UTHSCSA Neurocritical Care Rotation: EM Residents
Faculty Rotation Director: Rachel Garvin, MD
Additional Faculty: Augusto Parra, MD, Ali Seifi, MD
Location: NeuroICU, UH Skytower 8th floor
Length of Rotation: 4 weeks
Overview:
The specialty of neurocritical care is relatively new in the spectrum of critical care.
Neurointensivists are specially trained intensivists with backgrounds ranging from
neurology to emergency medicine, that do a 2 year fellowship in order to care for
critically ill patients with a wide range of neurological disorders. Some of the
encountered conditions in the neuroICU include traumatic brain injury, strokes and
seizures. Residents in the neurosurgery ICU are exposed to patients with a wide
range of critical illness in addition to their neurologic dysfunction including
respiratory failure, renal failure, metabolic derangements, cardiac dysfunction,
sepsis and ARDS. Residents also have the opportunity for numerous procedures
including: placement of central venous lines and arterial lines, lumbar punctures,
intubations, and bronchoscopy. In addition, because of the unique nature of
neurocritical care patients, residents also gain experience with ICP monitors,
evaluating EEGs, reviewing neuroimaging and learning the specifics of the
neurologic exam. The experience in the neuroICU demonstrates the complicated
and unique issues that neurologic injury brings to managing a critically ill patient.
Team Organization:
The core neurocritical care team is composed of the attending neurointensivist,
nurse practitioner (NP) and/or physician assistant (PA), interns/residents from
several specialties, critical care pharmacist and the ICU nurses. Additionally, there
are respiratory therapists, nutritionists, physical and occupational therapists, social
workers and case managers. We also work closely with the surgical/trauma ICU
team, neurosurgery and neurology teams.
How the Team works:
Neurocritical care functions as a primary service and a consulting service. The
majority of our patients are admitted through neurosurgery, neurology or trauma.
We provide a full spectrum of care for all of our patients addressing each organ
system and its interaction with the central nervous system.
For the patient in our unit, we are the primary team and we write all of the orders.
However on consult patients, we discuss our recommendations for care with the
primary team and the orders are placed through their service.
Hours, Shifts, etc..
Residents will do a combination of days and nights. Daytime shifts allow exposure
to ICU rounds and nighttime allows for 1:1 faculty time for teaching and increase in
autonomy.
Average Schedule:
Week 1: M-F days; weekend off
Week 2: Monday day, Tuesday-Sunday nights
Week 3: Monday off. Tuesday-Friday day; weekend off
Week 4: Monday day, Tues-Sunday night
Day Shift Requirements: Monday - Friday
6am: Arrive to preround on patients
8:30-12/1: Round with ICU team
1-5: Procedures, note writing, family meetings, didactic sessions
5pm: Afternoon rounds
Night Shift Requirements: usually Tuesday night- Sunday night
5pm: Arrive to unit for afternoon rounds
6pm: meet with faculty to discuss patients, review topic of interest
5am: sign out to AM mid-level provider
Expectations for the Rotation:
a. Arrive on time
b. Round on a minimum of 3 patients, doing an assessment and plan on every
patient
c. Learn to do an appropriate neurologic exam
d. Ask questions: otherwise it will be assumed that you understand everything
e. Make time to read
Requirements and Evaluations:
a. Weekly didactic sessions to cover core neuro and general critical care topics.
b. Monthly “Cases in Neurocritical Care” presentation to review cases and discuss
relevant topics (4th Wednesday at noon).
c. Friday neuroscience grand rounds
At the end of the rotation residents will be required to do either a case presentation
or a journal article presentation on a topic relevant to neurocritical care, to be
presented to the neurocritical care team. Each presentation will be around 20
minutes in length with the date and time TBD.
Evaluation will be both written and verbal (1:1 with faculty.) Evaluation will be
based on the education goals listed below.
Educational Goals:
Goals for this rotation are listed below based on the ACGME required core
competencies.
Patient Care:
a. Perform a thorough history and physical exam, including a detailed
neurologic exam
b. Conduct an assessment of the patient’s multi-system issues and formulate a
systems-based plan
c. Observe and/or perform the following procedures
Central venous access placement
Arterial line placement
Orotracheal intubation
Bronchoscopy
Lumbar puncture
d. Demonstrate ability to communicate effectively and compassionately with
patients and their family members
Medical Knowledge:
a. Demonstrate understanding of categories of traumatic brain injury (TBI).
b. Demonstrate understanding of pathophysiology behind intracranial
hypertension and methods for monitoring and treatment
c. Describe the common etiologies of ICH, diagnosis and management goals
d. Demonstrate understanding of presentation of subarachnoid hemorrhage
(SAH), imaging used to diagnose, neurosurgical interventions, medical
management
e. Demonstrate understanding of vasospasm etiology, monitoring, diagnosis
and treatment.
f. Describe reasons for EEG monitoring in the neuroICU
g. Be able to understand differences between normal and abnormal EEG in the
ICU
h. Describe different modes of conventional mechanical ventilation
i. Understand grading and management of spinal cord injury
j. Describe nutritional needs of ICU patients
k. Demonstrate etiology and management of the following common neuroICU
conditions: altered mental status, respiratory failure, shock, sepsis, ARDS,
acute kidney injury, metabolic derangements (hyponatremia,
hypomagnesemia, hypocalcemia, hyperglycemia),
l. Describe the differences between cerebral salt wasting and SIADH
m. Understand pathophysiology of ischemic stroke and treatment modalities
n. Understand reading of common imaging studies on neuroICU patients
including CT, CTA, MRI, MRA
Practice-Based Learning and Improvement:
a. Identify gaps in knowledge base and use resources to increase understanding
b. Perform literature search to review up to date information/studies that
pertain to patient care and be able to appropriately identify
strengths/weaknesses of study designs
Interpersonal and Communication Skills:
a. Demonstrate effective communication with all team members and consultative
services
b. Start to identify effective and appropriate teaching skills to participate in
education of other team members and students
c. Develop a system of self-evaluation of communication skills for both interactions
with team members and patients/families
d. Identify appropriate methods to discuss end-of-life issues with patients and
families
Professionalism
a. Maintain an appropriate appearance
b. Employ and enforce a respectful attitude
c. Maintain patient confidentiality
d. Demonstrate sensitivity to cultural differences
Systems-Based Practice
a. Describe the role of neurocritical care as a team within a the larger hospital
system
b. Identify cost-effective strategies that allow for the detailed care in the neuroICU
c. Demonstrate the ability to mobilize and integrate multi-disciplinary care into the
care plan for the neuroICU patient