THE UNIVERSITY OF NORTH CAROLINA
DEPARTMENT OF NEUROSURGERY
NEUROSURGERY RESIDENT/INTERN/STUDENT
RESPONSIBILITIES AND INFORMATION MANUAL
May 2014
SUPERVISION: Patient care including outpatient and inpatient shall be supervised at all times.
Attendings round daily on all patients and review the patient's planned care with the assigned
residents. An attending is present at all operative cases. The residents are assigned specific
attending coverage but are expected to have a working knowledge of all inpatients, including
consults. Outpatient coverage of clinics for all patients seen by residents are supervised by an
attending. All patient care information will be reviewed on a daily basis with resident and the
attending. The attending physician and chief resident are notified of all consultations both inhouse and in the emergency room by the resident. Medical changes in patients are promptly
conveyed; if a resident is unable to contact the appropriate attending, the Chief of the Division is
to be notified.
MORNING ROUNDS:
Every day
6:15 am
Rounds will begin in the Neuroscience Intensive Care Unit. Resident notes are to be written in
Epic prior to rounds. Intern notes are to be in the chart shortly after morning rounds if not before
then. Pertinent films from the night prior will be reviewed in the ICU at the beginning of rounds.
All service patients and all consult patients who are critically ill are seen. The format for patient
presentation is at the end of this handout. The residents will present the ICU/ward service patients
unless a student is assigned that patient. The intern is responsible for gathering vital signs on the
floor/stepdown patients prior to morning rounds. Interns will present the ward patients. These
patients will be seen by the team as a whole and plans will be modified by the Chief Resident and
the Attendings as necessary. Simultaneous pediatric ICU and ward prerounds are conducted by
the pediatric service resident alone. The resident on call the night prior will present the new
admissions/consults. In the absence of the interns or medical students the junior residents will be
expected to present the service patients. Each day a resident will be designated as the roving
resident to cover emergency consults, perform procedures and assure that diagnostic studies are
scheduled and performed. The roving resident will also be responsible for keeping a task list and
ensure the work gets carried out promptly. Junior/senior resident will be responsible for seeing
their assigned attending’s consults throughout the day and writing daily notes when appropriate.
Any issues discovered by the resident will be considered in determining which consults will be
seen on morning rounds.
EVENING ROUNDS: Monday-Friday start between 4:00 - 7:00pm. Rounds will begin in the NSICU. All
patients are seen during these rounds. New data are succinctly presented. New admissions, new
consults, and the fresh post-op patients are seen. Students present on AM rounds. All studies
performed that day are reviewed as a group. The on-call resident should be on rounds if possible
to review the plan about each patient for the night. Cases are assigned at the beginning of the
week. The on-call resident will also be responsible for assisting in procuring films for the next
day’s cases with the resident assigned to specific cases. The on-call resident is also responsible for
loading imaging on the Stealth machine as needed.
OPERATING ROOM:
M
Ewend
Hadar
Jaikumar
Sasaki-Adams
Bhowmick
Elton
Tu
W
X
X
X (except 3rd Wed. of month)
X (except 3rd Thurs. of month)
X
X
X
X
X
X
Th
F
X
On Monday, Tuesday and Friday there are two 7:30 am OR starts. On Wednesday there are two 8:30 am
OR starts. The resident responsible for starting a particular case will be in the operating room promptly.
The assigned resident will be responsible for bringing the pertinent films to the OR and ensuring that the
patient is expeditiously anesthetized, monitored, properly positioned, and prepped. The expected
preoperative preparation includes reading about and discussing the operation with the Chief
Resident/Attending in the days prior to the case and ensuring that all special equipment is present for the
case. Responsibilities also include setting up the microscope, Stealth, or endoscope, in addition to other
neurosurgery OR equipment. Each resident involved in a case is responsible for the care of the patient in
the recovery room. The assigned resident also is responsible for writing post-op orders. The attending will
determine who has dictation duty prior to completion of the operation
PROGRESS NOTES: They will be dated and timed. Residents will write daily notes on all ICU patients.
Interns will write all ward notes. When there is no intern, the residents will write the ward notes
during rounds. The resident/intern should assure that all information is updated and corrected
from repopulated notes. Notes by the junior/senior residents are to include specifics about the
neurologic exam, assessment and plan. Any significant event or studies the patient has should be
documented in the chart expeditiously. This is the responsibility of the junior/senior resident.
PROCEDURE NOTES: All procedures and interventions including suture removal, placement, and
removal of drains and sampling of CSF must be documented in the progress notes. They will be
dated and timed. Procedure notes are required in Epic for all procedures including LP, CVL/SGC,
Arterial Lines, Halo/Skull tongs, lumbar drains and ICP monitors/ventriculostomies. Operative
notes should be dictated within the day of the procedure with a brief operative note typed in Epic
if possible.
ADMISSIONS: The residents will divide up admissions and floor work as equitably as possible among
themselves. On all unscheduled admissions, the junior resident will call the Chief Resident and the
attending as soon as possible after evaluating the patient so studies can be obtained, and
arrangements for the OR made expeditiously. Admission orders and requests for studies should be
filled out as soon as possible after the patient arrives on the floor/ICU. A resident planning an
elective admission through the clinic, must contact bed control/admitting and dictate an H&P. The
resident must notify the Chief Resident and the consult resident. Every effort should be made to
update the problem list of the patient is Epic
PREOP: The intern is responsible for the clinic pre-op workup of patients scheduled for Same-DaySurgery admission. A brief history, physical exam, pre-op studies and a consent form must be
completed at that time, although the consent if often completed by the resident or attending
present. The resident assigned to the case is responsible for checking the results of the labs on
patients who are Same-Day-Surgery admits the next day. The resident or attending assigned to the
case must sign the day of surgery update for patients in PCS prior to the 7:30am OR start time.
Medical students should write an admission note on all patients they are assigned. They should
review their admission/progress notes with the Chief Resident/senior resident periodically for
constructive critique.
DISCHARGES: The resident/intern who discharges a patient must complete a full electronic discharge
form to include a follow-up plan, list of discharge medications, and list of major procedures during
the hospitalization, and a discharge neurological exam. Ideally, the summary is completed by
the day prior to discharge and reviewed carefully before signing for updates. Be sure that a copy
goes to the patient's referring/family MD. Copies of x-rays may in some cases be necessary to go
with the patient to other facilities, and this must be arranged in advance of discharge. Be sure that
the patient has all follow-up clinic appointments arranged before leaving the hospital.
Appointments for Neurosurgery are scheduled by sending an Epic phone message to Tina Mills, in
the Neurosurgery clinic. Other appointments are usually made through CPOE at the time of
discharge, unless otherwise arranged with the other service. All prescriptions should be provided
through Epic and the patient’s pharmacy entered into the system if known.
DEATHS: In the event a patient expires on the service, the attending and family should be notified
immediately. A written note or the discharge summary must document the events surrounding the
death, the time of expiration, attending, and family notification. Also, requests for autopsy should
be made, and if declined arrangements for transfer to morgue/funeral home should be coordinated.
The death packet should be completed and signed promptly. If organ donation is an option, the
patient's family should be made aware of this opportunity. CDS is available to counsel the family
in this regard and every effort should be made to assure they are present when this option is
brought to the family’s attention for the first time. Residents should place that patient on the
morbidity & mortality conference list.
CONSULTS: Consults require a written or dictated consult note, usually in Epic inpatient consult section.
Dictation confirmation numbers should be kept until the note is viewable in Epic in case of lost
notes. All consults must be presented to the Chief Resident and Attending as soon as possible so
care plans can be made expeditiously. All consults are to be evaluated when they are received and
not delayed to the next day even if they are non-urgent. A one hour response time is preferable for
non-emergent consults. Time consult was called and time consult was seen is required on every
consult note, especially trauma patients. Consult notes should be routed to the attending for cosignature.
TRAUMA ADMISSIONS/CONSULTS: Every attempt to gather as much pre-hospital data as possible is
made. Include in the history information specifics of accident (ie, ejected, seat restraints, rollover,
high speed, prolonged extrication), vital signs/GCS at scene. This information can be obtained
from the EMS sheet or by asking the medic team that brought the patient. A thorough evaluation
of all head/spine injured patients is necessary by the neurosurgery resident in the trauma room.
This includes vital signs, GCS score post-resuscitation, cranial nerve exam, motor/sensory/reflex
exam, HEENT exam to evaluate for signs of basilar skull fracture, penetrating injury, facial injury,
and inspection/palpation of the entire spine. BAC and tox screens are to be obtained on all
patients with depressed level of consciousness. Head and spinal cord injuries are managed
according to protocols which are to be made available to all neurosurgery residents. All patients
in the trauma room need a C-spine lateral, AP CXR, AP pelvis before being transferred to another
location. All trauma patients with decreased level of consciousness require complete spine
imaging. In patients for whom neurosurgery is consulted the spine can be "cleared" according to
the appropriate protocols. Absolute cooperation between the trauma surgery and neurosurgery
services is necessary to ensure expeditious and efficient handling of head and spinal cord injured
patients in the acute setting so as to avoid secondary insults. When a death certificate is completed
on a trauma patient be sure to list the original traumatic event as the ultimate cause of death.
NIGHT CALL: The in-house resident is expected to be knowledgeable of all neurosurgical service and
consult patients. He/She is to identify and correct all problems that arise with these patients in a
timely manner. He/She will evaluate all new neurosurgical consults that he receives on inpatients
or ER patients. Referrals from outside hospitals and making arrangements for their evaluation in
the ER will be processed through the transfer center. Calls from the transfer center should go to
the attending on-call. If no response, call the OR front desk (6-4355) and see if attending on-call is
in the OR. If so, and unavailable then have the Department Chair (Dr. Matthew Ewend), and the
Chief resident paged simultaneously. He/She is to see all post-op patients, and write post-op notes
on all patients operated upon that day that do not have a post-op note written by the resident
involved with that patients case. He/She is responsible for ensuring that all preoperative patients
are ready for the OR the night before. This includes completion of diagnostic studies, laboratory
tests, CXR, type&cross as indicated. All pre-op orders should be written and all consents should
be completed. Consults and admissions should be reviewed with the Chief Resident prior to
presentation to the Attending on-call. All ICU/ward problems of significance should also be
handled in the same manner. The interns primarily are responsible for fielding the general
problems that arise on the ward and stepdown units. They should discuss any problems with which
they feel uncomfortable with the in-house resident. All reported neurological changes should be
evaluated by the resident. The interns may also assist the resident with admissions and consults.
Medical students should notify the resident that they are on call and be sure that he has their pager
number.
Medical students are expected to be available in house when on call. They should take the
opportunity to see all the consults/admissions/operations that occur that night. They are to assist
the resident/interns with the management of the spectrum of neurosurgical diseases. All residents,
interns, and medical students should check with the in-house resident prior to leaving the hospital
at the end of the day. Call duty will not exceed resident work restrictions. On-call rooms are
available on 6 Neuroscience and these include a bathroom and shower facilities. The Chief
Resident may take call from home and will be off-call at least two full weekends per month in
addition to regular vacation and meeting time. Chief Resident coverage for time away must be
arranged in advance.
RESIDENT ASSIGNMENTS: The junior and senior residents will be assigned to specific attendings for
rotations of 3 months duration. During this time the resident is totally responsible for the care of
their attending's patients. He/She will make rounds with the attending during the day when
possible and be the liaison between the attending and the team such that patient care issues are
fully addressed and all parties are in agreement with current plans. The junior residents are to
follow the consults covered by their respective attendings. The junior and senior residents ensure
that the team is updated on the consult patients daily. The team will round on the consults that
require close following. If a consult patient becomes a service patient, then the respective resident
continues to take responsibility for following them.
CLINIC SCHEDULE:
DAY
Monday
Tuesday
Wednesday
Thursday
Friday
ATTENDING
Ewend
Jaikumar
Hadar
Ewend
Sasaki-Adams
Hadar
Hadar
Jaikumar
Bhowmick
Elton
Sasaki-Adams
Bhowmick
Elton
TIME
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
LOCATION
Caner Hospital Surg/Onc Clinic (1st & 3rd)
Spine Center
Spine Center
Cancer Hospital Surg/Onc (not 3rd)
Spine Center
Spine Center (only 3rd Wed. of month)
Spine Center (not 3rd Thurs. of month)
Spine Center
Spine Center
Children’s Specialty Clinic
Spine Center
Spine Center
Children’s Specialty Clinic
The resident assignments change every 3 months. The residents are expected to evaluate the clinic
patients, review them with the attending, and dictate a clinic note. Plans for additional studies and
follow-up visits are to be included in the dictation so that they can be scheduled through the office.
The appropriate clinic chart forms are also completed. Medical students will be assigned to
specific clinics during their rotations. Interns will be expected to perform preoperative evaluations
in the clinic. Clinic coverage will be assigned by the Chief Residents once the operative cases and
consult pager coverage have been assigned
SOCIAL SERVICE ROUNDS: The intern will attend these rounds each Monday morning at 11:30 am.
It is held on 6 Neuroscience. This meeting consists of a member of the 6NS nursing, discharge
planning, social services, PT/OT/ST, and others concerned about facilitating a patients discharge
and post-hospital care placement. The intern summarizes briefly the nature of each patient’s
problem, rehab concerns, and discharge needs. Discussion ensues, a plan is formulated, and
updates on last weeks concerns are given. Results of the meeting are passed on to the rest of the
team by the intern on evening rounds that day.
NEUROSURGERY CONFERENCE SCHEDULE: A copy of the current schedule including times and
locations is included in this packet. Wednesday is the designated conference day each week.
These conferences are mandatory for all residents and medical students, optional for the interns.
A description of each conference follows.
Neurosurgery Clinical Conference: 7:00 – 8:15am
Radiology Conference room, WHB0122 Basement of Women’s Hospital.
Conference rotates on a weekly basis to include:
Resident presentations
M & M Conference
Journal Club
Guest Lectures
Neuropathology Conference – 10:00 – 11:00 am (intermittent)
Case review of macro/microscopic pathologic specimens from recent operative cases.
Radiology Conference Room, Women’s Hospital Basement
Neurosurgery Clinical Didactic Rounds – 7:30-9:00am Thursdays
Didactic lectures after rounds on clinical topics for resident team education, Pons.
Brain Tumor Board – 7:30am Friday except 4th Friday of the Month
Discussion of Neurooncology patients with Radiology, Hematology/Oncology and
Radiation Oncology representatives present.
Cancer Center conference room
Biomechanics – varies
Monthly discussion of assigned chapters of Benzel Textbook with Dr. Hadar over dinner.
Skull Base Didactic – varies
Monthly discussion of assigned chapters with Dr. Sasaki-Adams over dinner.
FORMAT FOR PATIENT PRESENTATION/PROGRESS NOTE:
Introduction
Subjective
Objective
This is (hospital day/POD) for Mr./Mrs. (name) who is a (age, handedness, sex)
hospitalized for (brief history) and is S/P (operation or procedure). Since last rounds, the
patient has had (events, studies, or therapeutic interventions).
State patient complaints in his/her own words, if applicable.
Give vital signs, and In's and Out's since last rounds including drains, etc. Include Tmax,
BP, HR, RR, and any pertinent trends. If an ICU patient, then must also include values
such as CVP, Ventilator settings, ICP/CPP.
Exam includes pertinent neurologic exam (eg., GCS, including best/worst/left/right scores,
cranial nerve, motor, sensory, reflex, and cerebellar findings), and systemic exam (eg.,
chest, cardiac, abdominal).
Lab data are presented.
Radiologic and other study results are given.
Pertinent medications are listed. Give day # and dosage of all steroids and antibiotics.
Include PRN medications as well.
Assessment/Plan:
Create a problem list for the patient. Use the following categories to organize this section,
but include actual diagnoses. Layout treatment plan here as well.
Neurologic
Respiratory
Cardiovascular
Fluid/Electrolyte/Nutrition
Infectious Disease
Hematology/Coagulation
Gastrointestinal/Hepatic/Renal
Indwelling Catheters
Activity (PT/OT/ST)
Disposition
OBJECTIVES FOR ROTATING SURGICAL INTERNS AND MEDICAL STUDENTS:
1.
Develop a basic understanding of the pathophysiology of intracranial mass lesions, vascular
lesions, hydrocephalus, brain and spinal cord injury and degenerative spine diseases.
2.
Perform a basic neurological examination and be able to interpret the findings.
3.
Deliver concise, pertinent, accurate and organized patient presentations on rounds.
4.
Write organized progress notes containing accurate and pertinent information with a clear daily
plan.
5.
Develop a basic knowledge of normal/pathologic findings on head CT and plain films of the
cervical spine.
6.
Gain a basic understanding of the pathophysiology and management of patients with brain tumors,
aneurysms, brain/spinal cord trauma, radiculopathy/myelopathy associated with degenerative
disc/spine disease, and common pediatric neurosurgical disorders such as hydrocephalus and
spinal dysraphism.
7.
Familiarity with common neurosurgical operations.
Expectations:
1.
Assist residents with procedures on the floor and in the ICU.
2.
Participate in assigned neurosurgery attending’s clinic.
3.
Gain as much experience as possible while on call in-house by working closely with the resident.
Faculty Intern Teaching Session Objectives
I – Evaluation of Low Back Pain
The intern will be able to take a relevant history for evaluation of a patient with low back pain. He/she will
be able to obtain the relevant history for specific radiculopathies. He/she will be able to do the appropriate
examination including the mechanical signs. Mechanical signs will include Lasègue’s sign, Patrick’s sign,
femoral stretch test and assessing for paravertebral muscle spasm. He/she will learn the muscles involved in
the major lumbosacral myotomes.
II – Evaluation of Neck Pain
The intern will learn how to take a relevant history for a patient with neck pain and determine if there is a
high probability of a radiculopathy. The relevant mechanical signs will be known. The major cervical
myotomes will be known as well as the appropriate dermatomes.
III – Management of Intracranial Pressure
The intern will be able to evaluate and manage a patient with elevated intracranial pressure. He/she will be
able to indicate the appropriate algorithm for managing patients at risk for increased intracranial pressure.
IV – Interpretation of Cervical Spine X-rays and Clearance of Cervical Spine in Trauma
The intern will be able to interpret the cervical spine series of a patient with degenerative changes as well
as after cervical spine trauma. He/she will be able to identify the three columns of the vertebrae.
V – Interpretation of Head CT Scan
The intern will be able to evaluate the head CT scan and assess for mass lesions as well as intracranial
hemorrhages and skull fractures.