1. Intro to General Consults

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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.

11. 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

12. 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 to RAVEN clinic)
Home for General Consult – call General Consult Attending before 5 PM, or NYP on Call attending after 5 PM

13. 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, 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

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

15. 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)

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

17. 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!!!

18. 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

19. 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.

20. 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