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The Team

  • a senior resident
  • a junior resident
  • a psychiatry intern
  • med students (usually 2-4)

The Schedule

  • Mornings: The weekday mornings are spent in clinic (except Wednesday, which is protected for conference).
  • Lunch: Bring a lunch unless you like VA food. When you have clinic or conferences at the U, park in Taubman and grab a voucher for free parking from Lashawn or Donnella.
  • Afternoons:
    • VA senior and junior: Afternoons are spent rounding with the inpatient attending on the neurology inpatients, seeing consults, and finishing notes from clinic. Most days are done around 5, but it's not uncommon to be there later finishing notes or seeing consults. The senior's continuity clinic is on MONDAY, and the junior's clinic is on TUESDAY. You are expected to arrive on time, so be sure to leave the VA by 12 or 12:15.
    • VA senior handles outpatient prescription refills and other similar miscellaneous issues that the MA brings to your attention.

Outpatient Clinic

  • Arrive by 7:30 AM to clinic, which is located in the trailer across from the Ophthy Suite on the 1st floor (near the Liberty elevators, Station 17). Team room is in the back.
  • As patients come in and are roomed by MAs, their sheets will be placed in the team room.  Grab them on first-come, first-serve basis and put your initials on the sign in sheet so we know who is seeing whom. Spend a few minutes reading up on story, then see them and staff with an available attending (proritize having RVs seen by attending who saw last time, and if possible have NPs seen by attending whose specialty it is, i.e. stroke patients seen by stroke attending, etc)
  • Med students new to the rotation should shadow with resident for the first patient in any given clinic; after that, they can see RVs on their own and staff alone with attending, and write notes/orders for attendings to sign. Usually med students can see 2-3 patients per half-day. OF NOTE, Dr. Segal wants med students to SHADOW ONLY for his patients.

Consults

  • Daytime Consults: 8:00 AM - 5:00 PM; this time range is flexible within reason
    • Consults are paged to the senior resident from the requesting service. A consult order must be placed by primary team for you to write a consult note; if one not submitted, just enter the consult order yourself.
    • Consults are divided up by the senior resident (between senior, junior, and psych intern) and staffed with the inpatient attending; med students should see consults/follow inpatients and can write a note, but the patient should still be seen by the resident, and the resident needs to be the one to submit the final note. 
    • The senior (or junior if the senior is in clinic) should contact the attending to determine a rounding time.
    • Outside VA phone consults and transfer requests will be called to the VA senior by the AOD to review; discuss with attending prior to giving final recs.
    • If ER consult comes in during clinic, it is expected that a resident will break off from clinic to see the patient, and staff with one of the clinic attendings, NOT the inpatient attending. If a floor consult comes in, if not emergent then it can wait until the afternoon and be staffed with the inpatient attending per usual.
  • Afterhours Consults (5:00 PM - 8:00 AM on weekdays, and all day on the weekends and holidays)
    • All afterhours consults are paged to the resident on call.
    • Afterhours consults are staffed by phone with the on-call attending.
  • The on-call attending list is usually posted in the residents room.
  • The on-call list can also be found at:
    1. Go to http://vaww.ann-arbor.med.va.gov:1030/default.asp
    2. Hover over the "Service Schedules" drop down menu at the top of the page.
    3. Select "Neurology"
    4. Open the file for the appropriate month.


Inpatient Service

The service is usually on the small side, i.e. 2 or less. The psychiatry intern pre-rounds on any neurology inpatients, and handles their cross-cover, orders, and notes. Inpatients are generally individuals with fairly low acuity and stable neurological conditions. Any patient with multiple or unstable problems should be on a service that has in house coverage (usually medicine). If a patient would have been on the neurology service, but due to their other issues goes to another service, then it's good form to follow the patient as a consultant. The exact arrangements should always be discussed with the on-call attending first when staffing the consult / admission.


Call

Call is from home, and averages q3 over the month. Call is normally pretty laid back. It's fairly uncommon to have to come in, but it does happen (roughly 1 in 3 nights on average over the month).

  • The incoming VA senior is responsible for creating the call schedule; early in the month that is PRIOR to the rotation. In academic year 2015-2016 we have a V3 position so the call will be split up between the senior, the junior and the V3. VA residents work weekdays and weekends, each taking one weekend in a 2-week block; V3  residents can ONLY be on-call Sunday-Thursday nights, NOT Friday nights or weekends and will not be expected to round on inpatients on weekends or VA holidays. Be as accommodating as possible, understanding that you may not be able to be make everyone happy.  Email Bonnie at the VA no later than the 15th on the month prior to the rotation with the schedule.
  • WEEKDAYS:  call is split between the VA residents the V3 with each resident taking about 5 days per half-month.
  • WEEKENDS (Friday night through Sunday evening OR Monday morning): either the senior or junior resident is on-call during the entire weekend ; V3 residents are not eligible for this period. In the weekend mornings, the on-call resident rounds on any neuro inpatients, sees new consults, and sees any follow-up consults that are still active; they should page the weekend on-call attending to figure out rounding times.
  • The psych intern is first-call for cross-cover of inpatients, though should have a low threshold to call the on-call neuro resident if they have questions or concerns. If anything arises that necessitates the psych resident to come in overnight (ie, patient worsening), the on-call neuro resident should also be coming in too. 
  • The on-call neuro resident should receive signout from the VA residents at around 5PM, including inpatients, active consults, who the on-call attending is that night, and who the psych intern is.

STROKE

1)      For daytime acute strokes at the VA, you CAN call the Brain Injury Group attending IF you want to discuss case, but it is NOT required to call them (provided you discuss the case with your VA attending). 

  • If there is delay in being able to get CT scan (ie, CT tech is not in-house), then tell ER to emergently transfer patient via ambulance to UofM; if that occurs, inform the BIG attending and UofM neuro resident on-call of the pending transfer/patient information. If the patient is inpatient already, we do not have this option, and transfer would only occur if need intra-arterial TPA/thrombectomy. AS A RULE OF THUMB, IF IT TAKES A LONGER TIME TO GET A CT HEAD THEN TO TRANSFER THE PATIENT OVER TO UofM, JUST TRANSFER THEM TO UofM (do whatever gets them TPA the fastest).
  • If it is an inpatient stroke and they need tPA, there is usually not a problem getting the CT scan emergently.
  • If you give tPA and patient seems to likely need intrarterial intervention begin the process of transferring to UMHS as soon as possible.

2)      All stroke patients (even subacute stroke admits) need an initial NIHSS documented within 24 hours.

3)      All stroke patients need a dysphagia screen documented before administering anything PO.  This is generally done by nurses in the ED, but MUST be documented.

4)      Please document that tPA was considered and (if applicable) why it was not administered.

5)      Patients receiving TPA should first be admitted to MICU (likely under MICU care with neuro consulting, though this is negotiable) for close neuro checks/monitoring; once stable, they can be transferred to general neurology floor.

EEGs

  • EEGs are read by the senior resident.
  • Go to the VA EEGs page for details.


The Residents Room

The neurology residents room is on the 4th floor. It's home base during the afternoons. Take the Freedom elevators (by the urgent care entrance) to get to it. Follow the signs to EEG if you get lost.   The key is in a lockbox at the end of the hallway, code 734; PUT THE KEY BACK WHEN YOU ARE DONE WITH IT. The key opens both the resident room, and the EEG-reading room.

Streaming UMHS Noon Conferences through Adobe Connect

https://connect.umms.med.umich.edu/neuroconf/

Then you can login as a guest with your name. Write a comment and let them know you are there so someone can sign you in for conference.

Parking

  • Parking is in the lot on the north side of Fuller (i.e. across the street from the front of the VA). The parking garage and the lots next to the VA are not for residents. On the weekends, you can park in the lot on the south side of Fuller. Overnight, you can park in front of the ER (at the back of the hospital) too if you are called in for consults.
  •  Talk to security to get a special passcard that opens the door near the auditorium in the front of the hospital, making for easier access in the mornings and after-hours.


VA Computers

The VA uses the CPRS system for writing notes and electronic order entry.

  • If you have questions regarding your login / passwords, go to the IT support office.
  • CPRS Lists
  • CPRS Orders

 Access CPRS from home (PC):

1. Download VPN

2.Go here for further instructions:  http://www.med.umich.edu/i/clinical/cprs1.html

Basically, you have to get permission first (takes a few days for approval, can only apply for approval via a computer AT the actual VA), THEN install an additional app on your computer. Of note, if you don't have access at a time when orders are needed, nursing MAY accept verbal orders at the time if you ask nicely.

VA Notes and Encounter Forms

VA Outpatient Clinic Orders

      ¿  Step 1: Click on provider tab next to patient's name in CPRS

      ¿  Step 2: Change the provider from yourself to the staffing physician.

      ¿  Step 3: Write orders.

      *** This ensures that the results will be forwarded to the appropriate attending physician so that results are not lost when residents rotate off the VA.

VA Outpatient Clinic Misc

  • Complete check out sheet and give to patient – or  talk with our coordinator for help to do so.  The sheets are maintained and reviewed; required information at check out:  Is follow-up required?  When?  Labs today (yes or no), Picking up meds at window?  Anything else can be completed after clinic is done.
  • Lab orders need to be in and signed ASAP, meds too if they expect to pick them up today
  •  Separate pt discharge instruction sheets are available
  • Enter all clinic orders under the Attendings' name
  • Lab orders specific for neurology can be accessed on order screen, left column "specialty clinic orders"
  • Do not schedule routine return visits <4 months.  If we are seeing a consult as a 2nd opinion, try to return them to consult originator – do not schedule to return to clinic
  • If MRIs are to be done same day as return visit, indicate on 'requested date' a date that far into the future/same day of the week
  •  OT and PT will see walk-ins same-day for equipment needs
  • EKG and monitors should be sent directly to 7th floor cardiology for same day completion
  • Many services are available at satellite locations.
  • You can only use the infusion center 1) With the center director's direct consent, and 2) Only if the patient is SUPER STABLE AND INDEPENDANT. Otherwise, need to admit to Gen Neuro service overnight and have the director write for chemo orders (rituximab, IVIG, etc). 

VA Tools

VA Tips for med students and psych residents

-Med student tips

Psych intern tips

Ordering IVIG at the VA:

1)  Go to "Templates," -> "Shared Templates," --> "Hematology/Oncology," --> "Legacy One-Prescriber Chemo Orders Notes," -> "IVIG"
2)  It then asks you to create a note.  I have not received clear instructions on what note to select, but chose "Neurology Inpatient"
3)  Fill in all prompts, including daily dose and number of cycles.  Remember that IVIG is usually dosed based on the Ideal Body Weight (unless the patient is cachetic).  There are calculators online.
4)  Do NOT forget to consent the patient using the software provided by AAVA.  If you fail to do this, you'll likely get paged to come in prior to administration of the IVIG (which chances are will be between 3-5am, just because that's when pharmacy will get around to sending the dose to the floor!)
   - To consent, make sure the computer is hooked up to an electronic signature pad then:  On the top of your patient's chart, click "Tools" then "I-MedConsent" (the 3rd option from the top).  A separate browser will open, that hopefully is linked to the patient chart.  If this fails to sync, you may have to close all programs and log back in.
   - Find the neurology procedures on the left, and select the correct procedure.
   - Go through all prompts, which you should read to the patient when they are with regards to risks.  Eventually you will get to where you first will place your signature.  Then the patient will be asked to place theirs.
   - Continue until complete.

 
 
 
 

VA Pharmacy issues

The VA pharmacy can get medications from other hospitals (UMHS or St. Joes) within a few hours if they are not at the VA. Keep this in mind if you desperately need something that is not in stock.



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