Vascular neurologic disease is common, increasingly complex, and frequently a component of patient care in the neurocritical care unit. The skillset needed to manage patients with acute brain injury and concurrent vascular neurologic issues is highly specialized and in demand.
Training for the vascular neurology rotation occurs in the inpatient and consult stroke services at NYPH-Columbia campus over two weeks during the first year of fellowship. Upon completion, fellows are proficient in the complex management of a wide range of vascular neurologic issues in patients with severe acute brain injury. The following set of core educational objectives is designed to clearly communicate the expectations of neurocritical care fellows in terms of knowledge, skills and attitudes during their elective in vascular neurology.
These educational goals are met through a series of clinical experiences in vascular neurology (supervised clinical practice in the Columbia inpatient and consult stroke services), regularly scheduled seminars and conferences neuroradiology and vascular neurology, multidisciplinary conferences (neurovascular, critical care grand rounds) and individual projects.
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INDEX OF COMPETENCIES: PC=Patient Care; MK=Medical Knowledge; PBLI=Practice-Based Learning & Improvement; ICS=Interpersonal & Communication Skills; Prof=Professionalism; SBP=Systems-Based Practice |
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This rotation is a two-week rotation, to be completed by the end of the first year of fellowship. At the end of the rotation, the fellows are expected to demonstrate the following:
Objective 1 (PC, ICS, PBLI, MK): Demonstrate proficiency in all medical and diagnostic procedures considered to be essential for the area of vascular neurology practice by:
- Demonstrating competence in the following procedural vascular neurology skills, applications of advanced technology and instrumentation for monitoring the physiologic status of patients with vascular neurologic issues:
- Neurologic: Consistent completion of a thorough neurologic exam on adults with vascular neurologic injury. Interpretation of cerebral and carotid ultrasound as measures of intracranial physiologic monitoring. Interpretation of neuroimaging including transcranial Doppler, computed tomography, and magnetic resonance imaging.
- Respiratory: Recognition of patients requiring mechanical ventilation (both invasive and non-invasive) as pertinent for patients with vascular neurologic issues on the inpatient and consult vascular neurology services.
- Cardiac: Interpretation of cardiac telemetry and interpretation of echocardiography and cardiac output monitoring on patients on the vascular neurology services
- Renal: Evaluation of renal function based on blood and urinary laboratory results. Evaluation of renal function based on imaging studies including renal ultrasound and computed tomography of the abdomen and pelvis.
- Gastrointestinal: Appropriate nasogastric tube placement, use and interpretation of enteral feeding, and management principles of percutaneous enteral devices.
- Hematologic: Fellows will be able to evaluate and manage hypercoagulable conditions, and correct intrinsic and extrinsic coagulopathies for patients with acute vascular neurologic issues. Fellows will show appropriate selection and use of transfusion products for patients with acute vascular neurologic issues
- Infectious disease: Fellows will be proficient in classification of common infections in critically ill patients and apply isolation techniques. Fellows will interpret and apply principles of pharmacokinetics, drug interactions, and management of antibiotic therapy.
- Nutritional: Fellows will demonstrate appropriate application of parenteral and enteral nutrition in. Fellows will appropriately monitor, assess metabolism and nutrition of patients with acute vascular neurologic issues
- Physical therapy: Fellows will be familiar with use of specialized beds, traction, and fixation devices for specific injuries in vascular neurology.
- Communicating with patient families current and projected clinical courses for patients with vascular neurologic issues
- Recognizing common diagnoses in vascular neurology such and developing a comprehensive differential diagnosis regarding etiology. Examples include (but are not limited to):
- Acute ischemic stroke – including presentations with administration of tissue plasminogen activator and neurovascular intervention
- Acute hemorrhagic stroke
- Hypoxic-ischemic encephalopathy
- Infectious and rheumatologic causes for vasculitis
- Reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and other disorders of cerebral autoregulation
- Increased intracranial pressure and herniation syndromes
- Brain death
- Developing and executing a therapeutic management plan for patients with common diagnoses in vascular neurology
- Participating in a multi-specialty team of physicians, medical students and allied health professionals in patient management.
Objective 2 (MK): Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care in vascular neurology by:
- Recognizing and independently managing common cases of vascular neurology including:
- Acute ischemic stroke – including presentations with administration of tissue plasminogen activator and neurovascular intervention
- Acute hemorrhagic stroke
- Hypoxic-ischemic encephalopathy
- Infectious and rheumatologic causes for vasculitis
- Reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and other disorders of cerebral autoregulation
- Increased intracranial pressure and herniation syndromes
- Brain death
- Supervising residents and students in the diagnosis, evaluation and treatment of vascular neurology issues
Objective 3 (ICS, MK, PBLI): Acquire and demonstrate the ability to synthesize and apply knowledge and understanding gained from basic science, clinical research, and information technology to provide accessible information to patients and support one’s own education by:
- Leveraging information technology to gather the most up-to-date scientific evidence to make informed decisions regarding diagnostic and therapeutic interventions.
- Proficiently using information technology to manage information, access on-line medical information, support their own education, and apply this information in the clinical care of patients.
- Finding, assessing, and assimilating the best evidence for clinical decision-making and continuously evaluating and improving patient care practices.
Objective 4 (SBP, PROF, ICS): Leverage knowledge of medical systems and regulatory requirements of medical training and practice by:
- Participating in analysis of safety event(s)
- Disclosing patient safety events to patients and their families (simulated/actual) with guidance from mentor as needed
- Performing patient safety and/or quality improvement project(s)
- Delivering patient-centered care with focus on individual needs of patient and family
- Leading interdisciplinary patient-centered care
- Advocating for safe and effective transitions of care
- Adjusting individual practice to address needs of specific patient populations
- Modifying individual practice to optimize care within a broader health care system
Objective 5 (SBP, ICS, PROF): Demonstrate professionalism and expertise in using the system of care in a way that is beneficial and essential for patients, by:
- Effectively communicating with other members of the health care team (i.e., other physicians, nurses, social workers, etc.) to coordinate and optimize patient care.
- Advocating for quality patient care and assisting patients in dealing with system complexities.
- Functioning as a team member to facilitate and optimize patient care.
- Demonstrating effective listening skills and providing patients the opportunity to explain their problem and concerns.
- Actively participating in the education of patients, families, medical students, residents and other health care professionals.
- Demonstrating superior interpersonal and communications skills with professional associates and other health care providers.
Objective 6 (ICS, PROF, PC): Demonstrate the ability to interact and communicate with patients in a manner that is culturally sensitive and patient-centered, by:
- Demonstrating respect, compassion, integrity, and responsiveness to the needs of patients, their families and society that supersede self-interest.
- Providing care that is sensitive to each person’s age; gender; and cultural, economic, and social circumstances.
- Demonstrating clear, understandable, and effective interpersonal and communication skills to counsel and educate patients and their families.
- Demonstrating a commitment to ethical practices pertaining to patient privacy and autonomy, the provision or withholding of clinical care, confidentiality of patient information, informed consent, and conflict of interest and business practices.
- Creating and sustaining a therapeutic and ethically sound patient-physician relationship.
- Creating and sustaining an environment where patients and their families feel comfortable asking questions about the patients’ diseases and treatments.
- Promoting an environment that supports shared decision making by including patients and families in decisions and choices about treatment.
- Effectively and empathetically delivering bad news to patients and their families.
Objective 7 (ICS, PROF, SBP): Demonstrate the ability to interact, communicate and work effectively with clinical and ancillary staff in inpatient neurology, ED (Emergency Department) and consult arenas, by:
- Supervising patient care activities in the neurology inpatient, ED, and consult arenas.
- Obtaining and providing appropriate consultation.
- Carrying out respectful and effective communication with: colleagues, nurses, and ancillary staff in a way that encourages cooperation and patient-based care.
Objective 8 (PROF): Demonstrate the ability to conduct oneself in a professional manner by:
- Consistently exhibiting a professional appearance; neat, well-groomed, conservative attire in compliance with the hospital dress code
- Consistently demonstrating professional attitudes consistent with being a physician, with an emphasis on responsibility, compassion, sensitivity to diverse patient populations and cultures.
- Continuously adhering to ethical principles, confidentiality, informed consent and a commitment to excellence and on-going professional development.
- Exhibiting dependability, responsibility and self-respect.
- Arriving for clinical duties and completing work in a timely manner and with appropriate attention to detail
- Consistently demonstrating personal integrity and altruism.
- Serving as a role model for residents and medical students.
Objective 9 (PROF, ICS): Demonstrate teaching skills by:
- Providing instruction to residents and medical students in vascular neurology.
- Exhibiting leadership in advising, teaching and supervising residents and medical students.