Please login to MHB dynamic role as consult senior and get teams to contact you that way – it should make it easier.
Welcome to Consult Senior!
For the new system, you will still be triaging consults to both the stroke and general consult residents, but you don’t need to arrange stroke rounds. Just make sure for consecutive stroke codes that the loop is closed and someone is going. Just remember, if one service is overwhelmed and the other isn’t busy, you can ask the junior to shift over to the other service if needed.
The day starts at 7:30 when you come in and get signout from CNF. You hold the stroke pager from 7:30-8:00am. The juniors come in at 8am for rounds/conferences and the swing resident comes in at 10am.
As you probably remember, the schedule is as follows:
Monday – 8am consult rounds, NI1
Tuesday – 8am Radiology rounds, 8HS
Wednesday – 8am consult rounds, NICU conference room
Thursday – 8am Morning report, NI14
Friday – 8am consult rounds, NI1
To stay organized and on track during rounds, it helps to make a list of all the patients who have to be staffed from the afternoon before/overnight. The priority is always to see the overnight consults first (usually ED than inpatient). In the afternoon, the priority is to see ED consults that could go home first unless there is a really sick consult that needs to be staffed emergently. All consults need to be staffed with an attending (general or stroke) within 24 hours of being seen.
Your role as consult senior is to hold the pager, divide up consults amongst the juniors, and help run rounds. You should also staff the med student consults. Remember, med student consults need a separate note — you cannot addend a med student note.
Rotator consults can be staffed by you or by one of the juniors if it’s not too busy. Those notes can be addended with updates to the HPI, your exam, and any changes to the assessment and plan.
Afternoon consult attendings that they should plan on rounding from 1-4pm, even if the residents aren’t ready. If you have follow ups that need to be seen, they can be seen by the attending (with the students) on their own before rounds. Ideally, the resident will also be present for the follow up, but that may not always be possible.
If everything is quiet, you can sign over the pager to the swing/general consult resident at 6:00. If you are not signing out to CNF directly, please make sure there is clear signout for all patients. The general consult junior will be doing a swing shift from 10-8, and take consults up to 7pm. After that, new consults go toCNF,
You should hold one of the stroke pagers. It’s also good to have a text chain to make sure the communication loop is closed and someone is definitely going. This also helps for letting people know where to begin afternoon rounds.
Make sure every consult on the list has a resident assigned to them. The residents should do their own followups and keep you updated, but sometimes they need reminders.
Make sure all consults are added to the list!
Weekend consults that are not signed off of need to be seen with one of the weekday attendings.
A few things to note:
RAVEN TIA clinic is in action.
Please make sure that every consult patient has a junior assigned to them so that follow ups are less likely to fall through the cracks.
Below are some tips on being consult senior from Dr. Lennihan. Also, the ED now has mobile heartbeat. I don’t know if people have found it helpful to text them, but you can consider using mobile heartbeat if you’re interested.
- Morning and afternoon, see ED patients first unless there is an urgent consultneeding attending involvement elsewhere
2. Include time for followups morning and afternoon. My recommendation is tohave the afternoon attending start on followups before 1:30 (unless there are ED consults) with the individual resident/student (or just the student of the primary resident is otherwise occupied) and allow other members of the team to complete new consults to be presented later in the afternoon.
3. After a new consult is seen, make explicit plans for when the patient needs to be seen in followup; in general this will be the next day for ICU patients
4. Only one resident responds to stroke codes. If there is a second stroke code, the stroke fellow gets directly involved. Only if there is a critical need or there is nothing else going on, does a second consult resident respond to a stroke code. This is so that consult residents can be presenting their patients on attending rounds and so that consult residents can be learning at attending rounds as much as possible.
- Most psychiatry interns and neurology interns can see consults independently without having you see the patient as well before attending rounds. But you have torecognize the occasional inexperienced or unsophisticated intern who cannot put together a coherent evaluation and formulation. In that situation, you will have todo more than just send the intern to do the consultand hope for the best. And you should always review the consult before attending rounds toanswer questions and ascertain if it is urgent for the attending to see the patient.
If you have a fourth year student on the team, you have tosee the patient and write a separate consultnote.
Consults on whom advanced stroke imaging is done (MRI stroke protocol, CT angiogram) gets presented to the stroke fellow and ultimately the stroke attending, not the general consultattending.
Please also leave a very clear list of Friday afternoon consults that need to be staffed on Saturday morning. We’ve had some problems with this.
All discharges from the ED need to be staffed with an attending – including strokes.