The designated neuroscience floor at Allegheny General Hospital has 36 beds dedicated to the care of neurologic and neurosurgical patients, with three rooms designed for extended-stay video-electroencephalography (EEG) monitoring.
The faculty and house staff also monitor 8 maximum-observation beds for trauma/intensive care neurology/neurosurgery patients and 23 beds in the Surgical or Neuro Intensive Care units.
The department diagnostic laboratory capabilities include the EEG/Evoked Potential (EP) Laboratory and Electromyography (EMG)/Nerve Conduction Velocity (NCV) Laboratory, in addition to continuous video-EEG monitoring.
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|
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PGY2 |
Stroke |
GEN |
Float |
EEG |
Buddy |
Stroke |
GEN |
Elect |
Float |
Elect |
Stroke |
GEN |
|
PGY3 |
Elect |
EEG |
CHP |
Elect |
Elect |
CHP |
GEN |
Buddy |
Stroke |
GEN |
Float |
NICU |
|
PGY4 |
Stroke |
GEN |
Float |
NICU |
Buddy |
EEG |
CHP |
Psych |
Elect |
Elect |
Elect |
Elect |
Neurology residents care for patients in the General Neurology Clinic and in subspecialty clinics such as those listed below.
Allegheny General Hospital was one of the first medical centers in the country and the first in western Pennsylvania to be designated as an Advanced Comprehensive Stroke Center by the Joint Commission. A multidisciplinary team that consists of three board-certified stroke specialists manages stroke at AGH in addition to three interventional neuroradiologists and fully staffed neurosurgery and neurocritical care services.
Neurology residents at AGH manage all aspects of stroke care. Neurology residents are the team leaders in the acute stroke alerts and direct the management of stroke patients in the emergency department, including screening and administration of tPA, advanced imaging, management of complications, reversal of anticoagulation and decisions regarding emergent endovascular procedures. Patients admitted to the stroke service are followed by the neurology residents throughout their hospitalization, which includes being the primary care provider in the neurocritical care setting as well.
Allegheny General Hospital is fully equipped with 3 MRI scanners (1.5 Tesla) with diffusion and perfusion weighted imaging capability, 4 CT scanners (CT angiography and perfusion imaging), digital subtraction cerebral angiography, transcranial Doppler and carotid ultrasound. The hospital also has a 23-bed Neuro Intensive Care Unit, 36-bed Neuroscience Unit and a 42-bed Telemetry Monitored Unit. LifeFlight is the aeromedical transportation system based at AGH and provides rapid transfer of stroke patients to AGH for acute stroke care.
While neurology residents provide care exclusively at Allegheny General Hospital, four other hospitals within the Allegheny Health Network system have primary stroke centers. Complicated stroke, hemorrhages and interventional cases are usually transferred to the Comprehensive Stroke Center at AGH for management, providing neurology residents with an opportunity to be exposed to high-acuity and challenging cases.
The stroke department is also involved in several clinical trials including IRIS, CLEAR III, Clot Lysis, POINT as well as registries such as GLORIA-AF.
The Comprehensive Epilepsy Center at AGH has three attending epileptologists on staff. There is an active epilepsy surgery program with participation of an epilepsy neurosurgeon and neuropsychologist. Neurology residents get significant exposure to the management of seizures and epilepsy via this clinic, but also in the resident continuity clinic, which is usually staffed by one of the epileptologists. There is also a weekly epilepsy surgery conference that the residents are expected to attend.
The EMU at AGH has 4 dedicated beds staffed by a technologist and a nurse. In the neuroscience unit there are an additional 8 beds that are hard-wired and ready to function as EMU beds.
The inpatient neurology service is in close relation to the epilepsy service and significant numbers of consults in the hospital are for seizures and status epilepticus. The EEG laboratory at AGH operates 6 portable video EEG machines and has 4 dedicated technologists. Neurology residents at AGH get a broad exposure to the management of seizures and epilepsy, both in the inpatient as well outpatient settings.
Two neuromuscular specialists perform approximately 1200 EMG studies per year. In the EMG rotations, neurology residents are exposed to a full range of neuromuscular pathology and are directly involved in performing neurodiagnostic studies, along with a fellow, attending and EMG technicians. AGH also has one of the few autonomic laboratories in the region for the diagnosis of small fiber neuropathies and other neuromuscular disorders.
The neurodiagnostic lab also has an outpatient and inpatient EEG service which performs approximately 2300 EEGs per year. About 250 Continuous video EEGs per year are performed. There are 6 portable Natus/Xltek EEG machines operated by four EEG technicians. Routine and long-term EEGs are provided throughout the hospital’s nursing units and critical care units providing neurology residents with exposure to a high variety of EEG findings along the ictal-interictal continuum.
At AGH there is also a full intraoperative monitoring service staffed by two neurologists and nine IOM technicians and residents interested in clinical neurophysiology are welcome to spend elective time in IOM.
Two highly experienced multiple sclerosis specialists work on staff. Thomas F. Scott is an internationally renowned expert on CNS inflammatory diseases and has published extensively on neurosarcoidosis, multiple sclerosis and neuromyelitis optica. Dr. Scott also authored the American Academy of Neurology’s guidelines on transverse myelitis. Dr. Scott and Dr. Desai are involved in ongoing clinical trials and have participated in pivotal clinical trials leading to the approval of several MS therapies.
The multiple sclerosis clinic at AGH has a specialized nurse and provides multidisciplinary care through the National MS Society local chapter. Patients with suspected CNS inflammatory diseases undergo comprehensive diagnostic evaluations and neurology residents are exposed to newly diagnosed as well as long-standing care of these patients. AGH also runs an MS infusion center for the administration of intravenous steroids and disease-modifying therapies in the outpatient setting.
All movement disorder diagnoses are represented in this program; subspecialty patient populations include over 3,000 patients with Parkinson’s disease, 250 patients with dystonia, and 100 patients with Huntington chorea.
The deep brain stimulation program includes comprehensive pre-operative evaluation, dedicated intra-operative neurophysiology monitoring, and post-operative management. State of the art stereotactic functional radiosurgery is also available at the center.
Residents get ample exposure to the diagnosis and management of movement disorders and work in close relation to the two subspecialists at this center.
Allegheny General Hospital has the only ALS Association-certified center of excellence for ALS in western Pennsylvania. The ALS Clinic is a group of multidisciplinary professionals from neurology, physiatry, social work, speech therapy and pulmonary care who meet regularly to support the ongoing care, diagnosis and therapy of patients with ALS. This allows for comprehensive care in one place at one time. The clinic has treated hundreds of patients and supported their families during the diagnosis and treatment of this disease.
The Myasthenia Gravis Association of Western Pennsylvania is located at Allegheny General Hospital and is a regional referral center for MG patients. Myasthenia Gravis care at AGH includes diagnosis through the Neurodiagnostic Laboratory and various types of therapy, including IVIG, plasma exchange, steroids and immunosuppressive therapy, as well as consideration of thymectomy. Neurology residents get valuable experience managing MG in the outpatient as well as inpatient setting and work closely with the two neuromuscular specialists on staff.
Stroke Service
In total, neurology residents spend five to six months on the stroke service at Allegheny General Hospital. The stroke team consists of one senior and two junior residents for the first half of the year, followed by one senior and one junior resident for the second half of the year. Rotators from Internal Medicine and Psychiatry are variably present as well. Patients come to the service from various referral sites in Western Pennsylvania, Northern West Virginia, and Eastern Ohio. The census consists of patients primarily admitted to the stroke service as well as patients on whom the stroke team is consulted. Patients are primarily located in the neuroscience intensive care unit (NICU), the stroke unit, or the clinical decision unit (CDU), though patients can be located throughout the hospital. The team rounds on all patients each day, starting generally between 9 and 10 a.m. Patient histories, labs, imaging studies, and treatment plans are reviewed each day with the vascular neurology attending. Residents on the service alternate weekends rounding on the team, after which they may sign out to the on-call resident and leave.
The stroke service admits ischemic strokes throughout the year. Primary intracerebral hemorrhage patients are admitted to the stroke service during the second half of the month, rotating with neurosurgery who admits them the first half of the month. Patients with SAH, SDH, or EDH are not admitted to the stroke service.
Admissions to the service are completed by the floater, buddy, or overnight call resident (see below). Residents on the stroke service are not pulled away to do stroke alerts, admissions, or consults.
General Neurology Service
Neurology residents spend five to six months on the general neurology service at Allegheny General Hospital. The general neurology service consists of one senior and one junior resident, in addition to a resident from Internal Medicine and/or Psychiatry as availability permits. The census consists of patients primarily admitted to the general neurology service as well as patients on whom general neurology is consulted. The team rounds on all patients each day, starting generally around 10 a.m. Patients present to this service with a wide variety of pathologies, ranging from bread-and-butter to zebra. Patient histories, labs, imaging studies, and treatment plans are reviewed each day with the general neurology attending, with high value placed on resident and student education. Bedside teaching is emphasized, and residents/students are not infrequently assigned topics of study to later review with the team. Special attention to diagnostic dilemmas is made. Opportunities in procedural experience with lumbar punctures are plentiful.
Residents on the service alternate weekends rounding on the team, after which they may sign out to the on-call resident and leave.
Admissions to the service are completed by the floater, buddy, or overnight call resident (see below). Residents on the general neurology service are not pulled away to do admissions or consults.
Floater
The floater rotation is a unique opportunity for the participating resident to be involved in “first contact” history taking, examinations, and on-the-spot, sometimes acute, decision making. Residents spend 4.5-5.5 months as floater. There are two floaters on each weekday of the month. During this rotation, the residents are responsible for alternating all stroke alerts, admissions, and consults occurring during the daylight shift hours of 6:30 a.m. to 5:30 p.m. The patient is seen by the resident, properly staffed, and decisions are made, including decisions regarding IV tPA and mechanical thrombectomy. For each case, the floater is expected to generate a sensible and comprehensive differential diagnosis, in addition to suggesting appropriate work-up and treatment. After this is done, the floater places the patient on an inpatient service, whether stroke or general neurology, or signs off as appropriate. While the floater is not responsible thereafter on rounding on the patient each day, they are encouraged to follow the case for learning purposes.
Floaters have no weekend responsibilities, unless they are otherwise on-call.
Buddy
The buddy rotation is functionally the same as the floater rotation, with the difference being that the buddy works in the evening, generally from 4 p.m. to 12 a.m., assisting the on-call resident with all responsibilities. There is one buddy resident per month. They have one week day off per week.
Epilepsy
Each resident spends one month per year on a dedicated epilepsy rotation. This is an excellent opportunity to learn complex seizure and epilepsy diagnosis and management. While on this rotation, the resident will admit all patients to the Epilepsy Monitoring Unit for phase 1 and phase 2 evaluations, and will additionally round on admitted patients with intractable epilepsy and status epilepticus. During the first year, the groundwork for reading and interpreting EEGs is laid through multiple daily reading sessions with an epileptologist, in addition the weekly EEG conference held for all residents by Dr. Kevin Kelly. These daily sessions continue on into the second and third neurology years, refining the residents skill in EEG. Finally, the resident participates in biweekly epilepsy conferences by presenting difficult epilepsy cases to a group of physicians and experts from neurology, neurosurgery, radiology, and neuropsychology. Presentations include planning for patients that require intracranial monitoring, neuromodulatory devices, laser ablation, or resective surgery.
Resident Clinic
Throughout their three years in neurology training, residents maintain a weekly longitudinal clinic, led by Dr. Kevin Kelly. The clinic is one morning each week and occurs throughout the year, no matter the residents primary rotation. This is a general neurology clinic, and patients with a wide range of disorders are seen. Every attempt is made to ensure that a cohort of patients follows each resident throughout their time here, allowing continuity and establishing important physician-patient relationships.
Call
A brief mention is made here regarding the programs on-call system. The on-call system remains in place, instead of a night float, by a consensus of the residents. Calls are in-house and last approximately 24 hours. This system allows for a greater number of elective months, as no dedicated night float months need to be scheduled. By year, roughly 3-4 calls per month are required as a PGY 2, two per month as a PGY 3, and one per month as a PGY 4.
