Tips for GP trainees working in stroke medicine.

British Journal of General Practice, January 2013 53 INTRODUCTION Stroke units make a big difference to the lives of your patients and their families, following what is generally an earthshattering event. While working in a stroke unit, you will see a vast spectrum of patients, some who make a full recovery, some who subsequently deteriorate, and the majority who fall somewhere in between. You may work on a hyperacute stroke unit, a stroke rehabilitation unit, or an integrated unit, which combines both. Stroke medicine is a subspecialty of geriatric medicine, however stroke is not just a condition of older people. Practising stroke medicine relies on a good core working knowledge of general medicine and neurology. You may have heard of multidisciplinary teams (MDTs) before. In no other field of hospital medicine will you have the opportunity to work so closely as a member of an MDT and see what positive effect they can have. Expect to be working as part of an MDT comprising of nurses, occupational therapists, physiotherapists, speech and language therapists, and neuropsychologists. All are integral to an effective stroke unit. Together, you will participate in complex discharge management. Communication underpins stroke medicine; failure to communicate well with patients and within the MDT will result in poor outcomes for your patients. You will see people with life-changing conditions, be sensitive to this. No one expects a stroke to happen. Working in a stroke department will allow you to develop transferable skills to the field of rehabilitation medicine. This article provides a guide to help you through a typical job on a stroke unit that will allow you to feel more prepared for the days ahead, the expectations on you as the FY2, as well as covering your educational needs. THE BASICS 1. Understand how stroke presentation relates to neuroanatomy. 2. Revise how to conduct a full neurological examination: cranial nerves, peripheral nerves, speech, and cerebellar function. 3. Learn about the Face.Arms.Speech. Time tool, ROSIER (Recognition of Stroke in the Emergency Room), and the ABCD2 score (as a risk stratification tool for a transient ischaemic attack [TIA]). 4. Learn about the NIH Stroke Scale used in the assessment of an acute stroke. 5. Make sure you know the indications for urgent CT scanning, how to organise one, whatever the time of day or night, and how to get it reported (National Institute for Clinical Excellence [NICE] guidelines). 6. Remember a patient who has had a stroke must be nil-by-mouth until they have passed a swallow screen performed by a trained member of staff. If the patient is nil-by-mouth, don’t forget their hydration and nutritional needs. 7. Get used to writing up medicine as oral (PO) or nasogastric (NG) rather than simply PO. This will make sure that the patient gets their medicine on time as well as saving you time. 8. Understand the role that thrombolysis, antiplatelet, and anticoagulation therapy play in acute stroke. Find out about local arrangements for stopping them prior to percutaneous endoscopic gastrostomy (PEG) insertion and carotid endarterectomy. 9. Get used to the routine blood tests and medications which are used for stroke. 10. Think homeostasis. Stroke can knock the body severely off balance; monitoring of blood glucose, blood pressure, and oxygen saturation are all important. 11. Familiarise yourself with the helpful stroke guidelines produced by NICE, M Yates, GPStR1, BMBS, MA, DFSRH, DMCC, Defence Postgraduate Medical Deanery. O Speirs, MRCP, consultant stroke physician, Frimley Park Hospital NHS Foundation Trust, Surrey. Address for correspondence Matthew Yates, Department of Elderly Care, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Surrey, GU16 7UJ. E-mail: [email protected] Submitted: 8 March 2012; final acceptance: 12 March 2012. ©British Journal of General Practice 2013; 63: 53–54.