Goals and Objectives:

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1. Exposure to a broad spectrum of pathology.

2. Development of the neurological physical examination.

3. Focus academic study towards anatomy and the concept of localization.

4. Initial practice with formation of differential diagnosis.

5. Perform the initial assessment of the patient and actively participate in all aspects of patient care, including history and physical, diagnostic and therapeutic planning, procedures, and writing orders.

6. Mastery on identifying and managing most of the common neurological presentation, especially acute, and life-threatening pathologies.

7. In-depth discussion of all cases with the attending before initiation of all but the most necessary diagnostic, studies, or therapeutic interventions. 

8. Engagement in general inpatient and outpatient settings, to allow interest to evolve and help guide future planning.

9. Competency in skills in lumbar puncture

10. Junior residents are responsible for maintaining medical records.

 

Responsibilities:

• Arrive no later than 7:00 am for sign out from night float. Handoff for new patients and overnight events from 7:00 - 7:30 am.

• Splitting neurology pagers at the time of the sign out, and physically carrying 9093 pager.

• Pre-round from 7:30-8:00 AM.  To assess clinically unstable patients, patient with significant events overnight, and/or new admissions.

• Formal rounds start at 8:00 AM with the team including senior resident, junior resident, and medical student. The junior resident is expected to well-versed with the cases, history, pertinent examination findings, and updates. The junior resident with present one liner on the patient. Optimally the junior resident should be rounding with a working station (WOW), and updating the progress note, putting orders, sending important pages. 

• CAP rounds on 6W Nursing Station from 9:15-9:30 AM. The senior resident will be running the rounds, but it is important for the junior resident to be present to update the list and for proper early communication with the nursing staff and the ancillary services.

• After round the junior resident should start working on the list. Early in the day, the senior and the junior residents are expected to run the list, to help communicate updates, and facilitate workflow.

• Junior residents are responsible for making all the necessary care for the patients on the service up until the time they sign out their pagers and leave the hospital.

• Direct admission to the floor: Junior resident is in-charged of making direct admission to the service, whether the patient is accepted from another facility, or the clinic. The consult resident is responsible for covering ED admissions. The junior resident should always make sure of getting a full sing out for patients admitted by the neurology consult team/resident before the patient arrival to the ward, and to assess the patient soon after the having the handoff.

• Accepted transfers to the floor from other services have to be seen at the time of acceptance, a detailed handoff and a transfer document/discharge summary must be received from the transferring service. Juniors then will examine and assess the patient and make sure that an acceptance note is in the system.

• The junior residents can escalate to the senior resident and the attending when required, clinically challenging situations for the junior’s level of training or in any other aspect of patient’s care or medical staff communications.

• We have always to remember that our priority #1 is quality patient care.

• As a part of the team, juniors play a fundamental role in maintaining harmony and collegiality inside our team.

 

Short call:

 

Signing out the inpatient service to the consult resident at 5 pm. By the time of singing out, it is expected that progress notes are up-to-date and signed, required orders are made, and communications with other teams and family were covered.

 

Long call:

 

Long calls are alternating between the junior resident and the junior consult resident. If one or the other is doing more than two consecutive weeks, the number long call is evened out over the two weeks period.

• 5:00 pm junior resident should be ready to receive the sign out from the consult residents.

• 5:00 pm to 7:00 pm the long call resident is covering the inpatient neurology service, the consult service, new consults and stroke codes. Resident’s pager must cover the junior neurology and the consult neurology pager.

 

Managing the pager:

• Triaging is a fundamental skill for excelling as a resident. It will allow you to control your pager and not the other way around.  The junior resident should have the expertise to triage cases and respond according to the sense of urgency.

• The ultimate goal for all pages to be answered immediately.

• Responding to pages (especially consulting services) should take place within no more than 5 min.

• Stroke pages are of the highest priority.

• The stroke pager is a responsibility. Whoever is carrying the pager is responsible of attending to all the stroke codes and not presuming that it will be covered by someone else.

• If the patient is performing a procedure or in any situation in which he/she can’t reach to the stroke pager immediately, should arrange that another neurology resident is covering carrying the stroke pager with a clear communication regarding the whose responsibility to respond to Brain attacks/stroke codes.  

 

Signing out to NF:

• Handoff should in Epic should be updated. The handoff should provide most of the essential details to the night house staff like pertinent parts of history and examination, and covers all the anticipated events overnight, with suggested interventions.

• The long call resident is expected to sing out no pending consults/admissions to the night float resident but is not unseemly to sing out consults/admissions that arrive after 6:30 pm. No more than two pending consults should be signed out.

• Support and even distribution of work is a critical factor for the whole team well being.

 

Didactics: 

 

Junior residents will be responsible for preparing for  and attending all didactic activities. The academic half-day is mandatory.

• RITE exam questions

• Anatomy review

• Continuum topic

• Journal article

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Basics

There are two juniors - stroke and general. The team also consists of the consult and senior residents. 

Pagers: 8024 (stroke) and 9093 (general). The pagers are also cell phones and the numbers are ****** and ********. 

Hours: 7am sharp (try to be a little early) to 5 some days (short call) or 7 other days (long call). The juniors decide together who will be short/long call each day, typically at the beginning of the week. 

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Workflow/Schedule

Arrive at 7am. Get signout from nightfloat so they can go home. Typically general gets signout first, then when Will comes (typically at ~7:15) we talk about stroke patients.

Everyone takes their pagers for the day (split off individual pagers since NF typically forwards all of them to one phone) and prints their lists.

730-8 or 830 - morning conference. See lecture schedule for specifics. Typically MR on Mon/Thurs, lecture Tues/Fri, chair rounds Weds. Thurs is also grand rounds.

CAP rounds (interdisciplinary on the floor) are at 845am for stroke and 9am for general on 6 west. 

Teaching rounds are typically 9-12 depending on the length of the list. 

Rounds structure:

Stroke - Split patients 50/50 with Will first thing in the morning. He will sign his pager into his patients and handle orders, family meetings, etc. as well as the notes, and you take the other half. He will run CAP rounds, but be prepared to answer questions about your patients. You don't need to pre-round. The attending comes around 9 usually, and we typically start with PCU (stepdown) patients. Grab a WOW for rounds so you can write your note, look at imaging, and enter orders. The stroke nurse typically also attends rounds. You can make suggestions for the plan, and the attending will correct it as needed.

General - You will carry the whole list (typically shorter than the stroke list by about 50%, so don't worry). Some attendings will want you to pre-round, so ask your senior what their expectation is. The senior will run CAP rounds, and they will also round with you. Grab a WOW for rounds so you can write your note, look at imaging, and enter orders. The senior typically makes the plan, and the attending might correct it as needed. If there's an LTM EEG patient, the epilepsy doc (Suski or Bagla, usually) will usually be the attending of record, so you'll have to talk to them about the plan, not the wards attending. 

***On Mondays, because Will doesn't work, the two juniors will split the stroke list and the senior will cover the general list alone. ***

You carry the pager all day and are responsible for all orders, family updates, consults, and progress notes on your patients. 

Starting at 12pm, the stroke junior also takes the stroke code pager from the consult resident. The average is a little less than one per afternoon. 

After noon conference/lunch, do your work for the day (consults, notes, etc.).

At 5pm, the short call resident can sign out to long call if both are not busy. Short call should update their handoff page in Epic before leaving. It's usually nice to print out a list of your patients and write in any crucial info for them (e.g. "crazy family - already updated today, don't go see if possible" or "on heparin drip - watch for bleeding".

At 5pm, the consult resident will also leave. They will sign out anyone they admitted to general or stroke during the day. 

From 5-7pm, long call will cover both inpatient services, all consults, and all stroke codes. This is BUSY, so prepare yourself for it. Try to have all of your work done before 5 or else it will get crazy. Any consults placed within 30min of the following shift can be signed out to the following shift unless they are urgent or are stroke codes.  All consults prior to 30min to end of shift are expected to be done unless you are inundated with consults. 

At 7pm, sign out to night float. 

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Responsibilities/Expectations

Notes - keep them concise and UPDATED. Don't be a slacker and copy forward. 

ICU transfers - these typically come in the afternoons. You need to lay eyes on the patient when they get to the floor (briefly), and then edit the orders (remove bedrest, add PT/OT, change the electrolyte sliding scales, etc.)

Keep the handoff updated - at a minimum, check it in the morning to make sure nobody added something there they forgot to tell you, and update it before you leave for the day. Will has a very specific handoff smartphrase in Epic that he likes to use (see Epic tips/tricks for more details). 

Discharge summaries should be started on admission and updated with pertinent details of the patient's hospital course on a regular basis. A template is available in Epic for general and stroke discharges, see the Epic help page for details. At the end of your rotation, discharge summaries are expected to be up to date until the date of transition, and if this is not done the oncoming junior reserves the right to text/call you repeatedly until it is done. Discharge summaries need to be completed on the day of discharge, but you don't need to write a progress note for that day. 

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What you can expect of other people

The ICU team functions completely separately - they have separate NPs and attendings who only see ICU patients. 

Attendings are available by text and if they're not answering by pager, at all times. They want to be updated for any big events (unstable patients, discharges, people leaving AMA, transfers), and they don't mind being texted about seemingly mundane things - they're there to help you. 

The ward senior is in charge of surveillance over all patients with neurological issues in the hospital. This means knowing the patients on the Neurology inpatient service AND the Neurology consult services, and having at least some awareness of the NCCU patients (especially when they are pending transfer to the floor). 

The consult resident does ED and floor consults all day, and stroke codes between 7am-12pm. If someone needs to be admitted from the ED, they will write the H&P and put in orders, then sign the patient out to the floor team in the evening before leaving. 

Will is the PA who helps on stroke. He only works Tuesday-Friday, and is gone in clinic in the afternoons so often can't take the complicated or needy patients who might need in person attention in the afternoon. He has a lot of experience and knowledge, so feel free to ask lots of questions - he's very helpful.