General Consults

General Consults

 

General consults is a time when you will really hone your skills as an independent neurologist. You will see neurological consults in the ED, Milstein, and CHONY OB/GYN with a wide variety of complaints including altered mental status, dizziness, pain, headache, vision loss, trouble walking, seizures, ICH, stroke, and many other issues.  You will be the face of our department, and many other doctors (including attendings!) will look to you for guidance on neurological issues. 

General Logistics

  • Log into Mobile Heartbeat, with ED as your location.  Also, check to see if you are able to login to the stroke/INR group for text broadcasts when you have an INR case.

  • The consult senior will hold the pager, and distribute consults to you, the rotators, and med students.

  • The day starts at 10 AM for you, at which time you should be settled and ready to present consults from the day prior.  Touch base with the senior to see where the team is located

  • Consults is busy so you won’t always be able to be present on rounds, but you should try to as much as possible

  • You will sometimes be asked to staff a patient with one of the med students

  • After you see a consult, give your preliminary recs to the team if time-sensitive.  The ConsultSenior will let you know when you will staff with the attending.

  • Occasionally, if the stroke or oncology consult resident is overwhelmed, you will be asked totake a non-general consult.

  • If you decide that a patient should be admitted, it is YOUR responsibility to touch base with the admitting team (at least senior, sometimes junior too) to give signout.

  • Patients admitted to the NICU waiting for a bed should still be monitored closely by the consult resident prior to getting a bed.  A MD needs to accompany the patient to the unit, but it can be the ED resident (or you if they are really swamped).

Weekday Schedule:

10am – AM rounds, present patients from night before

11am – New consults, follow-ups

1pm – Afternoon rounds

4pm – New consults, follow-ups. 

5pm – You will also see urgent Neuro-onc consults

6pm – Take stroke pager from stroke consult resident (and cover stroke codes and stroke consults), take general pager from CSr

7pm – Signout to CNF.  Last consult GIVEN at 7pm

7-9pm – Finish and assist with consults as needed

 

Weekend Schedule:

Friday 24-hr shift (8 or 10 AM Fri, to 10 AM Sat)

If you are scheduled for a Friday 24-hr shift, you will come in for your scheduled shift (for Gen Consults 10 AM, for Stroke Consult 8 AM), and the day will proceed as usual until 6 PM, when you take the pagers. Overnight, you will be responsible for all consults (Milstein, ED, Ob/Gyn), AND for all stroke codes (ED, Milstein, and CHONY).  At 7:45 AM, you will give the pagers to the Saturday consult resident, and then present to the Weekend Consult Attending.  Rounds should be done by 10 AM, and you must leave by 11 AM.

Saturday 24-hr shift (8 AM Sat to 10 AM Sun)

On Saturday, you will come in and take the pagers at 8 AM. For the next 24-hrs, you will be responsible for all consults (Milstein, ED, Ob/Gyn), AND for all stroke codes (ED, Milstein, and CHONY).  At 7:45 AM, you will give the pagers to the Saturday consult resident, and then present to the Weekend Consult Attending.  Rounds should be done by 10 AM, and you must leave by 11 AM.

 

CHONY Stroke codes:

  • If you are called to a CHONY stroke code for a Pediatric patient, you are still the primary responder.

  • The peds neuro fellow will also be present, but you have more experience evaluating for stroke codes.  If none of the Peds Neuro team is present, call them and make sure they are the way.  The exception to this is overnight, where they will come in only if you feel the stroke code is “real”.

  • Remember, you should get a CT head if you have any suspicion for stroke, but you should avoid radiation if you feel there is a very low likelihood of stroke.

Staffing:

*All stroke codes are staffed with a fellow first (Stroke fellow M-F 7:30 AM-5:30 PM, and Sundays 7:30 AM-3:30 PM) or NICU fellow (5:30 PM- 7:30 AM)

*For anyone being discharged from the ED, they MUST be discussed with an attending (Gen Consult or Stroke Consult as appropriate).

*If a patient is being admitted to another service and stable, you can present the patient in the morning

Weekdays

  • 8 – 12 PM staff with AM consult attending

  • 1 – 5 PM staff with PM consult attending

  • From 5 PM-8 AM, call “NYP attg on call” for general consult patients, and the “Stroke service attending” for stroke patients.

Weekends

  • 8AM – 5 PM staff with weekend consult attending

  • 5 PM – 8 AM, call “NYP attg on call” for general consult patients, and the “Stroke service attending” for stroke patients.

 

Other tips

  • Carry a Mobile Heartbeat!  It is often the only way to get a hold of ED residents, and the only phone that reliably works in the ED for the rest of the consult team to get in contact with you.

  • Have a low threshold to call the NICU fellow. Any blood in the head should be discussed with the NICU fellow.  For any patient that there might be a chance that they go to the NICU (even if deciding between the NICU and stepdown), call the NICU fellow as soon in the consultprocess as possible.

  • When you are seeing a consult, do not forget to think about immediate treatment.  For example, AEDs and HTN meds are often forgotten in the ED, even if that is the patient’s primary complaint.

  • If you are worried about a patient, talk to your senior!  They are there to help you.

  • You will see A LOT of consults, especially on the weekend.  Many have found it helpful to start a note with their exam and prelim plan before moving on to the next patient.  That way you don’t lose track of your exam, and the team

  • Try to cluster your calls to the NYP attg on call overnight, HOWEVER, they are always available if you need them.  If you think there is a high probability that a patient will be discharged pending a test, you can call the attending earlier in the night to discuss your plan if the test shows what you predict, and contingency plans if you don’t.