient(s) the night before.

Staff

Please do not call the staff without first consulting your senior. If you have a problem with your senior, make an appointment with one of the Chief Neurology residents.
 

Daily Schedule

Medical Student Lectures: Schedule and syllabus materials are provided at the time of registration in the Department.

Ward Rounds are every morning at either 8:30 or 9:00 (depending on the morning lectures). New patients and new problems will be discussed here. You should have notified your Senior of any significant changes in your patient's status before this time (since you will see all of your patients before rounds, as above).

Rounds end by 11:00 or 12:00 depending on the day's schedule.

Consults will be done during the afternoon. (Stat consults are done immediately.)

Neuroradiology Rounds are at 4:00 p.m. weekdays in the Radiology Conference Room, Hb6. You are responsible for obtaining and hanging any new films on either primary or consult patients which have not been reviewed with Neuroradiology (please just put up Neuro-type films). The films should be on the board before 4:00 p.m. This means you will have to start "rounding up" your films by 3:30. If you are in clinic or otherwise unavailable, have someone else take care of this for you.

Further Lectures in the Resident Lecture Series, Neuroscience Grand Rounds, and other conferences take place every week. Details can be obtained by calling the Neurology Lecture Hotline at x5-6097, which is updated every week. Some of these may be "over your head," but most will have something to offer you. Attend them if you can.

Meeting with Medical Student Fellowship Coordinator

You will meet with Dr. Katzan, when feasible, toward the beginning of your second week and again during the last week on service. This is primarily to give you an opportunity to provide us with your comments and thoughts (positive and negative) regarding your experience. The Education Coordinator will page you to schedule the meeting.

Evaluation of Performance

Your evaluation form will be completed by the Staff with whom you have spent the most time, but every attempt will be made to solicit input from other Staff (when relevant) and the residents with whom you have worked.

Your level of interest, effort, diligence, rapport with families and patients, and medical knowledge are all important to us and will provide the basis for our evaluations. On the last day of the clerkship, you will take the Neuroscience examination, given to all Case students rotating through the Neuroscience Clerkship. The examination takes place on the fifth floor of Hanna House, at University Hospitals. For any questions about the Neuroscience examination, contact Kristin Stacy at (216) 844-5550.