Intro to General Consults

GET EXCITED! On Consults you… are the FIRST neurologist on site are the EXPERT (well…comparatively…) have (some) discretion to admit and initiate a treatment plan represent Columbia Neurology to other departments

Things to Look Forward to Increased independence and autonomy New types of patients/cases! Real time feedback Opportunities to teach

General Consult Team Structure PGY 4 Neurology Resident (Consult Senior) PGY 3 Neurology Resident from 10 AM – 7PM + Psychiatry intern or Neurology prelim +/- Peds neuro resident + 2-3 medical students +/- Sub-intern

Roles PGY 4 (7:30am – 6* or 7 pm) Responsible for stroke codes between 7:30 am and 8 am (when Stroke Consult arrives) Holds pager during the day -> Triages and assigns consults Rarely sees consults (exceptions: overwhelming number of consults, sometimes will staff med student cases) Assists with staffing rotator consults Present for all of rounds and directs flow of rounds: Prioritizing patients in ED that are waiting for dispo decisions Deciding which follow-ups need to be seen Expediting the attending Addending consult note with attending input (when needed) Manages the “list” Monitors need for follow up, especially of rotators’ patients Helps update consult section of handoffs

Roles PGY 3 (10:00am -7:00pm*) 10 AM – 6 PM 6 PM- 7 PM 7 PM Be ready for rounding at 10 AM, and try to stay on rounds (unless doing another consult) See consults assigned by Consult Senior (usually General, unless there is overflow from Stroke) Onc consults go to separate consult service M-F, 8AM - 5 PM Post-arrest consults from morning (not overnight) staffed with NICU attending in PM Staff consults with med students See follow-ups as you (or senior/attg) see necessary Touch base with primary team (neuro or other) Update consult handoffs 6 PM- 7 PM Hold General and Stroke Pager (acute strokes, non-urgent consults) 7 PM Last new consult at 7 PM Signout to CNF *You cannot leave hospital without signing out* 7 PM to 9/10 PM Finish consults, call attendings for ED dispo if necessary, signout to admission teams

Roles Rotators (Psych and Neuro prelims) See 1-2 consults/day Typically given consults before 4:30 pm Ideal rotator consults will give them a chance to present to an attending Non-urgent Inpatient To be staffed with general attending

Weekly schedule (Rounds twice daily) AM Conferences and Rounds Monday 8am in NI1 call room Tuesday 8am neuro-radiology Milstein 9am rounds NICU conference room Wednesday 8am NICU conference room Chief of service 8:30-10am 10am NICU conference room Thursday 8am morning report, NI14 9am rounds NI14 Friday 8AM in NI1 call room PM Rounds – Consult senior will coordinate time and location with attending

Common Consults Headache – diagnosis and management Altered mental status Seizure/Myoclonus Neuropathy Myasthenia Gravis Weakness Dizziness Post-procedure peripheral nerve injury Post Cardiac Arrest

Approach to ED consults Neurological or non-neurological? If non-neurological, resist the urge to specifically comment on management No further neurological work-up -> home, admit to another service If neurological, disposition: Home with or without follow-up Admit to ward/stroke/grad/EMU; regular or stepdown? Admit to NICU Acute management BP goals Medications (especially AEDs!!! And antibiotics!) Reversal of anticoagulation? Platelets? Neurosurgery consult needed? Upcoming scans (i.e. 6 hr post-bleed scan) If going to another service, talk to admitting service as well as ED.

Tips in the ED Get acquainted with everyone, but don’t linger Prioritize ED patients over ICU/floor (in general) Quick chart review before calling back Try not to lose energy getting mad at the ED team Be wary of accepting patients to neurology service (“endorsement”) before labs or other critical tests have resulted Communicate recommendations clearly in person or by phone Ok to reorder tests if ordered incorrectly ONLY if you tell the ED you are doing so Neurology is not the admitting service for neurosurgical patients Teach ED team *ED attending has final call on dispo team

Who staffs consults Dispo Stroke/NICU fellow initially for tPA - page 80021 Stroke consults may be retriaged to General attending if NO concern for stroke NICU fellow – you must call to discuss any blood in the head, thrombectomy case (but can call them for anything) Dispo NICU – call NICU fellow as soon as you know you have a possible NICU admission to start to find beds Ward – call Ward Senior/Junior Stroke – call Stroke Senior/Junior (usually you have already talked to fellow) EMU – rare. Must be approved by EMU attending. Ward – MUST be cleared with Lennihan or grad attending Another service – can wait until next rounds to staff (unless urgent decision needed) Home from Stroke codes – call Stroke Consult attending before 5 PM, or Stroke service attending after 5 PM RAVEN candidate – must be staffed with Stroke Attending (if accepted, send email to RAVEN clinic) Home for General Consult – call General Consult Attending before 5 PM, or NYP on Call attending after 5 PM

Neuro-Onc Consults Requests for consult are seen by neuro-onc resident when…. Patient is KNOWN to neuro-oncology group Neuro-oncology specifically requested by NSGY or med oncology attending (you will rarely be called about these) At request of gen neuro ward/consult attending (ie – management question vs a diagnostic question) New Primary CNS Lymphoma patient Consults are seen by general consult team when… New diagnosis If admitted to ward, email neuro-oncology group to make them aware but they may not want to see until path/outpatient If new met or CNS involvement, defer to primary team when/if to incorporate neuro-oncology. Not known to neuro-oncology (med onc is managing brain mets, patient follows elsewhere) Neurological emergency (ICH, herniation, seizure) General neurology question (anticoagulation, AED manangement) Neuro-Onc resident unavailable

Movement Consults High threshold for their involvement Only patients known to them, management questions, DBS patients, ward service in need of guidance EMAIL MovDisConsult@cumc.columbia.edu Pt name, MRN, Location Requesting attending and contact info Reason for consult

Blocking consults Be extremely careful Non-neurologists often know something is wrong, but can’t put their finger on it The stranger the story is, the more likely it is to be real. Psychogenic etiology is a diagnosis of exclusion In the end, it is easier to just see the patients Seeing the patients now trains you to know who really needs to be see (Also builds rapport with teams calling consults)

Curbsides Be very careful Some services minimize Offer to arrange follow-up

Professionalism Points Avoid chart wars and accusatory notes Never order tests/meds without discussion Always be polite Remember nursing staff are encouraged to activate acute strokes “Bad” consults are a teaching opportunity!!!

Other logistics Consult Pager 86876 Stroke pager (ANF) 87276—held by one of the PGY3s Consult iPAD Add to _Neuro Consult list or _Neuro Stroke Consult Make sure ED patients are displayed Billable notes (need full exam including fundoscopy - .examfull) Addending rotator notes Staffing med students

Weekends / Consult Call Fridays overnight – usually (not always) covered by Stroke Consult 8 am – 8 am, then rounds Saturdays 24 hours – usually (not always) covered by General Consult 8 am – 8 am, then rounds Sunday days - 8am-6pm (CNF arrives at 6pm on Sunday). You will tell CNF what needs to be staffed in AM *Weekend rounds should end by 10, and you should leave by 11.

Weekends / Consult Call Tips Don’t procrastinate – you never know what’s coming! Record exam and basic points of plan before moving to next Remember to eat (and use the bathroom) Call if you need help!!! Sick senior is back up