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