VA CONsults
on this page:
The VA Consult Service is responsible for the evaluation and co-management of a variety of neurological issues being treated in the VA ED and VA Inpatient Medicine/Surgical Services. The VA Senior is a PGY-3 role and is an opportunity to develop clinical independence leading a team. The typical census for this service can vary greatly from 1-2 active consults to 5-7.
Day 1
Make sure you have gotten sign-out on any existing consults that need to be followed. Check with the previous VA senior as well as the Weekend Float resident.
At 7AM, take over the VA pager from the Weekend Float resident: transfer p11421 to your own pager. There is also a VA stroke pager which must be physically passed off from the previous resident.
Arrive at 7AM, chart review and round on any existing consults. You may need to see a new consult from overnight (check with the Weekend Float resident). See “Weekday Schedule” below.
Make sure you have access to the neurology shared drive (BAL Neurology share). This is where we keep sign-out lists and our master lists of consults, which you should update each day. If you do not have access, you will need to call the help desk (855) 673-4357.
Usually your first day will be a Monday. There will be VA clinic on Monday afternoon. Make sure you have received a clinic schedule for the afternoon from Renee or Latasha - consider emailing them on Friday so you can pre-chart.
Team Structure
Consult Attending: responsible for the overview of the whole team and to help with acute and complex decision making. The attending leads rounds in the morning and is available throughout the day for any patient care issues that may arise.
The attending will be available to staff consults each weekend day via phone with the overnight and prior day’s on-call resident between 9 and 11 am.
The attending serves typically either a 2 or 4 week period. Please refer to EZcall (Neurology Attending schedule) to see who is on service.
1 PGY-3 Senior Resident: responsible for completing/overseeing all consultations during the hours of 7am-5pm. You are the “senior neurologist” in the VA and will generally have a great deal of autonomy to make first-pass recommendations for your patients. If consultations are to be seen by the medical students you will need to personally evaluate the patient and review the described plan with them. Rounds with the attending will be directed by the senior and they are responsible for determining needs of follow up evaluation as well as ensuring recommendations are provided to the primary service.
In the afternoons you will be the leader of the VA Clinic staff. Your responsibility is to make sure that the patients are being seen efficiently, answer any questions the students may have and respond to any concerns of the case managers. Triaging consultations during this time period will be described below.
Additionally, and the most vital role of the VA Senior is the responsibility to teach your cohort of medical students. This is a time to develop your teaching acumen as you will be their primary source for education in the field of neurology.
5-6 Medical Students: students may see consults (also must be seen by the senior) and participate in clinics in the afternoons.
Occasionally there will be a medicine or psychiatry rotator as well. Patients seen by rotators should be evaluated by the senior also, and plans should be discussed prior to presenting to the attending.
Weekday Schedule
7:00 AM: Arrive with time to pre-round on overnight consultations and existing consults.
7:45-8:15 AM: Morning Report: each day in July and August, Tue/Thu only thereafter
8:15-11:00 AM: Attending Rounds. Either assign a student to learn the new cases before rounds or learn all overnight cases yourself and have evaluated them to present to the attending. It is up to the attending whether rounds occur in the team room or at the bedside.
11:30 AM-12:30 PM: Midday Didactic Conference. It is expected that you attend this conference and arrive on time. Only emergent clinical issues (ie BATs and Status Epilepticus) should prevent your participation in conference.
12:30-4:00 PM: Participate in VA Subspecialty Clinics on Monday, Thursday, and Friday. Continue to see consults from the ED and Inpatient services.
4:00-5:00 PM: Complete any consults that have been requested during clinic hours, follow up with Primary Services on any outstanding questions or results for previously evaluated patients. Prepare sign-out. Keep in mind that sign-out should be continually updated throughout the day as developments arise.
Exceptions to Typical Schedule
Wednesdays: There is a modified schedule due to Neurology Grand Rounds (2:00 PM -4:00 PM). There is no morning report on these days. Midday didactics run from 12:30-1:30 PM.
Clinic days: On your clinic days (usually Tuesday), you go straight from midday conference to Frenkil Clinic. You will be expect to continue to triage consults as they are called in during your clinic. You may have students evaluate these patients and then staff them with you once you have finished clinic. Should a more emergent consult be called such as a BAT or Status Epilepticus you will need to inform the clinic attending and excuse yourself to care for these consultations. You should not be routinely leaving clinic to see consults; this should only be done in the case of an emergency. You are expected to see all consults that have been called in during your time in clinic after you return to the VA (these may not be pushed to the next day).
Call
See the section ‘VA Neurology Call Policy’.
Triaging Consults
You will receive consults via the pager (11421) throughout the day and should attempt to call back within 10-15 minutes (even while in clinic). Any consults in the morning should be seen prior to midday didactics and afternoon clinic responsibilities. Consults called during clinic hours are your responsibility as well. If there is an acute neurological emergency such as BAT or Status Epilepticus you will need to discuss with your fellow clinic colleagues and excuse yourself immediately to attend to the patient. Non-emergent consults may be seen after you have completed your clinic responsibilities or in the rare circumstance when the clinic is experiencing low volume may discuss with your co-residents excusing yourself to efficiently evaluate the consultation.
While in your Frenkil clinic on Tuesday afternoons, you may ask your medical students to see non-emergent consults during the afternoon so that you can staff them and more efficiently evaluate the patients when you return.
Documentation
Consult templates should be distributed to you at the beginning of the year by your chiefs or other seniors. Liz Lounds is likely the most helpful in this endeavor.
If a consult is seen by a medical student, you will need to write a separate note including all of the pertinent information of HPI, PHM, Medications, ROS, Examination, Imaging Review and Assessment and Plan. Consults evaluated by a rotator do not require an additional note from the senior.
EEG & EMU Information
Routine EEG
Techs are available at the VA from 7am-10pm. In order for an EEG to be performed, it must be approved by the neurology team verbally or in a note. The consulting team is responsible for placing an EEG consult and may document that they spoke to you within the consult request. If the EEG is time-sensitive, contact Regina or the EEG techs (phone numbers below).
EMU Patient Workflow
Sign Out
Sign out is kept on a Word Document. You will receive the most updated version from the VA Senior completing their rotation ahead of you and continue to update daily. This should include the patient name, last 4 SSN and location in Column 1; reason for consult and brief HPI in Column 2; recommendations in Column 3; Primary Team in Column 4.
Additionally, there is an Excel sheet in which you will need to track all consultations. The second tab is to document stroke consults and some basic information regarding their stay such as tPA status and swallowing evaluations.
Voicemail
You are responsible for checking each phone in the VA Team room voicemail on a daily basis and follow up as necessary. To access the voicemail dial 7000 and the passcode is 1234.
Important Names and Numbers
VA pager: 11421
VA team room door: 412
Voice Mail: 7000 then code 1234
Liz Lounds Cotten, MS, RN
Nurse Manager
O: 410.605.7463 P: 410.447.6408 F: 410.605.7937
Dr. Fishman: 6612; 410-274-5354
Dr. Hafer-Macko: 410-746-5406
Dr Tang: 610-220-1809
Dr. Cupka: 5713
Dr. Macko 410-627-0125
Neuro Team Room: 3157/5167
Neuro Office: 7060/6624; Fax 410 605 7937
Neuro Clinic: 5456/7/8
Neuro Clinic case manager: 4705
Epilepsy Fellow Pager: p12054
EEG tech: 3573, p410-447-0015
EEG VA office (Regina NP): 7414, 3573; 443-742- 8547, 410-447-0016
MRI read/neuroradiology: 6383, 4774, 7400
MRI console: 6979/6369
CT tech: 6377
Emergency room: 7272, 5125
MICU: 6143
SICU: 6164
CICU: 6100
CCU: 6100/5484
GEMU: 5408 / pager 9962
Green: 5262/5219/4819
Pink: 5469/5470
Purple: 4877/4878
Blue: 5484
Orange: 5257/5281
Yellow; 5263/3003
Gold: 5375/410-447-0112
Psych: 6177
Medicine admissions: pager 8633
Vascular Surgery: 5697; 410-447-0274 /410-460-0049
General Surgery: pager 410-447-4406
Angio: 7390/6297
Lab: 5328
Cytology: 5317
Pathology: 7250
Outpt Pharmacy: 6575
Inpatient Pharmacy: 7106
Outpatient Echo: 410-605-4537
Eye clinic: 7230
Neurosurgery UMMC: b9290
Neurosurgery pager at VA: (410) 389 0292
Neurosurgery office: 5673
Neuropsych (inpt): 410-637-1389
To page someone: Dial 7999 then the beeper #
VA IT/helpdesk: 330-1115 or 410-642-1115, (855) 673-4357
GOALS & OBJECTIVES
Be able to evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.
Develop appropriate differential and initiate further diagnostic testing and management for movement, neuromuscular, cognitive/behavioral, demyelinating, seizure, neuro-oncologic, and neuropsychiatric/somatofoam disorders, along with headache and neurologic manifestation of systemic disease.
Accurately perform neurologic exams on comatose or braindead patients.
List the indications, contraindications, and complications of Lumbar Puncture and perform the procedure.
Incorporate feedback and develop a learning plan.
Review literature to incorporate evidence-based medicine in patient care.
Appropriately order and interpret neuroimaging studies.
Clearly and completely document patient care in a timely fashion.
Communicate effectively with other members of the care team, both verbally and through documentation.
Recognize and manage neurologic emergencies.
Be able to describe basic and advanced neuroanatomy.