Rotation Description and Goals
The inpatient Neurology teams are divided into the General Neurology and the Stroke service. During the Epilepsy and EEG elective rotations, residents also have the opportunity to see patients in the Epilepsy Monitoring Unit (EMU).
This service consists of an attending physician, a supervising resident (either a PGY-3 or PGY-4), a PGY-2 resident, and a PGY-1 level from either the neurology or psychiatry programs. Our nurse practitioner, Jena Neesen, also sees patients as well as coordinated 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 on a daily basic, typically 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 stroke team now includes a senior resident for almost all months of the year in addition to an attending physician, a PGY-2 neurology resident, and a PGY-1 level resident from neurology, neurosurgery, or PM&R. Jen Kaluza is the nurse practitioner on the team who not only follows patients but also assists with coordinating discharge planning and assuring that stroke core measures are properly documented via the Stroke Navigator. 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 should 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 and stroke neurology teams by a designated night float resident. The night float resident arrives to take check-out from the day team at 1800 and provides check-out to the day team at 0700 from Sunday evening to Saturday morning. Night coverage on Saturday is provided by the PGY-2 on 24-hour call. Night float is only provided by levels PGY-2 and above. There is an average of 4-5 weeks of night float per resident per year.
Epilepsy Monitoring Unit (EMU)
This 6-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. Residents review the long-term EEG data with the epilepsy attending and participate in rounds to assist in further clinical decision-making.
Weekends & Holidays
Just like during the week, the general and stroke teams round separately 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-2 resident works a 24-hour call starting at 0700 on Saturday and ending at 0700 on Sunday, including a four-hour period from 0700-1100 on Sunday for transition of care. The PGY-3 resident rounds both days of the weekend and is expected to cross-cover for both inpatient services on Sunday in addition to giving checkout to the night float resident at 1800 on Sunday evening. 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. 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. Once per month, the VA neurology resident is also expected to arrange a time to meet with the internal medicine residents to review acute stroke protocol and provide education on performing the NIH stroke scale. Dr. Fernandes is the site director of the VA and rounds on the inpatient service on Monday, Thursday, and Friday. Dr. Bertoni rounds on Tuesdays and Wednesdays. The inpatient VA resident alternates weekend calls with a senior resident (typically a PGY-4).
Children's Hospital & Medical Center
At Children's Hospital & Medical Center, the team consists of a PGY-3 neurology resident who is supervised b the pediatric neurologist on service. One occasion, there are also medical students and neurosurgery residents on the team. The inpatient child neurology rotation takes place either at UNMC or at the Children's Hospital & Medical Center. The neurology resident takes a history, performs a neurologic examination, and collects and reviews available laboratory data prior to presenting to the attending. There are no overnight call or weekend responsibilities while on pediatric neurology. Your pediatric neurology NEX exam is expected to be completed during this rotation.
Ambulatory Rotations & 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 Gold Clinic. 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 and ambulatory rotations, residents have the opportunity to gain general neurology exposure at UNMC of at the Twin Creeks location in Bellevue. In addition, subspecialty clinics are also available at either Bellevue, UNMC, or Village Pointe and may include Behavioral/Cognitive Neurology, Epilepsy, Neuromuscular, Neuroimmunology/Multiple Sclerosis, Neuro-Oncology, Movement Disorders, and Vascular/Stroke Neurology.
In January 2017, we also instituted a resident run clinic on Tuesday and Wednesday afternoons 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 referred on 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)
- Vascular Neurology/Stroke
In addition, residents have 3 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
- Pain Medicine
- Research Elective