NEUROLOGY GUIDE

Updated: 06/26/2024

Welcome to the pediatric neurology service! During your PGY-1 year, you will spend 1-2 weeks with us and will learn much about epilepsy and childhood neurological conditions. We are constantly striving to provide an excellent learning experience while balancing your education with service obligations, so please let us know if you have thoughts, suggestions, or concerns about how the rotation is functioning.

As part of Neuro rotation improvement, there is a handbook to help guide your learning. Please refer to it during your rotation.

Schedule:

Below is an approximate weekly schedule of typical conferences, rounds, etc. during the year. It is, of course, subject to change and rescheduling, and it should be superseded by any updates given to you by the fellow or attending on service. Note, you are expected to attend Pediatric Noon Conference from 12-1:15PM every day.

* Denotes conferences that are optional and may be superseded by patient care needs

** Fellow conference only

Every Thursday will be a “late” neuro day - plan to stay until 6-6:30p to help finish clinic and/or admit patients who have arrived during clinic hours.

* Note: UCLA-N cross-coverage

Most interns will cover two UCLA night shifts during the Neuro block (see example below). You are excused from Neuro the Friday of your covering night shift. You will be post-call on Sunday, and are expected to return to your Neuro clinical duties on Monday.

Responsibilities:

We are the primary team for the pediatric neurology service. Therefore we admit all of our telemetry admissions, ER admissions, PICU transfers to the floor etc., and are responsible for all admission history & physical exams, notes, orders and discharge summaries. There is a pediatrics hospitalist team (Silver Team) that is available to consult on our patients for primary pediatrics issues. As the pediatric representative on the team, you are our liaison to the hospitalist team with respect to general pediatric issues when they arise.

In addition, we cover any consultations that may come from other services, NICU, PICU, ER, and others. For consults coming from the PICU and NICU, you play the role of the primary neurologist for the patient and will write consult H&Ps as well as full daily consult notes. You are also responsible for conveying the neurology recommendations to the primary teams for these patients.

SERVICE REQUIREMENTS:

First Day:

Find peds neurology workroom on 5th floor of RR: if you are at Pennington, walk away from the entrance to the floor towards the offices located across the outdoor child life area
Enter through the glass door that says "5235 Pediatrics Echo Lab & Neuro Diagnostics"
Door code is 55235#
Neuro room is located immediately to the left
If this room is locked, take a right towards the secretary's desk. In the first drawer under the printer is a key attached to a wooden stick that will open this door.
It is appropriate to let yourself in in the morning and pre-round there. The peds neuro fellow & residents typically use this room as home base.
Ask your fellow about their expectations for the day and to help you with general workflow.

Expectations for an average day:

Check patient assignments on list emailed every evening & morning (~7:30am)
Pre-round in workroom (or wherever you can find space), including bringing up any EEG green sheets to the EEG workroom before rounds (ok to ask fellow about this on the first day)
Rounds usually at 8:30 or 9am. Check in with fellow RE: time and location
Rounds consist of table rounds, then EEG rounds, then bedside rounds
During EEG rounds, expect to take notes on the EEG findings on your patients which you can help describe during patient rounds and place in your note later.
Finish rounds and place orders
Noon conference
Clinic is in the afternoons on Monday and Thursday. These have been mostly video visits which can be done wherever you can find a quiet space! Consider using a call room or the basement resident room if empty.
If not seeing clinic patients, expect to admit patients with the fellow during the afternoon

Pre-rounding:

You should be available on pager at 8AM every weekday in case the fellow needs to contact you about seeing a patient, etc. It is your responsibility to preround on your assigned patients before attending rounds begin.
This includes recording their overnight events as described by the RNs, vitals, following-up on any labs or other studies that were pending, and examining the patient daily.
If you are unable to pre-round on all of your patients for any reason, please call or page the fellow on service so accommodations may be made.

Tele rounds:

You are responsible for knowing the interim events your patients on video EEG have had overnight – specifically when they occurred along with a description of the event. It is usually helpful to photocopy the event sheet from the bedside that the parent annotates.
You are also responsible for recording the preliminary video EEG reads as described by the epileptologist who is reading the studies. This information should be in your daily notes. A preliminary report may be in the chart that afternoon.

Communicating with primary teams:

Immediately after rounds, it is your responsibility to complete all orders, consults, notes, and discharges on your patients and communicate our daily recommendations to the primary teams on the consult patients. Discharges should take priority.
Care connect requires that the discharge medications, including non-controlled substances, must be cosigned by someone with a DEA. This may be done by anyone on the peds neuro team (adult neuro resident, fellow or attending). Any controlled medications (such as opioids, benzodiazepines, and barbiturates) will require a physical triplicate prescription.
For PICU and NICU consult patients, convey the recommendations to them as soon as possible.

Helpful topics to ask the fellow (or attendings) to teach if there is time:

General EEG interpretation (would prioritize this near the beginning of the rotation!!)
Basic neuroimaging modalities/findings
Seizure meds

Admission Orders:

Admission orders need to be placed as soon as possible after seeing a new patient. Scheduled Admissions should include the following orders - seizure precautions, vitals Q Shift, EMU Peds EEG Video monitoring, Ativan or Diastat PRN, continuous pulse ox, if indicated.

All presurgical admissions will need a PET, which is typically scheduled before admission. Please check CareConnect for orders placed. For all PETs, patient should be made NPO except medications at midnight with ½NS (No D5!). MRI brain is also part of a pre-surgical workup. This should be done after seizures are captured because the EEG leads may be metal. When you and the team decide when MRI should be done, it is your responsibility to complete and fax the sedation request form to anesthesia and confirm the date and time.

Continuous pulse ox may not be needed for ESES admissions unless the patient has a history of grand mal seizures or other seizures with oxygen desaturation.

Consults:

The fellow on service will assign you to see both scheduled telemetry admissions and new consults requested during the day. You may be asked to see a patient before going to clinic, or asked to leave our clinic to see a new consult. If an admission arrives prior to 5PM the patient needs to be seen by the resident, and an initial consult note needs to be entered on the day of admission, even though the patient may not be seen by the attending until the following morning.

Clinic:

Clinics are two half-days per week, Monday and Thursday, starting promptly at 1pm to approximately 6pm. They are located in 200 Medical Plaza, 2nd floor, Module 4 of the Pediatric Clinic. Please make every effort to be on time to clinic. We see all attendings’ patients in clinic.

You will learn about outpatient management of seizures, headaches, and other neurologic diseases.

Additionally, Dr. Jason Lerner has a headache clinic in 300 Medical Plaza on Monday afternoons. Please ask the fellow if it would be possible for you to attend this clinic, if you are interested.

Notes:

It is expected that your notes be completed in a timely fashion. This means that all notes should be signed and sent for addendum by the end of the workday (6PM). We know that on clinic days (Mondays and Thursdays, as well as your RRC clinic day) this may not be possible due to your clinic obligations. The absolute deadline for notes to be signed is 9PM. If you are having trouble completing your notes by 9PM, please let the fellow or attending on service know so that we might make changes to allow you to do so. The discharge summary and the progress notes must include the preliminary video EEG reads as well as all medication changes and their rationale. If you need clarification regarding this rationale, do not hesitate to ask your fellow.

In clinic, all patients who are new to the clinic as well as patients who have not been seen in over 24 months need to have a dictated/typed clinic H & P or consult note entered into the system. Please type your notes after all clinic patients have been seen for efficiency. You are responsible for completing notes, updating problem list, reconciling medications, assigning level of service, completing orders, printing AVS and closing the encounter within 24 hours.

Teaching:

You should also feel free to contribute to any other teaching being done by the fellow or the attending. If interested, let the fellow know if you would like to give a 10-15 minute talk on a relevant topic of your choosing.

Any questions or concerns regarding the above can be discussed with the on-service pediatric neurology fellow, attending, or program director, Dr. Meeryo Choe (mchoe@mednet.ucla.edu).

Schedule