Rotation Specific Objectives

• Adult EMU
  • Faculty Supervisors: Alison Pack, MD, MPH and rotating attending
• Pediatric EMU 
  • Faculty Supervisors: Danielle McBrian, MD and rotating attending
• Telehealth responsibilities at NYP Westchester/Allen Pavilion

Reading routine and Continuous EEGs for both adult and pediatric patients, as well as the Pediatric EMU remotely at the NYP Westchester, and the Allen Pavilion.

At the end of the rotations in Adult Epilepsy Monitoring Unit and Pediatric Epilepsy Monitoring Unit, the fellow will be able to:

Patient Care and Procedural Skills

1. Efficiently obtain a relevant and organized neurologic history that recognizes risk factors for seizures and epilepsy and is relevant to patient’s acuity and clinical setting.
2. Incorporate historical information from external sources.
3. Identify potential neuropsychiatric symptoms.
4. Perform a complete neurologic examination that includes a relevant systemic examination and incorporates all maneuvers (e.g. hyperventilation) appropriate to the patient.
5. Examine patients for common and uncommon side effects of antiepileptic drug treatment.
6. Perform a mental status examination, with particular emphasis for detecting potential neuropsychiatric comorbidities
7. Provide antiepileptic drug treatment for patients with common and uncommon seizure disorders.
8. Select appropriate antiepileptic drug relative to patient’s genetic/ethnic background and comorbidities.
9. Manage common and uncommon side effects of pharmacologic therapy.
10. Identify patients who are appropriate candidates for anti-seizure drug titration, change, weaning, and withdrawal and manage these changes.
11. Identify patients who are pharmacoresistant.
12. Identify candidates for non-pharmacologic therapy (e.g. ketogenic diet).
13. Appropriately utilize laboratory and other diagnostic modalities to monitor therapy.
14. List indications for surgical intervention and apply knowledge of various types of surgical interventions.
15. Identify patients who are appropriate surgical candidates.
16. Actively participate and lead discussion of cases in epilepsy surgery conference.
17. Plan and manage phase 1 surgical evaluations.
18. Manage neurologic issues in the post-operative patient.
19. Identify candidates for devices approved for treatment of epilepsy.
20. Diagnose and manage convulsive and non-convulsive status epilepticus.
21. Recognize and manage uncommon types of non-convulsive status epilepticus.
22. Recognize primary and secondary causes of status epilepticus.
23. Recognize and manage patients with refractory status epilepticus.
24. Recognize life-threatening, idiosyncratic complications of anti-seizure drug therapy.
25. Educate patients and caregivers regrading seizure first aid and the use of rescue medications.
26. Recognize and identify when a patient has a cognitive, behavioral or psychiatric disorder associated with epilepsy.
27. Obtain an appropriate cognitive, behavioral, and psychiatric history in patients being evaluated for seizures.
28. Recognize when a patient’s neurological symptoms are of psychiatric origin. Identify major cognitive, behavioral, or psychiatric side effects of antiepileptic medications
29. Identify psychiatric co-morbidities in patients with non-epileptic seizures.
30. Appropriately refer patients for neuropsychological testing in evaluating patients with cognitive, behavioral, and psychiatric disorders.
31. Recognize when a patient’s psychiatric symptoms are of neurologic origin.

Medical Knowledge

1. Demonstrate knowledge of neuroanatomy and neurophysiology relevant to localization of epileptic focus.
2. Localize epileptic lesions to specific regions of the brain based on history and examination.
3. Select and interpret diagnostic modalities (e.g. EEG, video-EEG, magnetic resonance imaging) to localize epileptic focus.
4. Demonstrate knowledge of and indications for ordering routine and advanced (e.g. PET, SPECT) diagnostic tests.
5. Demonstrate knowledge of and indications for ordering invasive diagnostic tests (e.g. intracranial electrodes, WADA).
6. Individualize diagnostic approach to specific patient.
7. Accurately interpret results of routine diagnostic tests. 
8. Utilize relevant results of routine diagnostic studies. 
9. Demonstrate knowledge of common and uncommon types of seizures and epilepsy.
10. Demonstrate knowledge of seizure and epilepsy classification.
11. Demonstrate knowledge of common and uncommon or rare electroclinical syndromes. 
12. Demonstrate knowledge of clinical and diagnostic findings in common and uncommon seizures and epilepsy.

Interpersonal and Communication Skills

1. Develop positive relationships with patients and families and manage simple and complex conflicts.
2. Actively participates in team based care.
3. Engage patients in shared decision making.
4. Use easy to understand language in all phases of communication.
5. Effectively communicate during patient hand-overs using a structured communication tool.
6. Accurately document transitions of care.
7. Completes documentation accurately in a timely fashion demonstrating synthesis, formulation, and thought process.
8. Effectively communicates during team meetings, discharge planning, and other transitions of care.
9. Educate patients about their disease and management, including risks and benefits of treatment options.
10. Effectively communicate the results of a neurologic consultation in a timely manner.
11. Effectively gathers information from collateral sources when necessary.

Practice-Based Learning and Improvement

1. Acknowledge gaps in knowledge and expertise in epilepsy.
2. Incorporate feedback and develop appropriate learning plan based on clinical experience.
3. Use information technology and scholarly articles to address and answer patient care issues.
4. Critically evaluate scientific literature.

Professionalism

1. Demonstrate compassion, sensitivity, and responsiveness to patients and families.
2. Demonstrate non-discriminatory behavior in all interactions, including with diverse and vulnerable populations.
3. Consistently demonstrate professional behavior, including dress and timeliness.
4. Describes effects of sleep deprivation and substance abuse on performance.
5. Demonstrate appropriate steps to address impairment in self.
6. Demonstrate compassionate practice of medicine and incorporate patients’ socio-cultural needs and beliefs into patient care.
7. Demonstrate appropriate steps to address impairment in colleagues.

Systems-Based Practice

1. Describe team members’ roles in maintaining patient safety.
2. Identify and report errors and near-misses.
3. Describe potential sources of system failure in clinical care such as minor, major, and sentinel events.
4. Describe basic cost and risk implications of care.
5. Describe cost- and risk-benefit ratios in patient care.
6. Make clinical decisions that balance cost- and risk-benefit ratios.
7. Identify responsibilities and duties involved in the care of patients with seizure disorders.
8. Be aware of state driving laws as they relate to patients with seizures.
9. Appropriately utilize and consults with allied health professionals and community resources involved in the care of patients with seizure disorders.
10. Advocates for patient care in all aspects (e.g., work, school).
11. Identifies community resources for care givers.
12. Understands the differences in expectations of care in comprehensive epilepsy centers vs. other health care centers.

Adult and Pediatric ICU Continuous EEG

• Faculty Supervisors: Alison Pack, MD, MPH (adult) and Danielle McBrian, MD (pediatric) and rotating attending

The goal of the adult and pediatric continuous ICU EEG rotations are to provide trainees with the knowledge for the use of continuous digital video-EEG in the context of acute brain injury, encephalopathy, and coma. Trainees will have extensive knowledge of basic EEG patterns seen in coma and encephalopathy, quantitative EEG trending for recognition of acute brain events including seizures, ischemia, hemorrhage, and vasospasm. Trainees will also learn the role of EEG in multimodality monitoring in acute brain injury patients, both with scalp EEG and intracranial EEG and the use of video-EEG recording to formulate specific treatment strategies in complex critically ill patients.

By the end of the academic year, fellows should be able to:

• Objective 1: Interpret continuous video-EEG monitoring studies in adults and children and manage the findings, recognizing the indications and limitations of continuous digital video-EEG monitoring in critically ill patients of all ages (Medical Knowledge).
• Objective 2: Recognize and treat non-convulsive seizures and non-convulsive status epilepticus (Medical Knowledge).
• Objective 3: Design and apply specific quantitative EEG protocols for trending and identifying acute brain events, including measures of rhythmicity, asymmetry, amplitude, power and alpha-delta ratios, and use of compressed spectral array (Medical Knowledge).
• Objective 4: Recognize and manage post-anoxic coma and post-anoxic myoclonic status epilepticus (Medical Knowledge).
• Objective 5: Demonstrate proficiency ineffective interpersonal and communication skills with professional associates and other health care providers (Interpersonal & Communication Skills, Professionalism).
• Objective 6: Demonstrate proficiency in using information technology to gather the most up-to-date scientific evidence to make informed decisions regarding diagnostic and therapeutic intervention (Practice-Based Learning & Improvement).