Rotation Description and Goals
The inpatient Neurology teams are divided into the General Neurology service and the Stroke service. During the Epilepsy and EEG elective rotations, residents have the opportunity to see patients in the Epilepsy Monitoring Unit (EMU). Residents on inpatient services are expected to arrive to the resident workroom by 7am for checkout and pre-rounding.
The General Neurology service consists of an attending physician, a supervising resident (either a PGY-3 or PGY-4), a PGY-2 resident, and two to three PGY-1 level residents from either the neurology, PM&R, internal medicine or psychiatry programs. Our nurse practitioner, Jena Neesen, sees patients and coordinates discharge planning with the help of a floor case manager and social worker. Rotating medical students and/or observers complete the team.
The attending supervises the activity of the entire team and rounds with them daily. Rounds typically start around 0900 in the resident workroom. Then senior resident on the service is responsible for overseeing and organizing the assignment of patients to the team. Patients followed by PGY-1 level residents and other off-service rotators are also overseen by the senior neurology resident. The medical students and observers follow along with the neurology residents. Rounds take place daily seven days a week (including holidays), and potentially more than once a day in cases of emergency room or ICU consultations. The attendings also take time typically in the afternoon for resident education if time allows.
The stroke team consists of a senior resident, an attending physician, a PGY-2 neurology resident, and a PGY-1 level resident from neurology, neurosurgery, internal medicine or PM&R programs. Jen Kaluza is the nurse practitioner on the team who follows patients and assists with coordinating discharge planning and assuring that stroke core measures are properly documented. Rounds typically take place at 0900 in either room 6819 in the Clarkson Tower or in the clerkship workroom.
Traditionally, the PGY-2 resident carries the stroke pager and responds to activations under the guidance of the supervising resident. Residents will be instructed to enter the Acute Stroke Protocol order set and accompany the patient to the CT scanner. The stroke attending will also evaluate the patient and review imaging either via TeleStroke or at bedside, when available. IV tPA will never be given until discussed and instructed to do so by the attending stroke neurologist. When indicated, CTA and CTP are obtained and if there is evidence of a large vessel occlusion, the neurology resident is then responsible for directly contacting the on-call neurosurgery attending for possible thrombectomy.
Night coverage is provided for the general neurology, epilepsy monitoring unit and stroke neurology services by a designated night float resident. The night float resident arrives to take check-out from the day team at 5pm and provides check-out to the day team at 7am from Sunday evening to Friday morning. Night coverage on Friday and Saturday night is provided a weekend night float resident from 5pm-7am both nights. Night float is only provided by PGY-2 and above residents. There is an average of 4 weeks of night float per resident per year.
Epilepsy Monitoring Unit (EMU)
This 8-bed unit is located on the 6th floor of the Clarkson Tower. Patients are electively admitted on Mondays and are monitoring on video EEG throughout the week to either characterize spells or to localize known seizures. Intracranial monitoring, stereotactic EEG and epilepsy surgeries/procedures are also observed on this rotation. Residents review the long-term EEG data with the epilepsy attending and participate in rounds to assist in further clinical decision-making. This rotation is available both as a mandatory rotation and as an elective.
Weekends & Holidays
Just like during the week, the general and consult teams combine to form one team, while the stroke team round separately from them on Saturdays and Sundays. Four residents cover the weekend, including a PGY-2 resident, a PGY-3 resident, and either two PGY-1 residents from the inpatient services or a PGY-1 with an off-service PGY-4 resident. The PGY-3 resident rounds both days of the weekend and is expected to cross-cover for both inpatient services as needed in addition to giving checkout to the night float residents on Saturday and Sunday. PGY-1 residents round on both days and are able to depart after rounds at the discretion of the PGY-3 resident. They are expected to assist with new consults and admissions on both Saturday and Sunday. PGY-4 residents are typically also on call at the VA and may leave after rounds once their work is completed. They are not expected to see new consults and admissions at UNMC, though they can assist as needed.
Coverage does not change on holidays. Holidays that fall on weekdays operate just the same as any other weekday, and the same is true for holidays that fall on weekends.
EMU patients are discharged either on Friday or earlier during the same week of their admission, and therefore there are no weekend or holiday responsibilities for residents rotating in the EMU.
VA Medical Center
At the Omaha VA, one neurology resident (PGY-2 to PGY-4) level is assigned to the inpatient consult service for either 2-4 week blocks from 0800-1700. Neurology is a consult service only and does not admit patients. In addition to responding to inpatient consults, the VA resident is also responsible for answering E-consults with non-urgent questions from outpatient providers. On occasion, the VA inpatient resident will provide coverage for the outpatient VA continuity clinics when the general neurology clinic resident is unavailable or if there are other unanticipated issues.
Children's Hospital & Medical Center
At Children's Hospital & Medical Center, the team consists of a PGY-3 neurology resident who is supervised by the pediatric neurologist on service. On occasion, there are pediatrics residents, child psychiatry fellows, neurosurgery residents and medical students on the team. The inpatient child neurology rotation takes place mostly at Children's Hospital & Medical Center but also at UNMC. The neurology resident takes a history, performs a neurologic examination, and collects and reviews available laboratory data prior to presenting to the attending. The neurology residents during this rotation will also provide coverage every other weekend. There are no overnight call responsibilities while on pediatric neurology. Your pediatric neurology NEX exam is expected to be completed during this rotation. Thursday mornings on this rotation consist of lectures on different topics, case reports and journal clubs.
Ambulatory Rotations & Clinics
Neurology Continuity Clinics
All residents at the PGY-2 level and above are required to attend one pre-assigned half-day of clinic per week at the VA Bronze Clinic, which is located in the brand-new ambulatory care center. The clinic provides general neurology care to veterans, and each resident carries the same patient caseload throughout their three years of dedicated neurology training to establish continuity. Though attendings staff each clinic and are available for guidance, patient care is dictated by the resident and they are responsible for placing all orders, following up on tests and delivering results, and responding to patient phone calls.
General Neurology & Subspecialty Clinics
During the general neurology outpatient rotation, residents have the opportunity to gain general neurology exposure at UNMC main campus, UNMC Twin Creeks campus in Bellevue (a short 15 minute drive from campus) or at Methodist hospital, a short 8 min drive from campus. In addition, subspecialty clinics are also available at Bellevue, UNMC, or Village Pointe and may include Behavioral/Cognitive Neurology, Epilepsy, Neuromuscular, Neuroimmunology/Multiple Sclerosis, Neuro-Oncology, Movement Disorders, Interventional Pain medicine, Sleep medicine, Neuroradiology and Vascular/Stroke Neurology.
This is a resident run clinic on Thursday and Friday mornings every week that is overseen by a staff physician. The purpose of the clinic is to facilitate more immediate access and transition of care for patients discharged from the inpatient neurology services and/or patients referred or seen as a consultation in the emergency department. Patients are seen once in the resident clinic and then are either discharged from clinic or referred to establish long-term care with a general or subspecialty neurology clinic.
During the entire residency, our residents have the opportunity to receive 8 months of dedicated training in the following specialty areas:
- EMG/Neuromuscular Medicine (at least one month in PGY-3 year)
- EEG/Epilepsy (at least one month in PGY-3 year)
- General Neurology
- Movement Disorders
- Neuropathology (two weeks during the PGY-4 year)
- Psychiatry (typically one month during intern year)
- Vascular Neurology/Stroke
- Neurocritical care (mandated rotation during PGY-2 year)
In addition, residents have 8 months of elective time to do rotations of their choosing. In addition to the specialty areas listed above, there are opportunities in:
- Behavioral and Cognitive Neurology
- Neurocritical care
- Pain Medicine
- Research Elective
- Pediatric neurology