Neuro ICU

Neurological Intensive Care Unit

SITE

Columbia

DURATION

4 weeks

MEETING PLACE

Neurological ICU Milstein 8 Garden South at 6:30AM

CALL SCHEDULE

www.amion.com

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● Generally the EM resident will take approximately one 24-hour call and will work as the night float resident for approximately 1 week during this month.

ED SICK CALL RESPONSIBILITY

None

DAILY SCHEDULE

Sign-out from NF resident 6:30 AM

Pre-rounds 7:00AM

Attending Rounds 7:30AM-10:30AM*

Work Rounds (Fellow +/- residents) 4:30PM-6:00PM

Sign-out to NF resident 6:30PM

● Night float (NF) resident leaves after presenting all overnight admissions at the beginning of attending rounds.

● EM resident will participate in attending rounds, work rounds and didactics.

EM WEDNESDAY

CONFERENCE

Encouraged but not expected

EM ROTATOR PAGER

Personal Pager

CONTACT

Jan Classen, MD

Director, Neurological Intensive Care Unit

Director, Neurology Critical Care Fellowship

(212) 305-7232

Email: jac7002@nyp.org

Neurology Chief Resident:

Jessica Schulte jds2244@cumc.columbia.edu

*Attending Rounds duration varies from day to day.

Description of Rotation:

The EM resident will be an integral part of the NICU 1 team. The team is comprised of one neurology PGY 2/3 resident, one EM PGY2 resident, one neurosurgery intern or peds neuro PGY2 resident, one neurology critical care fellow and one attending. Please note that there will also be NICU 2 (neurosurgical post-op) patients in the NICU; the NICU 1 team is not responsible for the care of these patients. A neurosurgical resident is assigned to care for these NICU 2 patients. The neuro, neurosurg/peds neuro, and EM residents covering the NICU for the month will rotate as night float for approximately 1 week at a time. On Sundays, one of the scheduled residents will take 24-hour call.

The EM resident will develop the ability to evaluate, stabilize and treat the critically ill neurological and neurosurgical patient. Techniques particular to critical care neurology will be learned including intracranial pressure monitoring, ventilator management and fluid and electrolyte management. The resident will learn the ethical and legal principles applicable to the care of the critically ill neurological and neurosurgical patient including end of life discussions.

Educational Objectives:

- Develop the ability to evaluate, stabilize and treat the critically ill neurologic and neurosurgical patient based on sound judgment, available evidence, and patient preference. (PC, MK, PBL)

- Develop an understanding of the unique issues and concerns in the care of the critically ill neurologic and neurosurgical patient (MK, PC)

- Become familiar with the physiology of the critically ill neurologic and neurosurgical patient (MK, PC)

- Learn how to utilize medical technology including hemodynamic and intracranial monitoring in the care of the critically ill neurologic and neurosurgical patient (MK, PC)

- Learn about ventilator management and, in particular, issues and aspects of ventilator management critical to the treatment of patients with neurologic and neurosurgical illnesses (MK, PC)

- Learn how to manage the whole patient in order to maximize/optimize the patient’s neurologic status. This includes the management of blood pressure, electrolytes and glucose in the critically ill neurologic and neurosurgical patient (MK, PC)

- Perform critical care procedures such as placement of central lines and arterial lines, Swan-Ganz catheterization and ventriculostomy drains under direct supervision (PC)

- Describe dosage, indications and contraindications for the commonly used pharmacologic agents (MK)

- Demonstrate an understanding of the appropriate use of consultants in the critically ill neurologic and neurosurgical patient (MK, PC, SBP)

- Learn to identify brain death including the performance of an apnea test and cold calorics (MK, PC)

- Demonstrate an understanding of the ethical and legal principles applicable to the care of the critically ill neurologic and neurosurgical patient including end of life discussions (PC, ICS, SBP)

- Demonstrate effective use of informational resources, scientific studies and technology to enhance patient care and pursue self improvement and self education (PBL, SBP)

- Demonstrate good interpersonal skills among patients, families and professional colleagues (PC, ICS, P)

- Always demonstrate respect, compassion, integrity and honesty (P)

- Always advocate for quality patient care (P)

KEY: PC – Patient Care; MK – Medical Knowledge; PBL – Practice-Based Learning; ICS – Interpersonal & Communication Skills; P – Professionalism; SBP – System-Based Practice. Please refer to Section VI of this manual for a full description of ACGME’s Core and General Competencies.

Evaluations:

The residents will receive a core competency-based evaluation by the supervising attending following his/her 4-week rotation in the Neurologic ICU. The review will be forwarded to the Program Director and will become part of the formal semi-annual resident evaluation process. Immediate problems or areas of concern will be discussed as necessary on a case-by-case basis. The resident will evaluate the rotation via the web-based system. This evaluation will become part of the annual review of the program that will be reviewed by the Program Director.

Survival Tips:

• The coat storage area (RN staff room) with bathroom is the 2^nd to last door on the left as you walk into the unit. The code is 1-4-3.
• The on-call room is the door next to the family waiting room. Code 3-4-2-5 (last 4 digits of the neurosurgery pager)
• The code to clean supply is also 3-4-2-5.
• Get a drip/Neuro ICU med card from the pharmacist (Caroline)
• For febrile patients, there is a Neuro fever order set.
• Get signout from the EM resident before you.
• At 6:30am print out the Eclipsys signout form with the overnight events, vitals, neuro exam, plan. Prepare presentations for your assigned patients for rounds. You do not need to write a daily note, the attending writes notes during rounds.
• While rounding: you will be either the boarding, admitting, or assisting resident. As board, you will be responsible for updating the handoff for all presentations. Admitting resident places all orders. Assisting resident is responsible for making sure all images are pulled up for each patient as rounds are going on.
• After rounds, the board resident will update any remaining orders on all NICU 1 patients as well as making sure important goals for the day (consults, imaging) are communicated and completed.
• The assist resident will perform all procedures and help with the board.
• The admit resident will take care of all new admissions, including writing the note, placing orders, updating the handoff, and completing all emergent procedures. Be sure to run your plan by the fellow for every new patient.

Readings:

On Call Neurology, Second Edition. Randolph Marshall, MD & Stephan Mayer, MD, Saunders.

Emergency Medicine Concepts and Clinical Practice, Rosen 5th Edition, Mosby.

Emergency Medicine: A Comprehensive Study Guide, Tintinalli 5^th Edition, McGraw Hill.