Elmhurst PGY3 Guide

Overview

Congratulations on finishing your PGY2 year! Elmhurst affords you the independence to transition from junior to senior resident.

Over the course of your year at Elmhurst:

• You’ll develop your style as a senior resident by leading a team of Elmhurst interns, Mount Sinai medical students, and St. George medical students.

• You will see how poor access to health care affects the initial presentation of a disease. Your Elmhurst patient may tell you that they have no medical problems – but that is because they have never seen a doctor.

• You’ll learn to critically think about how a diagnostic test will change management. Elmhurst is a public hospital and attendings are conscious of cost. We don’t order CTAs for every patient. MRIs are not available overnight or often on weekends. You will need to explain how a diagnostic test will change your medical management.

• The volume is lower at Elmhurst, but often the patients are just as sick or sicker than at Mount Sinai. You’ll have more time to read about your patients in this lower volume environment.

• You will become more familiar with critical care and the brain death protocol.

• Your neuroradiology skills will improve as sometimes you will have the most experienced provider looking at your image. You MUST review all imaging yourself.

Although you may be physically located at Elmhurst, you remain an integral part of the Sinai family (and we promise to happily accept your transfers!). Please feel free to reach out to your attendings or chiefs for anything you may need! You are never alone.

Rotations Overview:

~ Elmhurst Floor- 4-6 weeks
~ Elmhurst Consult- 4-6 weeks
~ Elmhurst Clinic- 4-6 weeks
~ Elmhurst Night Float- 4-6 weeks
~ Pediatrics/Bronx VA - 6 weeks each
~ MSH ED consult – 4-6 weeks
~ Elective/Neurophysiology - 10-12 weeks total

Attendings/Staff:

EHC Attendings

~ Dr. Joseph Farraye (EMG)
~ Dr. Mallory Roberts (General Neurology)
~ Dr. Beth Rapaport (Epilepsy)
~ Dr. Hazem Shoirah (Stroke)

Support Staff

~ Aura Torres (Neurology coordinator)
~ Magda Zavala (stroke coordinator)

Getting There

• The Sinai-EHC shuttle leaves from 99th and Madison Avenue. Shuttle tracker: MshsShuttle.org (make this a favorite on your phone browser!)

• By subway:

  • Take the downtown second avenue Q line to 63rd St -> transfer to the Queens bound F train to the “Roosevelt Ave – Jackson Heights” station.

  • Alternatively, take the 6 train at 96th street going downtown -> transfer to the Queens-bound E train at 51st Street. Take the E train to Queens and exit at “Roosevelt Avenue, Jackson Heights”.

  • The subway ride takes approximately 45 minutes but can be longer on weekends when trains run less often.

• On weekends and holidays there is no shuttle service. Check for subway service changes in advance. Give yourself ~1hr for travel as you may encounter unexpected delays and less frequent train service.

• The floor resident may wish to take the 6:00AM shuttle to allow extra quiet time to review the list, see new patients, and chart review before the interns arrive at 8:00.

• If you are not taking the shuttle, it is generally kind to arrive in the morning by 7:30AM to allow the night float resident to catch the shuttle back to MSH, although this is not a requirement.

Elmhurst Geography

• Work/resident areas

  • Neurology team room - COVID location D3-85 Neurophysiology office (across from Diagnostic Cardiology). You will receive a key for this room. Usual location at the back of patient ward B4, code 4-2-5.

  • Neurology call room - D5 unit on the Labor/Delivery floor. Pass the L&D Reception desk through a set of double doors -> Turn into the short hallway on your right -> make a left through a door into another hallway with a row of call rooms. Ours is labeled “Neurology,” no passcode. It has a bunk bed, computer and phone. Sheets are changed daily by Housekeeping. If sheets have not been changed, call housekeeping at the number listed outside the door.

  • If the door to the call room has been accidentally locked, the security guards on the first floor can help you unlock it.

  • There is a gym on the first floor across the hall from security. Ask the security office for the form to obtain access.

• Patient Care areas

  • A4: ICU step-down (stroke patients; active seizure patients; telemetry offered)

  • B4: Regular floor (stable patient; pending rehab; ALC)

  • COVID - Currently scattered on various floors, including B3 which is telemetry-capable

Elmhurst Roles

Education/Conferences

• Noon conference: broadcast to Neurology team room or office. Grab lunch and watch with the medical students.

• Mount Sinai Grand Rounds: broadcast on Friday mornings at 8 am in the team room or Neurology office.

• Neuroradiology conference: held Fridays at 12 pm in Radiology Dept to review the imaging for the week with Dr. Solodnik or Dr. Weeks. The floor and consult residents must a list of patients to the radiologist (MRNs and desired scans) on Friday morning so they may prepare.

Elmhurst Patients

• Elmhurst, Queens is one of the most diverse neighborhoods in the country!

  • Common languages spoken: Spanish, Chinese, Bengali, and many more.

  • You will need to use the interpreter phone often (dial 41500 from an in-house line). You can use your Elmhurst phone and press the side button to enable speaker phone.

• Many patients are underserved and not in touch with regular medical care. Patients may be undocumented and uninsured. This makes their disposition challenging if they have any needs (e.g. Rehab, home care).

• Many of the patients you care for have had strokes but you will experience all kinds of neurologic disease at EHC both on the floor and consult rotations.

• You will participate in a lot of critical care, e.g. for large ischemic and hemorrhagic stroke patients. Patients who require shunts or hemicraniectomies are cared for in the SICU under neurosurgery, otherwise they can be admitted to A4 under neurology!

  • Do not be afraid to ask for assistance from Medicine TR for medically ill patients.

  • For patients on ventilators, there is a special pulmonary consult team consisting of an ICU fellow and attending who can help you manage vents and even wean patients for extubation.

• EHC has an agreement with Queens Hospital Center to accept hemorrhagic stroke patients (as long as they are not traumatic) who present originally to QHC.

• Patients NOT admitted to Neurology:

  • Traumatic hemorrhages are to be admitted to Neurosurgery.

  • SAH patients are generally admitted to Neurosurgery - there are rare exceptions, discuss with your attending.

  • Any patient whose primary problem is non-neurological (e.g. a post-cardiac arrest patient with coma should go to the CCU, a seizure patient with a toxic-metabolic disturbance should go to Medicine, metastatic process to CNS from a primary malignancy goes to medicine with onc/neuro following as consultants)

• Alternate Level of Care (ALC)

  • designation for patients whose active work-up is completed, are medically stable, and do not require IV access

  • patients are generally awaiting disposition from the hospital

  • require 1 note per week, discuss need for weekly labs with attending

  • Our own ALC patients are usually stroke patients who are debilitated but also undocumented/uninsured and thus qualify for no rehab or home care services and their families cannot care for them.

  • Patients recommended for acute rehab by PT/rehab cannot be made ALC.

When you need help

• There is always an attending on call (listed on amion.com, pw: ehc)!

• You MUST call an attending for any of the following (even if they are or will be admitted to another service):

  • tPA cases, LVO cases / transfer for intervention cases, ICH, Midline shift

• Call any time you are unsure and need assistance.

• PGY4s on call at Sinai will happily review a case with you!

• Call EHC Medicine TR for medically ill patients

• Pulm consult team to assist with vent management

Resources

• EEGs: performed M-F during business hours only, call tech in the morning for EEG needs.

  • Patients can be left up on EEG overnight but there are no live reads from home.

  • Over the weekend if you have a patient you are suspecting may be in status, that patient may need to be transferred to a facility with 24h EEG monitoring (ie: Bellevue or MSH)

• MRIs: performed M-F during business hours only

  • Prior to obtaining a scan you must place an order in EPIC and call neuroradiology (Dr. Solodnik or Dr. Weeks) to discuss the case.

  • When truly required for emergency cases in which emergency management will change (cord compression), radiology can call in a technician to obtain an MRI during off hours. Be prepared to defend your clinical reasoning.

• Rehab/PT: consults done M-F during business hours (sometimes PT on weekends/holidays)

  • Rehab consult orders (not direct PT order) must be placed in EPIC and often need to be followed by a phone call

  • PMR resident will see the patient first to assess for candidacy to Acute rehab vs SAR. If no action in 24 hours, your team should reach out to PMR/PT separately to expedite.

  • On occasion PMR and PT disagree about the appropriate dispo plan, in which case the patient cannot go to Acute or SAR until the two services agree and place notes recommending the same dispo.

  • Rehab number #42600 – may need to call daily to review cases

  • Acute Rehab: there is an acute Rehab at EHC on the A2 unit. On occasion they will take uninsured patients for charity services.

• SW: There is a specific SWer assigned to B4 and to A4. There is always a social worker in the hospital (even on weekends) and during off-hours there is sometimes someone on call. Inform the SWer of any discharges even if the patient has no needs, either at morning rounds or by phone call in the afternoon.

• DNR forms require 2 attending signatures. After hours, the medicine bell attending (available on Amion:ehc under “Medicine Attendings”), and an ED attending can sign these forms. Note: DNR orders MUST be placed by an attending in EPIC (a resident/intern DNR order does NOT count).

Elmhurst IT

• EPIC arrived to EHC in 2016. Prior information can be obtained through the “pre-epic encounter” tab on EPIC if you go to the “Encounters” section in chart review. Note: EHC EPIC is slightly different from MSH EPIC

• Sign in under “EL Neuro”

• Access consult list by “Service teams, ongoing professional consult, ongoing Neurology Consult” - it is very roundabout

• Floor list = “EL Neurology Service Team”

• EPIC links you to McKesson (for imaging)

• Update Signout under “Handoff” tab, we used the “To-Do” field for handoff,

• REVIEW ORDERS OFTEN – please check for HSQ and LISS orders as those tend to be missed by the interns at times and fall off after a few days. You can also only order labs for 3 days at a time so make sure AM labs haven’t fallen off.

• AMION: password “EHC”

EHC Stroke Codes

1) Basics

• You will ALWAYS have at least one intern with you

• Current protocol is for CT/CTA for all stroke codes, barring contraindication to contrast (same as MSH); you have CTP capabilities

2) Numbers (have these numbers handy on your phone or on the back of your ID)

• TPA (mixed by ED RN, call ED cardiac room): 43055

• CT: 42071, 42072, 42073, 41895

• EHC Transfer Center: 844-442-2337

• Fax Facesheet to: 1-9-844-206-0066

• Virtual / overnight radiology: 855-856-6465 / 866-941-5695

3) tPA (new AHA recs: door to tPA time should be within 30 minutes)

• Call EHC attending for all potential tPA cases

• Most radiology techs will not let you give tPA in the radiology suite

• Obtain CTH, take patient back to ED for tPA, then back for CTA

4) LVO Transfers

• Call EHC attendings and MSH stroke fellow for all potential LVOs

• Call EHC transfer center if proceeding w/ transfer (fellow calls MSH center) - they will ask for name, DOB, accepting physician, reason for transfer, ambulance type (need ACLS)

• ask for phone number for ED RN sign out

• ask for ambulance ETA

• Fax facesheet to transfer center (*intern job!)

• Intern roles: (1) obtain facesheet from patient registration in the ED and fax to transfer center, (2) obtain CD with images from main radiology desk (but CD should NOT delay ambulance departure if not complete)

• Keep MSH updated: post updates, ambulance departure, final exam

• Send copy of your consult note to accepting resident at MSH

5) Documentation

• You will be called about this constantly, so just try to ensure you’re doing it appropriately from the beginning

• Basic stroke template has everything in it that you’ll need to fill out, including time of code / CT interpretation etc, explicit reasons for any tPA delay (only list accepted reasons), swallow screen, etc

Escalation of Care Policy for Neurology Residents at Elmhurst:

(From Dr. Farraye, June 2018)

The purpose of this policy is to define under which circumstances the attending physician needs to be notified in a timely manner of a patient’s status or change in status. In particular, this refers to those conditions that may result in predictable morbidity or mortality, and thereby allow the attending to advise or coordinate the emergent management of critical problems as they evolve in real time. This policy is intended to outline not only potential neurological scenarios, but identify worrisome changes the general medical condition of the patient as well. It is common that patients are admitted to the Elmhurst Neurology service with critical illnesses, most often acute cerebrovascular disease. However, comorbidities typically exist, and serious medical as well as neurological complications can arise that require early awareness of warning signs and the capability of urgent management. The attending for the service or on-call should be routinely notified early on in the following situations:

1. In acute stroke:

2. Any and all acute intracranial hemorrhages being evaluated in the ED or other wards.

3. All decisions on administering or withholding fibrinolytics in eligible acute stroke patients.

4. All decisions on pursuing thrombectomy in acute large vessel stroke in eligible patients

5. In general Neurology:

6. Acute hydrocephalus

7. Large brain lesions regardless of etiology that cause major shift of cerebral compartments, with or without clinical signs of herniation.

8. Acute spinal cord compression or dysfunction

9. Status epilepticus not responding to two intravenous medications

10. Unsuccessful lumbar puncture after two attempts in each of two interspaces should be performed by an attending or by IR (Interventional Radiology).

11. All transfers of patients either out of the hospital for procedures or for a level of care not available at Elmhurst or acceptance of patients from outside institutions for transfer.

12. Any situation where the resident is completely uncertain of a patient’s Neurological diagnosis or proper management.

13. General Medical Management:

14. Active systemic bleeding requiring multiple transfusions or resulting in significant tachycardia, hypotension or change in mental status, particularly if a new complication not already known to the attending.

15. Significant hypoxia and/or severe hypotension not responding to general measures and not satisfactorily managed despite assistance from the Medicine, Cardiology, Pulmonary or ICU consultants.

16. An acute ST segment elevation myocardial infarction (STEMI) in a hospitalized patient on the Neurology service.

17. Frank sepsis, or SIRS in a patient on the Neurology service

18. Any instance where the resident is uncomfortable about management of major systemic complications despite evaluation by an appropriate consultant.

19. Any situation where a barrier exists in obtaining timely critical diagnostic testing or response from another service. Escalation to a more senior supervisor on site or the Administrator on Duty (AOD) should be considered prior to notifying the attending.