In Addenbrooke's Hospital, there are two wards for stroke and rehab, R2 (acute stroke and thrombolysis) and Lewin (subacute stroke and rehab), respectively. Both are often listed under stroke on some rotas but only Lewin will be listed under rehab. When you get your rotation in stroke at Addenbrooke's Hospital, be sure to clarify which ward you are meant to be working on and for how long before the start of the rotation. For example, an FY1/FY2 will typically do 2 months of stroke (1 month each on R2 and Lewin) and 2 months of acute medicine during a 4-month stroke rotation at Addenbrooke's. Generally, if you know you will be away for study leave, re-scheduled annual leave because of a swap or any other reason during one of your two months on stroke, it is advisable to arrange that to be your month on Lewin ward as relatively more continuity of care is expected on R2 due to the more acute patients. Also, if you would like to do clinics or get more forms and procedures completed, it would be relatively easier to schedule those during your Lewin ward rotation where you will have more time and opportunity for these. In addition, if you are keen to try to do a taster week in a different specialty try to arrange this during your time on Lewin. Lewin is slower paced compared to the acute stroke and many other wards, and so there will be the opportunity to spend time doing taster sessions or working on projects/audits if you prepare in advance. When working on the Lewin ward, there is ample opportunity to take part in interesting clinical audits. There is an audit meeting once a week which is important to attend if you would like to participate in data collection.

When clarifying which ward you will be working on prior to the start of the rotation (or at the very beginning if you start directly) try to involve your clinical supervisor for that block (one of the stroke consultants), the person who will be working on the other of the two wards (you will need to swap wards half-way through).You usually swap wards half way through but there is flexibility around this. You can also consult with the consultants on the ward at the time. Typically, the consultants change every month for Lewin and every 1-2 weeks on R2. Check that your name appears in the correct row and column on the Junior Doctor's Rota before and after making any changes. If there are any inconsistencies you should contact medical staffing.

The stroke team are very friendly and approachable. The consultants frequently provide ward round teaching. There is also lots of opportunity to teach medical students.

a 4 Month FY Block consists of 2 Months Stroke (which you should aim to divide into 1 month on Lewin and 1 month on R2) 2 Months Acute medicine (Which includes MSEU, Service Needs, ED and rota'd leave.

Patients with an ischaemic stroke will need neck vessel imaging (USS carotids if anterior circulation, CT Angio if posterior or intracranial lesion suspected) and cardiac monitoring in the form of telemetry and often a 24h tape on discharge,

The Stroke team has a dedicated MRI Slot daily. You need to call extension 6633 before midday to use it so as to identify a patient early. If there is no one then call to let them know as they can offer the slot to someone else and you have a better chance of getting 2 done another day. Always ensure that you check with consultants about the MRI slot as they may have a patient in mind.

Carotid dopplers: The VSU (Vascular studies unit - 58117) are very efficient at getting Carotid Dopplers done. Call them as opposed to General ultrasound.

Vascular surgery referrals: Be aware that CEA (carotid endarterectomy), if indicated, needs to be performed within 2 weeks of a CVA so refer to Vascular ASAP. Generally, internal carotid stenosis of greater than 50% on the affected side will require referral to the vascular surgery team for consideration of CEA. When making such a referral be sure to include the following information:

1. Details of duplex scan

2. Details of CVA including symptoms and presentation

3. Factors that may influence fitness for surgery

Patients with significant stenosis are likely to be started on dual anti-platelet therapy as the risk of subsequent infarcts is high.

Audits: Ensure that you are aware of any audits that are being done. Dr Nick Evans is heavily involved in stroke research and it is important that you contact him if there are any patients who fit the profile for a particular audit.

MDT meetings: There is a daily short MDT on the Lewin Rehab Unit at 12.00am and on R2 ward at 12.15am to briefly discuss patient's progress and to discuss any discharge planning updates. Try to record a brief summary of what has been discusssed on EPIC under 'DFM note'. On Tuesdays at 10.30am on the Lewin Rehab Unit, there is a more in-depth MDT to discuss patients progress and discharge planning in more detail. Each patient will require an EPIC entry after the MDT with a summary of the discussion, and there is a Lewin MDT pro forma as one of the existing smart texts to help with this.

On Thursdays at 11am, there is a stroke-radiology meeting usually held in the seminar room, where any interesting cases from the week and CT/MRI scans are reviewed and discussed.

Stroke Medicine is one of the most rigorously audited departments and as such the Discharge letter must follow a strict proforma. It is worth getting hold of the EPIC smarttext and learning how to autopopulate it. The consultants will be able to show you this.

Common jobs include examining patients, writing progress notes and discharge summaries, liaising with MDT members on regular basis (e.g. PT, OT, SLT), supporting discharge planning, keeping patients and family informed.

Examining patients: please look at the NIHSS and be confident in performing the NIH stroke scale without looking at the sheet under timed and acute scenarios. On the website you can also find a good training course that will give you good examples and a certificate at the end. You can also download the NIHSS app on your phone which is very helpful on the ward round.

Liaising with MDT members: please do this on regular basis to assess progress (do not just wait for the MDT). Look at the input/output and liaise with dieticians etc. The MDTs are useful in checking whether the patient is meeting milestones or there needs to be alterations to the discharge plan (e.g. further inpatient rehab) and planning discharge dates.

Supporting discharge planning: Patients' needs will be varied. Some may need further inpatient rehab in their local area. Services are likely to vary depending on where the patient lives. Check that the relevant doctors' and nursing sections of any referrals have been completed as well as the timely submission of N2s, N3s etc. Although doctors do not submit N2s and N3s, they should be aware of all details concerning a patient. Keep patients and family updated on any plans and progress, and aim for consensus.

Keeping patients and family informed: some of the patients will have expressive, receptive or profound aphasia. Nevertheless, attempt to explain as much as possible e.g. by using pictures, drawings and gestures. Please be aware that family visiting hours are often the only time for family to have questions answered and to be updated on progress. During those times, aim to be available on the ward and check-in with the families of any acutely or terminally ill patients as well as any where the plan has recently changed as a first priority. Make sure you document any discussions, including with whom (preferably including contact details), content and future actions, if any.

For discharge summaries, always email the relevant stroke secretary (Hilary Gibson) to inform her when discharge summaries are completed: this prevents patients being lost to follow-up and ensures that patinets get the correct information re future scans etc.

For out of hours handover, in the evenings there is a DME & Stroke ward cover doctor who will cover both Lewin and R2 Ward patients. You can handover to them via bleep (found on rotawatch or the junior doctor handover spreadsheet) from 6pm onwards.

On the weekends, there is a AME(C4)/Stroke ward cover doctor from 8.15am-9.00pm. Go to morning medical report in the seminar room on the 5th floor to identify your consultants for the weekend. First join the stroke consultant for the morning ward round of all the new stroke patients and any existing unwell patients. Not all of the stroke patients are seen daily on the weekend. Then, join the consultant and registrar on C4 for the remainder of their ward round (they will have started whilst you were on the stroke round but will expect you to join when you are finished). All the patients on C4 will require a review on each day over the weekend. The SpR for C4 will be around until 3pm to assist with C4 jobs, reviews and unwell patients, after which time if you need help, contact the medical registrar. After the ward round finishes, complete any jobs from both ward rounds and continue to provide ward cover for C4, R2 and Lewin Rehab ward until 9pm. At 9pm, attend medical handover in the seminar room in A&E.

Stroke SpR 152735

There is a really useful shortcut from R2 to NCCU which involves going down to Level 1. Ask Dr O'Brien - he will show you!