Elective Experience: Neurology/ Neurocritical care at Emory School of Medicine

Elective Experience: Neurology/ Neurocritical care at Emory School of Medicine

AOA all,

Bilal asked me to share my experience at Emory with you guys, so here goes nothing!

I was fortunate enough to be sponsored for a 6-week elective in neurocritical care at Emory University in Atlanta. Neurocritical care is essentially a subspecialty of neurology which requires a 2-year fellowship after completing a neurology residency. A physician specializing in neurocritical care is known as a neurointensivist, and
he or she essentially works in a specialized ICU for neurological and neurosurgical patients.

I ended up doing three weeks in neurocritical care and three weeks in vascular/stroke neurology.

Me with Muaza and Usama Qayyum (Class of 2011)

The three weeks I was in neurocritical care were not very stressful or hectic, but I did learn a lot. I would arrive at the hospital by 7 or 8 am, go over the patient list for about an hour with one of the
pharmacy students who was also on the rotation (it helped a lot to talk out the cases with a fellow student), and then begin rounds with the attending physician and the team of nurses on duty for that day at 9 am. This rotation was essentially all listening and discussion during rounds, from about 9 am in the morning until noon or 1 pm.
Patients in the neuro ICU usually have a decreased level of consciousness or are hooked up to ventilators or have other issues which make performing a standard neurological exam more difficult. The exams are performed hourly by the floor nurses or nurse practitioners as opposed to the neurointensivists or the neurocritical care fellows.
I would essentially participate in patient discussions and ask pertinent questions as to what was appearing on CT or MRI scans, why certain steps of management were being taken, why particular drugs were being prescribed, etc. There wasn't much room for hands on activity because of the nature of the condition of the patients. Among the advantages of rotating in neurocritical care were  that it was a relatively stress-free elective from a medical student's point of view; as it was my first elective, and adjusting to a new city and hospital was a bit overwhelming, a relative relaxed rotation environment was certainly a welcome break. In additional, critical care units implement a multi-system approach to patient management.
While my primary interest in the elective was studying neurological disease, the ICU environment allowed me to incorporate my knowledge of other systems to develop a more complete picture of the condition of

different patients. For someone like me who is interested in neuroscience but still not sure about whether his calling is neurology or neurosurgery, the neuro ICU let me explore a bit of both; although the focus was much more clearly on the medical management of patients, even the post-op neurosurgery ones. I found it to be an excellent precursor for my neurosurgery elective at Henry Ford later that summer. The cases I saw included: subarachnoid hemorrhage, status epilepticus, Lennox-Gestaut sydnrome, SIADH, neurosarcoidosis, and many others that I can't name off the top of my head right now.

After two weeks of neurocritical care, I emailed the neurology department education coordinator, and she was able to arrange a three-week elective for me on the general neurology floor at one of Emory's affiliated hospitals, Grady Memorial, one of the largest public hospitals in the U.S. (I think #5 in terms of public hospitals). This service focused on stroke patients. I actually had the honor of rotating with the director of the neuroscience and stroke center and professor and chief of neurology there for 2 weeks while he was the attending physician on the service. Although they were a bit tougher and busier than my three weeks in neurocritical care, I treasured these three weeks the most out of my entire experience in Atlanta. I would have to get to the hospital by 7 AM in the morning for sign-out rounds delivered by the night staff to the morning staff in the neuro ICU at Grady regarding all the patients in the ward and in the neuro ICU. This would take about 30 minutes. At 7:30, the chief resident of neurology would assign each of the 4-5 residents and 1-3 medical student working with him/her patients to check up on. Usually I would be assigned one new patient each day to complete a history and physical exam on to present to the attending physician during morning rounds that day at 9:30 AM. This would be more than enough time to prepare the case. I would start by pulling up the patient's file on the computer database and going through his/her most recent laboratory work-up, and briefly seeing his/her reason for admission. I would then go take a brief history and perform a directed neurological exam on the patient depending on the nature of his/her symptoms. I would then go back and look up any previous or recent imaging the patient had performed on them. I would try to read the scans myself with the help of the notes written by the radiologist. I would also ask some of the residents who had some free time to quickly go over the scans with me if time permitted. At 9:30, the attending physician arrived and the entire team of nurses, residents, medical students, the attending himself would sit together in a large conference room and go over each new patient. At this time, I would present a new case almost daily. After each presented case, the attending would pull up recent scans of the patient and go over how to read the scan and interepret its findings. For me, this was the coolest part of the entire rotation.The professor would break the scan down to a very basic level so that everyone in the room -- no matter what level of medical knowledge they possessed -- could understand what he was saying. There wasn't a feeling of stress or expectation to perform up to par. There would just be a genuine curiosity to listen intently to what the professor was saying and showing us because it was just so fascinating and
comprehensible. It really made me more confident about reading head CTs. After going over each patient, the entire team would go to each patient individually and see how they were doing. Brief discussions would follow each visit, and occasionally the attending would pitch questions to residents and medical students. Sometimes he would even have us look up interesting facts and case presentations.  By noon time, rounds would be over and everyone would take a lunch break. During lunch, there would usually be a conference on some interesting topics like epilepsy or neuro-ophthalmology or ethics regarding patients with neurological disease. After lunch, the residents would just follow up on their patients. The chief resident would have us go see interesting cases or teach us a particular topic or have us observe certain procedures. By 5 or 6 pm, we would be allowed to go home. During this rotation, I delivered a presentation on basilar artery thrombosis to one of the chief residents. Some of the cases I
saw included multiple sclerosis, generalized tonic-clonic seizure epilepsy, anterior spinal artery syndrome, lateral medullary syndrome, medial medullary syndrome, Broca’s aphasia, middle cerebral artery stroke, posterior cerebral artery stroke, cerebellar stroke, thalamic stroke, apraxia of eyelid opening,  and thalamic estasia.

Overall, my experience at Emory was amazing. I think the fact that it was a university program and that it ranks very highly in neurology had a lot to do with the excellent caliber of teaching. In addition, I found Atlanta to be a very fun city. There's a lot to see and do. The weather gets really hot during the summer so I would recommend going
around May or June as opposed to July. I had great company at the Villa International where I was staying. I met other medical students, doctors, and researchers from all over the world. We went out to eat and explore the city, so I wasn't alone or homesick when I came home from my rotation. This was something I completely hadn't expected but turned out to be a good surprise.

Outside CNN Center - Atlanta, Georgia

It also established a very solid base for my neurosurgery elective the following month, where there was less formal teaching and a greater expectation to be familiarized with the general tenants of neurological history-taking and exam performance.

Hope that was informative/helpful! Good luck in your electives hunt!

--
Smeer Salam
King Edward Medical University, MS V
smeer.salam@gmail.com