Inpatient US Clinical Experience in Neurology in Miami

Information about this clinical experience:

You will be under the supervision of a physician who is board-certified in neurology. This attending has an extensive background in teaching medical students and neurology residents. The physician is on staff at multiple hospitals within Miami including Jackson Health. The hospital where the preceptor is on staff has been designated a Comprehensive Stroke Center, meaning that the institution has been recognized to provide the highest level of specialized stroke care.

Rotators will be part of a multidisciplinary team tasked with the evaluation and management of patients presenting acutely with stroke. You will spend time in three different settings: the emergency department, neurocritical care unit, and hospital floor.

Emergency Department

In the emergency department, your team’s priority will be on the initial and rapid assessment of these patients. Several key questions will need to be answered. “Does this patient have symptoms and signs of focal neurologic illness consistent with a vascular territory?” and “When was the last time patient was known to be well?” The answers to these questions will help the team establish an accurate diagnosis of stroke and understand the timing of events or symptom onset, all of which are crucial for assessment and making treatment decisions. Rotators will learn how to utilize standardized stroke scoring systems like the National Institutes of Health Stroke Scale (NIHSS) to assess the degree of stroke severity and provide an objective means for monitoring for changes in the patient’s condition.

As part of the initial evaluation, patients will undergo neuroimaging. Rotators will take note of how a multidisciplinary team efficiently mobilizes patients to ensure that a noncontrast CT of the brain is completed without delay since “Time is Brain.” This phrase is the guiding principle for all steps and actions in the emergency department because during a stroke, every second counts, and delays in treatment can lead to irreversible brain damage. Learners will also become familiar with other forms of neuroimaging and their role in the evaluation of acute stroke, including CTA, MRA, transcranial Doppler ultrasonography, carotid Doppler ultrasonography, and CT/MRI perfusion studies.

Once the initial evaluation is completed, the team can make crucial treatment decisions regarding eligibility for rtPA and/or mechanical thrombectomy. As part of this process, learners will become familiar with inclusion and exclusion criteria for these interventions.

Rotators will find the “Five Ps” of acute ischemic stroke management useful in providing a structured approach to the evaluation and treatment of these patients:

• Parenchyma: Assess brain tissue with imaging to exclude hemorrhage and define infarcted, irreversible core

• Pipes: Evaluate vascular tree to identify site of occlusion or stenosis

• Perfusion: Map cerebral blood flow to identify extent of hypoperfused tissue

• Penumbra: Define area of ischemic but not yet infarcted tissue that can be saved through rapid intervention

• Patency or Procedure: Restore vessel patency through thrombolysis or mechanical thrombectomy to prevent further damage and future complications

Neurocritical Care Unit

Studies have shown that patients with severe neurologic illness have better outcomes and decreased mortality when they receive multidisciplinary care from a team of professionals with experience and expertise in neurocritical care. This team will include the attending, residents, nurses, pharmacist, social worker, physical and occupational therapists, and nutritionist. You will see how the entire team comes together to provide collaborative care.

In this unit, you will observe how patients are closely monitored with respect to the airway, ventilation, and blood pressure. You will understand how the latest evidence in the field will be applied to the management of specific conditions, complications, and situations, including cerebral edema, hemorrhagic transformation, postoperative care, and prevention of postthrombectomy reocclusion, stroke expansion, and recurrence. Useful resources to read include:

Neurocritical Care Aspects of Ischemic Stroke Management

Acute Ischemic Stroke (Internet Book of Critical Care)

Hospital Floor

Stroke patients transferred to the hospital floor will either be admitted here from the neurocritical care unit once their condition warrants transfer or from the emergency department if the stroke is minor and there are no indications for the patient to be in a higher level of care setting.

Regardless of whether the patient is on the floor or in the neurocritical care unit, efforts will be made to determine the etiology and mechanism of the stroke. Initiation of evidence-based treatments for prevention of complications and future stroke will also be focal points in the care of these patients. These will include VTE thromboprophylaxis, antithrombotic therapy, statin therapy, and anticoagulation, among others. Lifestyle modifications to control modifiable risk factors will also be emphasized.

During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision:

• Taking patient histories

• Performing physical exams under the physician’s supervision

• Presenting patients.

• Writing or entering progress notes (Meditech EMR)

• Researching the literature to answer clinical questions at the point of care

• Spending time with other healthcare professionals to understand their roles and responsibilities

Rotators will have opportunities to attend morning report with the internal medicine residents. In addition, there is a weekly vascular neurology didactic conference.

The patient population cared for in this hospital is diverse. Of note, 60% of patients are Spanish-speaking. If you’re not a Spanish speaker, there are multiple members of the staff that can serve as interpreters. The hospital also has interpreter services that team members can utilize.