Richard Leston, APP Supervisor, Department of Neurosurgery, Clinical Preceptor of APP Neurosurgery Clerkship
With: Alexis Catania, PA & Krista O’Leary PA-S
South Shore University Hospital was preparing to open its brand-new Neuro ICU in March of 2020, eager to become a major neuroscience center in Suffolk County, New York. This effort involved a rapid expansion of the neurosurgery department, adding a team of neurointensivists, and quadrupling the APP staff over the course of one year. Unfortunately, COVID-19 delayed the launch of our ICU while we joined in the efforts to combat the pandemic, turning in our pen lights and reflex hammers for stethoscopes and laryngoscopes. After several hard-fought months, our focus returned to neuroscience, and one of the first strategic moves we made was starting an APP student rotation.
Why Start an APP Clinical Rotation
Our unit is staffed with 24-hour APP coverage without assistance from residents or fellows. We depend on a cohort of well trained, highly capable APPs to provide high-quality care, and their wealth of knowledge and skills make them a natural fit to shepherd APP students during their clinical rotations. The department’s reliance on APP coverage for patient care was on full display during the COVID-19 pandemic, during which we managed to care for a significant portion of the hospital’s sickest patients.
The APP rotation provides a 6-week deep dive into the neurosciences, including exposure to neurocritical care, neurointerventional surgery, and the operating room. We set forth with the goal of creating a truly enriching, gratifying, and diverse educational experience. The rotation also created a stream of talent to help support the growth of our program, as these students have a head start over their new graduate peers if hired into a position in our department post-graduation. They will have gotten to know the nurses, other APPs, attending physicians, and administrators, and will have gained insights into best practices and pitfalls and how to appropriately navigate them.
Staff engagement is another great reason to start a rotation. Our entire APP staff enjoys training students, and teaching reinforces their own progress. Utilizing a department’s existing APP staff as educators also sends the message that they are experts in their field, that they have the requisite knowledge to teach others, and that their experience is valued. In our institution, we have even included APP-led workshops. Our staff provides one-on-one lessons including central line and arterial line placement, CT scan interpretation, EVD placement, and surgical skills training, while our neurointerventional team teaches basic interpretation of cerebral angiograms. These measures have helped produce a focused academic mindset in the department and a culture that strongly values education.
What We Did
Prior to accepting any students, we laid out a clear structure to the clerkship. We divided the six-week rotation into three parts, providing exposure to the neurocritical care unit, the operating room, and the cerebrovascular suite. The intent was to offer a broad experience and create an interest in the field by highlighting the variety and collaborative efforts involved in the care of our patients. We created a student handbook to introduce and orient students to the rotation, enumerate their responsibilities, and provide a list of common conditions, pharmaceuticals, and resources for further learning. Specific highlights are included below and can be utilized for those who would like to start their own rotation.
The Handbook (Excerpts)
Welcome to your Neurosurgery rotation at South Shore University Hospital! APP students will gain exposure to neuroscience while rotating through the neurocritical care unit, the operating room, and the cerebrovascular suite.
- Participation in weekly educational neuroscience conference
- Participation in daily critical care rounds
- Preoperative, intraoperative, and postoperative patient care
- Collaboration within the interdisciplinary team
- Assistance with admissions, patient list updates, sign out, and documentation
- Providing constructive feedback to improve the rotation for future students
- ID badge and security clearance
- Hospital and unit tour
- EMR (Electronic Medical Record) access and training
- Surgical scrubs access
- Review of student handbookand expectations
- Faculty contact information
During this block of the rotation, students will gain exposure to the management of critically ill patients with neurological disease.
Critical Care Rounds
Students will perform their own physical examination on their assigned patients, and review all relevant imaging prior to attending rounds. The student is expected to fully understand the plan of care and is expected to ask pertinent questions. As the clerkship progresses, students will be expected to formulate an assessment and systems-based plan during rounds.
Patients in the ICU that are going to surgery require preoperative optimization. The standard practice is detailed in the Neurocritical Care Preoperative Checklist.
Postoperative Management & Resuscitation
Unstable patients require immediate attention and stabilization by the Neurocritical Care team. Students are expected to learn while observing resuscitation and during clinical debriefing.
The decision to involve another subspecialty team by calling a consult is made by the Neurocritical Care attending. Students are expected to assist with this task.
Downgrading Patients from the ICU
The patient’s disposition (service and level of care) is determined by the neurocritical care attending upon downgrade. A full system-based sign out must be rendered to the accepting team and a transfer note is written upon downgrade from the ICU.
APP students are encouraged to help maintain an updated patient list. See the Neurocritical Care List Template. The list is a tool to assist with verbal sign out, rounds, and overall patient care. Changes to medications, device settings, new imaging, and updates to the plan of care are essential.
Students are expected to perform to provide a full organ systems-based sign out for their assigned patients at shift change.
Procedures such as point of care ultrasound, arterial lines / puncture, IV placement, foley placement may be performed right away with supervision. For advanced procedures such as central line placement, ICP bolt placement, and ventriculostomy (EVD) placement, the student’s role will advance from observer, to assistant, to operator pending their progression during the clerkship.
The APP student’s role will be to perform a detailed history and physical examination for any admitted patient. They will formulate an assessment and plan, with assistance from the clinical preceptor.
During this block of the rotation, students will gain exposure to the operative management of neurosurgical conditions. Students are expected to introduce themselves to the neurosurgeons, anesthesiologists, circulating nurses and scrub techs. Early in the rotation, students may simply observe cases in the OR, later they may assist with prepping, positioning, draping, loading films and setting up equipment. Students will have the opportunity to function as first or second assistant on OR cases pending their progression during the clerkship.
During this block of the rotation, students will gain exposure to neurointerventional surgery. Students will assist with the management of patients in the cerebrovascular suite and in the preoperative and postoperative setting. APP students are expected to progressively increase their role in the endovascular suite as the rotation progresses. Early in the rotation, students may simply observe cases, later they may assist with prepping, positioning, draping, loading films and setting up equipment. Students will have the opportunity to function as first or second assistant on endovascular suite cases pending their progression during the clerkship.
- Grand rounds
- Morbidity and mortality
- Clinical skills workshops
- Preoperative checklist
- Patient list template
- History and physical template
- Progress notes template
- General: Neuroanatomy, neurologic examination, evaluation radiographic tests
- Neurocritical Care: ICP management, analgesia & sedation, hemodynamic support, ventilator management
- Epilepsy: Seizure, EEG monitoring & anti-epileptic drugs
- Brain Tumor: Brain tumor medical management, surgery & radiosurgery
- Trauma: Traumatic brain injury, traumatic spine injury & ASIA scale
- Spine: Myelopathy, radiculopathy & spinal cord syndromes, spinal stenosis & degenerative disc disease, spinal decompression & spinal fusion
- Vascular: Cerebral angiography, aneurysmal subarachnoid hemorrhage, vascular malformations, intracerebral hemorrhage, ischemic stroke
Implementing this student rotation has been a fulfilling project for our department. Our students have enjoyed the rotation immensely and have provided excellent feedback. Many of the APPs within our department have stepped forward as mentors, which benefits their professional growth not only as clinicians but also as future educators and administrators.
Here are some samples of some of the feedback we’ve received, including from one student who (I’m very proud to say) joined our APP team, and from another who is strongly considering a career in neurocritical care:
Before starting the rotation I thought it would be a great way to be exposed to more surgical cases and critical care, which not many elective rotations have. On my first day I felt very welcomed and enjoyed the fast pace. This was also the only rotation where rounds were formally held in an office every morning prior to walking rounds. I liked that because the whole team could be exposed to the patients and offer any insight. My overall impression was that it was a very hands-on rotation with the ability to learn and brought me closer to being able to practice as a provider.
My major takeaway was that you get what you put into a rotation. I realized quickly that if I put in the effort to look up the labs on each patient, examine them myself, ask questions, and assist with procedures, I could gain a lot of confidence and skills as a future provider. The opportunities were all laid out in front of me for this rotation, and everyone was eager to teach and explain. There were also a variety of complicated cases I was exposed to, and the rotation provided the resources to research them further.
The rotation definitely altered my decision of which specialty to practice in after graduation, as I decided to take a job in this specialty. I particularly was drawn to neurosurgery/neurocritical care because I learned that this specialty has many educational opportunities and an endless opportunity to grow as a provider. The acuity of the patients and the fast-paced environment showed me what I could truly be capable of as a provider. My favorite part of the rotation was definitely the weekly lectures and rounding in the ICU. It was at these times where I was exposed to the most information and able to ask questions. I felt like I was part of the team, which I really enjoyed. My least favorite part of the rotation was the initial stress of it. I didn’t fully realize how mentally stressful these critical patients actually were, and it takes time to adjust to that. - Alexis Catania, PA
My overall impression of the rotation was the epitome of a versatile experience for a student. This rotation encompassed a cross-training style: rotating through the neuro ICU, neuro IR, and neurosurgery. It was exceptional to experience this department built up of those subspecialties. "Neuro" is such a challenging and difficult specialty to grasp and this overlap brought a united picture of all the moving parts. My major takeaway was an unlimited capacity to learn about the brain, the consequences and manifestations of any injury or disease to it, as well as the interventions to understand or fix it.
This rotation definitely played a role in altering my decision of which specialty I want to enter. In my didactic year, I believed the neuro ICU and neurosurgery were intimidating career paths that I was not sure if I would be compatible with. This hands-on rotation has actually driven a desire to apply for a position in the fall of my graduating year. It showed me the potential I could have in such a great specialty. It also showed me the significance of an APP’s role
My favorite parts of the rotation involved ICU procedures, ICU sign-out presentations, and the more emergent/critical neurosurgeries. I highly enjoyed the detail and magnitude ICU-level care achieves, as well as the high-risk surgeries where it takes steady sets of hands, a united team, and a ticking clock to save a life - Krista O’Leary, PA-S