Junior Resident

Senior Resident

Chief Resident

Patient Care

Perform a competent and comprehensive neurological evaluation including relevant history and detailed neurological examination.

Adapt the evaluation to pertinent positives and negatives related to traumatic brain injury, spinal injury, and ischemic and hemorrhagic stroke.

Perform comprehensive systemic assessment in relation to these same clinical entities.

Recognize the need for diagnostic studies and their prioritization in relation to common presentations of trauma, hemorrhagic and ischemic stroke. 

Recognize the need for laboratory studies related to multi-system homeostasis and other clinical assessment of these entities.

Recognize the common expected clinical course of patients with traumatic brain injury, spinal injury, ischemic and hemorrhagic stroke.  Recognize phases of illness with common systemic and neurologic complications (including periods of vulnerability to respiratory, hemodynamic, cardiac and other common complications).  Recognize specifically the clinical course of anticipated edema following traumatic brain injury, spinal injury and stroke, and its general principles of management.  Recognize specifically the time course and management principles of vasospasm following subarachnoid hemorrhage.
 
Specific rapid assessment of patients during neurologic emergencies, and the priorities of airway, hemodynamic, and neurologic resuscitation.

Recognize the indications and timing of operative intervention for traumatic brain injury, spinal injury, and hemorrhagic and ischemic stroke.  Initiate appropriate pre-operative testing for emergency surgical intervention.  Interpret pre-operative diagnostic studies and relation to common emergent and elective surgical interventions for trauma and stroke.

Understand and apply assessment and intervention paradigms for abnormal respiratory function, cardiac and hemodynamic function, and elevated intracranial pressure.  Understand and apply protocols for barbiturate induced coma, including timing of intervention and management of therapy and its common complications.
Understand principles of periprocedure management following catheter angiography and common endovascular procedures for treatment of aneurysm, vascular malformation, and therapeutic carotid occlusion.

Recognize guidelines and controversies related to management protocols in patient assessment and care objectives achieved as an Assistant Resident.

Mature prioritization of clinical assessment of simultaneous problems in the same or different patients.

Prioritize timing and urgency of surgical intervention for traumatic brain injury, spinal injury and stroke.  Recognize the impact of systemic conditions on prioritization and timing of surgical intervention.

Interpret and act upon changes in patient assessment related to systemic and neurologic function.

Apply patient care protocols related to peri-procedure management after catheter and endovascular procedures.

Develop mature clinical judgement related to the spectrum of clinical problems of traumatic brain injury, spinal injury, hemorrhagic and ischemic stroke. 

Develop independent plans of patient assessment and care related to these entities, including prioritization.

Supervision of the housestaff and medical student team in daily patient assessment and care.

Mature understanding of the literature and controversies related to patient assessment and care in traumatic brain injury, spinal injury and stroke.  Teaching of fundamental objectives to housestaff and assignment of responsibilities to achieve their respective educational objectives in this area.

Understand indications for, and controversies related to endovascular catheter procedures and their indications, peri-procedure management and follow-up.  Implement and supervise patient care protocols related to these procedures.

Junior Resident

Senior Resident

Chief Resident

Diagnostic Skills

Recognize the principles, indications, and interpretation of normal and common pathologic findings on x-rays of the cervical, thoracic and lumbar spine, skull and chest.  Recognize adequate and inadequate x-ray studies and common pathologic abnormalities on these respective x-rays, in association with trauma, stroke, and common complications in the intensive care unit.

Understand the fundamentals of tomographic computerized imaging (CT and MRI), normal findings, general localization of pathology in relation to neuro-anatomic structures and vascular structures, and the appearance of pathologic findings in association with trauma and stroke.

Recognize the indications for non-invasive vascular imaging with ultrasound, MRA, and CT contrast studies, the emergency use of these modalities and their common interpretation, and limitations of non-invasive vascular imaging.  Interpret carotid ultrasound and transcranial doppler diagnostic findings in the setting of trauma, stroke, and clinical vasospasm.

Understand the indications for catheter angiography, its general principles (including anatomic vascular access) and the broad interpretation of angiographic findings in ischemic and hemorrhagic cerebrovascular disease.

Correlate the location of focal cranial and spinal pathology to the region of the neuraxis, and ability to localize this region using anatomic landmarks, x-ray, and stereotactic guidance.

Perform routine lumbar puncture, and tapping of reservoirs and shunts (at least five each).

Understand and apply detail to protocols of spinal clearance and acute neuroimaging in trauma.  Clear patients with multiple trauma and correlate diagnostic finding with neurologic assessment.

Prioritize diagnostic interventions including particular choice and sequence of diagnostic studies in the setting of traumatic brain injury, spinal injury, and common syndromes of ischemic and hemorrhagic stroke.

Mature interpretation of diagnostic studies in relation to type of pathology, choice of surgical approach and intraoperative localization.

Mature interpretation of non-invasive and invasive vascular imaging including degrees of stenosis, level of pathology, types and location of intracranial aneurysms, and types of vascular malformations.

Supervise and perform more difficult spinal taps, fluoroscopic guided access, and localization marking of intracranial and spinal targets.

Mature and detailed under-standing of indications, principles, and interpretation of the full spectrum of neurodiagnostic armamentarium.

Understand guidelines, protocols and literature controversies related to diagnostic imaging in trauma and cerebrovascular disease.

Apply evolving techniques and new modalities to the patient care protocols and education of the housestaff and medical student team at their respective level of educational objectives.

Junior Resident

Senior Resident

Chief Resident

Technical and Surgical Skills

Perform placement of arterial catheters, central venous catheters, pulmonary artery catheters, and burr hole/twist –drill ventricular catheter placement, including indications, landmarks, performance of the procedure (supervised at least five, unsupervised at least five) and post-procedure verification of placement accuracy and application of the devices to the patient care plan.

Assist in image guided placement of intra-hematoma catheters (at least three).  Volu-metric assessment of intracranial hematoma and ventricular size in relation to catheter placement and drainage. 

Understand surgical anatomy and principles of exposure of the cervical carotid artery.  Assist in opening and exposure of cervical carotid artery (at least three cases).  Perform opening and exposure of cervical carotid artery (at least three cases) with supervision.

Understand principles of pterional craniotomy including layers of the scalp, management of temporalis muscle, placement of burr holes, and planning of craniotomy flap.  Assistance in pterional craniotomy for vascular pathology (at least five cases) and performance of pterional craniotomy for vascular pathology (at least five cases) with supervision.

Understand principles of surgical localization and craniotomy flap planning for vascular malformations and non-pterional craniotomy approaches to vascular structures.  Assist in non-pterional craniotomy approaches to vascular pathology (at least five cases).

Understand principles of acute spinal stabilization and traction-realignment in the setting of trauma and instability, including indications and potential complications.  See spinal objectives for additional technical/surgical objectives related to spinal pathology.  Understand principles of planning and timing of craniotomy and burr hole drainage for intracranial hematoma.  Performance of evacuation procedure of intracranial hematoma (assisting at least three cases, performance with supervision at least five cases). 

Performance of routine and complicated burr hole and twist drill procedures for drainage of ventricles and intracranial hematomas (at least ten cases).

Exposure of the cervical carotid artery for endarterectomy or proximal control (at least five cases) and performance of plaque removal during carotid endarterectomy (at least three cases).  Assisting in complete carotid endarterectomy procedure and arteriotomy closure (at least five cases).

Mature understanding of the planning and performance of pterional craniotomy for intracranial vascular pathology.  Performance of pterional craniotomy (at least five cases), and splitting of Sylvian fissure and microsurgical exposure of basal cisterns (at least five cases).

Performance of surgical approach to vascular structures via non-pterional craniotomy (at least five cases) with supervision, and excision of embolized or simple vascular pathology (at least three cases).

Supervision of Assistant Residents in burr hole and simple evacuation procedures for intra-cranial hematoma.  Performance of burr holes and simple procedures for evacuation of intra-cranial hematoma (at least five cases).

Mature understanding of surgical strategies and approaches to common and rare vascular pathologies.  Understanding and applying principles of intraoperative anesthetic management, proximal and distal control, temporary clip placement with brain protection, and intra-operative localization mapping as applied to vascular pathology.  Application of these principles in actual surgical procedures (at least ten cases).

Planning and execution of pterional craniotomy for common vascular pathology (at least ten cases).

Splitting of Sylvian fissure and microsurgical exposure of basal cisterns for vascular pathology (at least ten cases).

Microsurgical exposure and clipping of intracranial berry aneurysm (at least ten cases) with supervision.

Planning and execution of non-pterional craniotomy approaches to less common or more complex intracranial vascular pathologies.  Execution of craniotomy plan and exposure of vascular lesion (at least five cases).  Excision of simple or well embolized vascular malformation (at least three cases).

Assistance in microsurgical management of more complex cerebrovascular procedures (at least ten cases).

Planning and execution of craniotomy and burr hole plans, including indications, pre-operative and intraoperative localization, and execution of the surgical plan for evacuation of intracranial hematomas (at least ten cases).

Supervision of other housestaff in meeting surgical objectives at their respective levels (including assignment of cases).

Junior Resident

Senior Resident

Chief Resident

Administration and Teaching

Participate in the teaching of nurses and medical students regarding all educational objectives outlined above.

Participate in teaching conferences, presentation of cases, and writing of case reports. 

Increased teaching responsibility to medical students, interns and assistant residents in their various educational objectives. 

Supervision of more junior housestaff in performance of technical/surgical objectives at their respective levels.

Assistance in the organization of clinical and teaching rounds and conferences, and presentation of cases.

Preparation of topic reviews in lecture and manuscript formats, including literature summary and references.

Full administrative supervision of the neuro-ICU service, including patient care, identification of cases for database, morbidity/mortality identification and discussion, and supervision of medical student and housestaff team in every aspect of patient care.

Organize and administer teaching conferences.  Mature participation in specialty conferences.

Assign responsibilities to assistant residents and residents with the aim of fulfilling respective educational objectives.

Prepare original contributions to patient care protocols and/or the neurosurgical literature based on accumulated experience with clinical and educational material on the service.