Basics

Lahey night float is much more grueling than Tufts night float - expect an average of 5-6 consults per night. A bad night could be over 10. 

Pagers: 9093 (general), 8024 (stroke), 8025 (consult), 9751 (senior). 

Hours: 7pm sharp (try to be a little early) to 7am. You have to stay late for morning report on Mondays and Thursdays, but otherwise you can usually get out on time. 

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Workflow/Schedule

Arrive at 7pm. Print your lists (inpatient general/stroke lists). Get signout from the long call resident. Sign over the pagers to the one you want to carry and take the stroke pager. Don't be surprised if long call gives you 1-2 consults.

You're the only neurologist in the hospital at night. You're responsible for covering all the neurology inpatients on both lists, new ED consults, new floor consults, floor or ICU admissions, stroke codes, and new ICU consults. 

Since the ICU functions independently during the day, they don't sign out to you so you won't know the ICU patients. If the ICU has a question about a patient, they can just page the NCCU attending on call (pager 2000), and they can sometimes just figure it out on the phone. If they can't, the NCCU attending might tell them to page you because they trust your exam more than anyone else in the hospital at night. 

If you have a stroke code, or a consult or admission that seems like a stroke (use your judgement), call the stroke attending. 

If you have a non-stroke consult, you will staff with either the consult attending or the ward attending (they alternate days on call- check the schedule on the wall in the resident work room for specifics or just page the neurology attending on call on MassNet). In the morning, sometimes the attending who was not on call the night before will call the work room or come by right after 7 so you can give them a quick signout before you leave. 

If there's an ED consult that's getting admitted to the ICU (either because one of the other attendings said they need to go to ICU or because they have to go for some other reason like intubation), you call the NCCU attending to staff. 

If someone is being admitted to the floor or PCU, you put in orders. If it's admitted to the ICU, the medical teams put in orders.

 

NCCU

Working with the Neurocritical Care Advanced Practitioner Overnight 

As our NCC Advanced Practitioners begin to start taking night calls at Lahey starting July 1st, they will be sharing some of the workload with the resident for patients requiring ICU level of care. For the first several months of 2019, the NCCU AP coverage will not be every night. The neurology AP and night float resident should touch base at the beginning of the shift (between 19:00 and 20:00) to ensure that neurology night float resident knows whether there is coverage present for that specific night (and their schedule is published on Amion, click here for details). The NCCU AP will carry the pager number 2999.

All pages for new consults will still go to the neurology night float resident. It is the responsibility of the neurology resident to appropriately triage. Below we have outlined how to appropriately triage consults in different settings.

It is important to remember that the night float resident and AP will need to work as a team for ICU patients and communication will be essential with this new system. If the AP is occupied with an unstable patient or is performing a procedure and is unable to see an urgent consult at the time, then the neurology resident is required to see the consult.

Consults in the Emergency Department

• If the night float resident receives a consult from the ER  for a stabilized patient who has already been determined to be admitted to an ICU setting (i. e. the patient is already in the ICU), then the neurology resident should page 2999 to let the NCC AP assess the patient, provided he/she is not in the midst of managing an emergency or performing a procedure in the ICU.

• If the night float resident receives a consult from the ER for a patient with a neurologic emergency (status epilepticus, active herniation, etc.) then the resident should immediately go to the ER and not delay patient care.  While assessing the patient in the emergency room, they should ask the ER staff to page 2999 so that the AP can aid and take over the remainder of the patient’s care, provided she/he is not in the midst of managing an emergency or performing a procedure in the ICU. The AP will staff with the NCC attending and complete the consult/admission. The neurology resident does not need to document an H&P/consult note.

• If the night float resident receives a routine consult but after assessing the patient or staffing with the on-call attending it is determined that the patient will require the ICU, then the following should occur:

  1. The resident should call/page the NCC attending directly to formulate a plan

  2. The resident should page 2999 to sign out the patient to the AP.

  3. The resident should communicate with the ER physician that the patient requires the ICU so that the admissions triage can arrange for an ICU bed.

  4. The resident is responsible for documenting a consult/H&P. The AP and resident should work together for admission orders.

  5. The AP will assume the remainder of the patient’s care afterwards.

  

Stroke Codes

• Stroke codes in any setting (ED, ICU, or floor) must be seen by the neurology resident. The neurology resident is required to staff the patient with the on-call stroke attending and document a stroke code note.

• If the patient is already in the ICU, then page 2999 to sign out the assessment and plan to the AP after staffing.

• If the patient is in the ED or floor afterwards requires the ICU, then the resident should page 2999 to sign out the patient to the AP and 2000 to also staff with the NCCU attending (or at least give them an FYI).

Consults from the ICU

• All new consults from the ICU should be triaged to the NCC AP.

• If the AP is occupied with an unstable patient or is performing a procedure and is unable to see the consult in a timely fashion, then the resident is required to see the patient, staff with the on-call NCC attending, and sign out the patient to the AP.

• Pages regarding known consults from the ICU on patients that are being followed by the NCCU team should be triaged to the NCCU AP so that they may address any questions.

• Pages regarding known consults from the ICU on patients that are being followed by the NCCU team on nights when there is no NCCU AP coverage will need to be discussed with the on-call NCCU attending.

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Morning Report

At both Lahey and Tufts, the NF resident is responsible for presenting at morning report. This consists of presentation of a case from over night (it can be interesting or super simple, there's always something to learn). If you miraculously saw nothing overnight, you can present a patient you've seen recently, or you can present a paper. 

The general structure is presentation of the chief complaint/reason for consult, chronic medical issues/history of present illness, and pertinent history items from SH/FH/meds/PMH/PSH. Faculty will interrupt repeatedly to clarify details from the history, or to ask you about localization or differential. You then present the vitals/exam, and again may be asked a series of questions. 

This presentation process can often seem intimidating, but is in fact one of the best and most important parts of the residency training.  At no other time will your work be considered, mulled, and probed by numerous faculty all at once.  They will often ask you questions to which you don't know the answer.  That is ok, as they are not looking to see how ignorant you are but are looking for an opportunity to teach.   Your job often is to do a focused exam,  what is difficult is know what to focus on, and if you missed a part of the exam that they ask you about, this is not about chastisement, but for you to remember that this seemingly irrelevant exam detail is actually pertinent to the presentation of the patient.