SCCM Resource Library-Pro/Con: Do You Need a Neurointensivist (EEG)?

Video Transcription

Good morning, everyone. I want to introduce myself first. My name is Jose Diaz-Gomez. I'm honored to be the Congress Co-Chair. Currently, I work at Baylor College of Medicine.  My current position is I'm the Section Chief for Cardiothoracic Mechanical Circulatory Support and Transplant Critical Care. However, in the past, I have worked as a Neurocritical  Care Attendant, and I was able to grandfather under the UCNS. And because of that, I feel  absolutely privileged to moderate today's session, which is, Do You Need a Neurointensivist?  So we have several objectives for this session. Number one, we want to describe those diseases  across the neurologic and neurosurgical pathologies that need continuous evaluation by Neurocritical  Care Specialists. We want to recognize which critical care patients have neurologic conditions  that may be better served in medical, surgical ICUs, and perhaps do neurologic consults on a case-by-case basis. And finally, we want to review the advantages that Neurocritical  Care training confers on clinicians who must care for patients with neurologic or neurosurgical  conditions. Given the multi-specialty approach that we have in the SCCM, it is my privilege today to introduce our two speakers. Dr. Rosira Kan is an Assistant Professor of Clinical  Medicine at Western University College of Osteopathic Medicine, and she will be giving  us the lecture as the pro. And the pro statement will be, Neuro-ICU specialists should be seeing  all neuropathologies in the ICU. That's what we do. That is what we do. Our second speaker is Dr. Alexandra Reynolds. She's an Assistant Professor of Neurosurgery and Neurology, and  she's a Neurointensivist at Mount Sinai Hospital in New York. Her lecture will be the con, and it is titled, Brain May Be Involved, but Neurology Consult in ICU May Suffice.  Thank you. That is our approach in these next two presentations, and after that, I will be more than happy to moderate your questions or any other comments. Thank you very much.  Hi, everyone. Thank you so much for coming to this presentation. I'm going to be discussing why a neurointensivist really is needed. My name is Dr. Rosira Kan, and I am currently  a locum tenens ICU physician. I'm just kind of flying across the United States to COVID ICUs, but I'm also an Assistant Professor of Clinical Medicine at Western University  in California. That's an osteopathic medical school, and I'm a former co-director of the Neurosurgical ICU at Keck Medical Center in California at USC. Just some disclosures.  My training is in internal medicine, and I did a two-year fellowship in critical care at Mount Sinai, which is actually where Dr. Reynolds works currently. I got extensive  neurocritical care training just because of the way that our ICUs were set up. My board certifications are actually osteopathic medical boards in both internal medicine and critical  care, and so I may or may not be a little bit bitter that I wasn't able to grandfather into those UCNS board certifications. Well, my other colleagues all did, so I'm just a  little bit sad. Dr. Reynolds brought up a lot of great points. However, to really, really bring home the point that a neurointensivist is needed, I would love to start with a case,  because I think that's really where we dive into neurocritical care, because I truly believe  that it's the finer details of clinical management that makes a big difference, and that's what  I'm going to prove to you today. In this case study, we have a 45-year-old male with poorly controlled hypertension. He presents with ataxia, dysarthria, blood pressure is very  elevated, 225 over 115, and the head CT shows this right cellular bleed with near compression  of the fourth ventricle and dilation of the lateral and third ventricles. This is a board review question that is in a neurocritical care board review book, and so, of course,  what's the best next step in management? Now, I want you to just kind of think about this for yourself. Think about it just to yourself. You can put it in a chat box if you want,  but really, what I'm trying to do is get you to think about this in a sense of what would a neurointensivist do, and what are general intensivists kind of trained to do initially,  and what are even just general hospitalists? What's top of mind? And so, the actual correct  answer is surgical evaluation of the hematoma. This patient needs a suboccipital crani right away, but I suspect that many of you either picked A or B in your mind, and that's not  uncommon. I chose this question very specifically to kind of trick you and get you to think a little  bit differently. And so, the main point that I want to make is that it really truly is these  finer details. It's not simply blood pressure management with severe neurocritical care cases. In this particular case, there is a distinction between an infratentorial bleed and a  supratentorial bleed. So, supratentorial bleeds, yes, blood pressure management you can be a little  bit more aggressive with, but in general, a neurointensivist is really thinking about this  formula, cerebral perfusion pressure, and it's this finite focus in on cerebral perfusion pressure  that makes all of the difference, because we're thinking about MAP and ICP together in order to  ensure that we're perfusing the brain, and we're paying attention to the brain's autoregulation.  And so, answer choice A, if you set a target MAP of 100 or less, then you are going to risk  hypoperfusing the brain, because in this type of scenario, we would assume the ICP is somewhere  between 30 to 40, and with that assumption, you're right at that very scary borderline of  cerebral perfusion pressure of 60, and that's just not acceptable. That's not really the next best  step in management. And then, of course, an EVD, yes, it would be fantastic to know what those  intracranial pressures are. However, because this is an inferentorial bleed, we are going to risk  upward herniation. And so, I'm wondering if this particular case study sort of surprised you,  because it's just globally thinking and focusing on the brain a little bit more differently. And so,  I want you to imagine even trying to create a protocol around a patient like this. What are  we going to say? If the blood pressure is this, but it's a supratentorial bleed, and by clinical  evaluation, we're estimating the ICP to be around here, then this is how much you would want to  lower the intracranial pressure, and it's just too confusing, because each patient is going to  present differently with different timelines. We all know that brain is time. Time is brain. We  want to get there acutely and make these quick decisions, which is something that an intensivist  trained in neurocritical care can do. This is why a protocol in this particular case may not work,  because it's going to be too confusing. There's too many confounding factors going on with that  patient. And that's why experience really matters in the ICU, and actually there really is data to  suggest that a neurointensivist is indeed actually better at this. In this particular study, this was  published in 2012 in Neurocritical Care, and it looked at the impact of a neurointensivist on  outcomes in critically ill stroke patients. This is a really great study, because in this particular  institution, it was a level one trauma center, JACO, Stroke Certified Hospital, university-affiliated,  and between the years of 2005 and 2010, they had appointed a neurointensivist trained in neurocritical care. Prior to that, they looked at the patients basically from 2003 to 2005,  and then in the time period where the neurointensivist was at the institution, the neurointensivist obviously helped create more protocols, more bundles, specifically around  subarachnoid hemorrhages, acute ischemic strokes, intracranial hemorrhages, and then afterwards,  from the neurointensivist had left and then was not replaced at that university, and so between  the years of 2010 to 2011, they gathered the data to see if what the neurointensivist had brought and the changes that were made were actually still sustainable. You can see it was  very well branched out retrospective study, and they also compared the effects of a neurocritical  care unit compared to the other general critical care units, where sometimes we will have stroke  patients be boarded if the neurocritical care unit is busy, and this particular hospital had  an 18-bed neurocritical care ICU. It was fully branched out to evaluate for ischemic stroke,  hemorrhagic stroke, and subarachnoid stroke. The protocols that were all implemented were specific to subarachnoid vasospasm. Advanced neuromonitoring like cerebral oximetry,  those were introduced shortly after this neurointensivist arrival, so it really was a very dedicated neurocritical care unit along with the neurointensivist, and we would hope to  see these kind of impacts on general protocols to be sustainable. However, here's the data,  and to Dr. Ronald's point, in the ischemic stroke, there really wasn't a lot of significant difference except for hospital length of stay, which of course in neurointensivist and  in neurocritical care, you're going to keep these patients longer because you understand the finite  time period where anything can go wrong. Sure, maybe death wasn't affected, but let's take a look now at intracerebral hemorrhages. Same thing, we're seeing hospital length of stay,  first ICU length of stay, those are really where the differences are, but when we get into  subarachnoid hemorrhages, this is where we see a significant difference with a neurointensivist  trained person. The ICU length of stay, that's statistically significant, but take a look at  the in-hospital death. Now we are actually seeing a significant mortality benefit. Died by three  months, same thing, we're seeing that benefit, died by 12 months. What is it that a neurointensivist  is doing? Because as you can see in analysis one, there is no statistical significance between a  neurocritical care unit and the other ICU. Protocols aren't going to carry you through very complicated neuro cases, such as a subarachnoid hemorrhage, like I mentioned before,  infratentorial bleeds. Dr. Reynolds brought up this study, I'm going to poke at her a little bit, but this was published a year after that study was published, Burns et al. in 2013,  and her argument was that there really was no significant mortality difference. However, this study was 74 supratentorial intracranial hemorrhage insults. The real question is that,  is that really what we would label a complicated neuro ICU case for a neurointensivist expertise  to really shine? If we're talking about protocols, the statistical significance is seen with blood  pressure control. I believe that the blood pressure control and the statistical significance  is here because of this. There is a different global focus that neurointensivists have where  we think about cerebral perfusion pressure, MAP, ICP as a bundle. It's not just all of the organs.  Of course, we're looking at the entire body, but we're also really very focused on the finite  details and auto-regulation of our brain. I really do love that Dr. Reynolds highlighted a  lot of the benefits of having protocols, and it's a great start, but really to have bigger impacts  on complicated neurocritical care cases, specifically, like I mentioned here today,  subarachnoid hemorrhages and infratentorial bleeds, a neurointensivist really is needed.  The pathophysiology gets extremely complicated. We're saying this specifically also with COVID,  there's not a lot of intensivists that are going to jump to managing ECMO. It is a sub  specialization, and I really believe that we need to start mapping out the neurocritical care field as such. Honestly, we don't have enough neurointensivists, like she said,  to care for all of these patients. Really, I would love to see more papers similar to the  one that I discussed that was published in 2012 with a neurointensivist on board from the years  of 2005 to 2010, but what specifically is it about a neurointensivist that is responsible for these  better outcomes in subarachnoid patients? Because we know it's not protocols. It's not the protocols,  and so what exactly is that? If we can really capture that, then we can try to mass train  other intensivists, introduce this into critical care curriculum, increase with ACGME the guidelines  on how many months of neurocritical care are expected to be done during fellowship training.  I got an ample amount of neurocritical care training during my fellowship, and it's because  of the way that our fellowship is set up, as Dr. Reynolds knows, but also I had requested additional  months of neurocritical care just because I had such a big passion for it, and so I think that  culmination of experience, whether you are neurology or internal medicine trained, can really be  extremely powerful. I think it's experience that really pushes this envelope, and I want to see  more papers look at this in a global sense so that we can replicate it rapidly and create specific  training to be able to fill in this gap that we have, this shortage that we have, and I do love  that currently we are really seeing ICU as a multidisciplinary team-based approach, especially  with this pandemic. It is very vital that every single team member is recognized. It's very vital  that every team member's expertise is taken into account, and in these type of situations, if you  feel like you are lacking that experience, call your neurology colleagues, call your other intensivist  colleagues. I certainly would not be comfortable running ECMO, and I would lean heavily on my  colleagues if there was a time period where I would need to manage these ECMO patients. So this  multidisciplinary team approach is really where we're seeing a lot of growth and a lot of really  amazing outcomes for all of our patients. Thank you very much. Hi, my name is Alex Reynolds. I am  an assistant professor of neurosurgery and neurology at Mount Sinai Hospital, and I'm going  to be arguing that we do not need neurointensivists. My only disclosure is that I am a neurology and  neurocritical care trained neurointensivist, so I will be arguing against the utility of a person  trained like myself. So let's start by asking which patients exactly meet criteria for neurocritical  care. So on the one hand, there are certain diagnoses such as stroke, traumatic brain injury,  and global cerebral edema that seem fairly obvious as primarily neurocritical care, but as we go down  the list, it becomes less obvious where the line should be drawn. Does every cardiac arrest with  hypoxic ischemic encephalopathy require neurocritical care? And even worse, how about  all the undifferentiated coma in every ICU? Even with a relatively stringent definition, we might  find that a patient may not actually be best served by a neurointensivist. So a patient who  suffers a stroke while on ECMO may have a very different set of needs than a patient who has  a large stroke from atrial fibrillation. Similarly, a patient with isolated TBI is very different than  the patient with polytrauma. Global cerebral edema may not be an appropriate diagnosis for  primary neurocritical care if it's in a patient who's had recurrent cardiac arrests with the need  for mechanical circulatory support, or if it's a patient with acute liver failure who's awaiting  liver transplantation. So you know, it really isn't clear exactly which patients may benefit  from a neurointensivist. Let's talk about who's taking care of these patients. This is a study,  this is looking at the PRINT study, which looked at survey results from worldwide sites that are  members of a neurocritical care research network. We see that the vast majority of patients with  neurological injury are being taken care of by pulmonary critical care or anesthesia. There are  some variations by content, but even in North America, which has the most neurocritical care,  neurointensivists are taking care of less than a third of patients who have primary neurological  diseases. If we try to get more granular and maybe even more objective without relying on survey responses, we can look at a study of inpatient claims from the United States of  patients with at least three days of critical care claims while in the ICU. There was a range  of anywhere between 30 to 60% of patients who were cared for by someone with formal neuroscience  training as the primary physician. Those patients who were taken care of primarily by someone with  a neurological background were three times more likely to be based in an academic medical center,  and the likelihood of management with a neuro-trained person increased proportionally with the patient's county-level socioeconomic status, which really does seem to point to some  inequities if we think that neurointensive care is a benefit. This is an older study,  but looking at national access to neurocritical care units in the United States, which is one of  the countries with the most amount of neurocritical care involvement, these colors in the red color  range show access to a neurocritical care unit within 45 minutes of travel time, and the blue  range is within 90 minutes of travel time. You can see that neurocritical care is largely a  feature of the coasts and of bigger cities in the Midwest. The real question is, is this boutique  neurocritical care actually leading to better outcomes? In this study of traumatic brain injury  patients from 2018, when adjusted for severity of brain injury, there was no difference in mortality  if the patient was in a general versus a neurological ICU. The only thing that affected  in-hospital patient mortality was the presence and use of standardized protocols. The presence  of a dedicated neurocritical care unit or who the director was or whether the ICU was open or closed  didn't matter at all in terms of hospital mortality. If the argument then becomes, well, you don't need a neuro-ICU, but you do need a neuro-intensivist, let's look at this older  study from Boston University. Here they were looking at before and after the creation of a neurocritical care service that did not have a dedicated ICU. The neuro-intensivists were  used more as a consultative service. You can see that there was no change in mortality,  there was no change in hospital length of stay, no change in poor outcome or discharge destination  that was favorable to home or acute rehab, even after involving a neurocritical care consultant.  You will note there was an increased ICU length of stay for these patients. The only real things  that changed were things that were easily protocolizable, such as the intensity of blood  pressure control, the presence of pharmacological DVT prophylaxis, and the presence of dysphagia  screen before PO intake. While those things are very important to the joint commission, for example, we know that these are things that can be very easily implemented as a protocol.  So why do we need to hire several expensive neuro-intensivists to run a consult program  when we could just use protocols? When we think about the importance and the utility of protocols  in the ICU, we know that protocols help to streamline care, standardize care. They allow  for adoption of the newest guidelines and data to the patient's bedside. We know that this helps  with cost and it decreases cognitive errors. There are some people who don't like protocols, who suggest that if you use the protocol inappropriately, let's say if it's not  updated or it's based on poor evidence, or if it's used in an inappropriate patient, then it actually can lead to worse care. But I would posit that these are things that are very  easily fixed with the use of a neurology or neurosurgery consultant who would work closely  with the ICU and that if a patient needs more individualized treatment, then that's where a  subspecialty consultant is routinely used in an ICU setting. ICUs are filled with protocols and  we know that these protocolized bundles have improved outcomes. Daily sedation interruption  and spontaneous breathing trials, lung protective ventilation with low tidal volumes and sepsis  bundles have been the more studied protocols, but certainly we don't say that every patient with ARDS needs to be taken care of by a pulmonology trained intensivist. If there  are serious deviations from the protocol that are necessary, then that's when we call in the  consultant. But for example, our hospital has a ventilator weaning protocol for trach patients and that's actually nursing and respiratory therapist driven. It does not require an  intensivist or a pulmonologist to be making every single change on the ventilator or every decision  about when a patient can go on and off of trach collar. So if you are looking for guidelines,  look no further than the Neurocritical Care Society and that's potentially the best use of a neurointensivist is to create these very algorithmic based guidelines based on the  data that's available for many of the diseases that are traditionally felt to be neurological,  but really none of this is rocket science. When we look at the hundred most cited articles in  neurocritical care research, certainly they're mostly written by neurointensivists who spend  most their time with neurological patients, but look where they're published. The top 10 journals  are majority general critical care or even just undifferentiated medical journals. These are all journals that generalist intensivists routinely read, so we can be sure that they  are keeping up to date with the latest literature in the neurologically ill critical care population.  When we think about the backgrounds in critical care doctors, most intensivists come from a background of internal medicine, anesthesia, or emergency medicine. These are residencies  that are filled with education about the physiology of the body. Neurologists, on the other hand, do one year of internal medicine and then two years of neurocritical  care and so they may not have as much formal training to deal with the many medical issues  that neurological patients suffer from. Even the most neurologically devastated patients can have  severe medical complications such as tachycephalic cardiomyopathy with acute cardiogenic shock,  all sorts of respiratory failure that may require emergent intubation, neurogenic pulmonary edema,  disorders of sodium, acute kidney injury, infections, and so there really isn't any reason that a neurointensivist would be more likely to be able to deal with these very  critical systemic complications. And then lastly, let's talk about the real backbone of neurocritical care, which is not the neurointensivist. Most of the importance  of neurocritical care is in the multidisciplinary care that's provided to the neurological patient.  Close nursing checks identify neurological deteriorations, not the physician. The supportive care for prevention of deep tissue injury and sacral ulcers, improvement of nutrition,  family and patient support, early mobilization and training on speech and language or swallowing  pathology, these are all multidisciplinary teams that are contributing to the stabilization of the patient. Lastly, let's talk about the backbone of neurocritical care, which is not  the neurointensivist. Most of the importance of neurocritical care is in the multidisciplinary  care that's provided to these neurologically injured patients. Close neurochecks identify  neurological deteriorations that often prompt care. The supportive care prevents deep tissue  injuries, allows for improved nutrition, family and patient support is key in these disease  processes, and early mobilization and training for speech and language or swallowing pathologies,  these are all much more important to the stabilization of the neurologically ill patient and the advancement of their care than any single neurointensivist is.  To summarize, neurological diagnoses make up a huge proportion of critical care. It isn't clear that all of these are primary neurological problems. There aren't resources  for neurointensivists to take care of all these neurological diagnoses and further, the neurologically ill patient can have significant organ failure or advanced critical care needs  that would be best served by a different type of intensivist. There is no data to suggest that neurointensivists are better at taking care of these patients, but we do know that  protocols really help and multidisciplinary care is probably most important for better outcomes. The COVID pandemic has taught us to leverage  the use of telecommunications for large conferences like this, but also to lend virtual clinical  experience. This may be the solution for equitable care if we think that a neurointensivist can  lend expertise in specific patient populations at certain times, but certainly the neurointensivist  is not necessary to be the primary caretaker for all patients with neurological injury in the ICU. So with that, thank you for your time.  Good morning, everyone. It is my pleasure to moderate this session.  Let me share with you something really short, which is when I immigrated to the United States,  I was a practicing intensivist in South America, in Columbia, and I helped quite a bit to the  implementation of the Brain Trauma Foundation. Dr. Jose Suarez, who is the leader in neurocritical  care at Johns Hopkins, gave me the opportunity to come to the United States and do a rotation  with him. So I have implicit bias on having the most amicable discussion in this subject.  I was privileged to become a UCNS grandfathering individual, and I was practicing until a couple  of years ago neurocritical care, but I'm not a neurologist. I'm not a neurointensivist in training. So for that reason, I really want to do my best moderating this session.  As a CM member, I want to really open the discussion with the following statements. Number one, we will do care for academic and community hospitals. We want to enlighten  this discussion, having in mind that we can be practicing in both settings. We care for advancing the research agenda. We care for really genuine teamwork in the ICU.  So having those things in mind, I want to start the discussion with one question for each of our wonderful speakers, Dr. Kan and Dr. Reynolds. The question is as follows.  If you will be, remember the map that Dr. Reynolds put there, where you have some super specialized units in the East Coast, in the Midwest, versus other places that don't have  that level of neuro ICU care. So imagine you are a director in one of those, either you are in a highly academic center versus a non-academic center. How you will envision,  how you will organize your service to provide the best care to your neurocritically ill patients?  Dr. Kan?  Oh, that's such a great question. I would definitely want to seek out  neurocritical care subspecialists, whether they be neurology trained or internal medicine trained. But what I'm really looking for is a lot of experience  because I truly believe that experience in neurocritical care medicine is what makes a great neurointensivist. And like I mentioned, the studies show  that patients do better with subarachnoid hemorrhages, infratentorial bleeds, and that's kind of where the finer details come in. So I would definitely need at least one  employee trained in neurocritical care that can help expand the knowledge base of other colleagues. So not everyone in the group would need to  have that robust neurocritical care knowledge because we do learn from each other, but you would definitely need one neurointensivist. Well, regardless of your geographical location  in the United States, that's your minimal requirement. Is that correct? Yes. Yes, that's my opinion. I'm sticking to it. Great. Dr. Reynolds?  That would be, I mean, in an ideal world, sure. I think, you know, as I kind of mentioned at the end, I think the leveraging of telemedicine,  I think particularly in these times can be very helpful. So, you know, whether you have a small group of neurointensivists that can kind of reach out  on a PRN basis and provide their particular expertise to places that need it, whether it's as consults or kind of tele-rounding every day,  I think that's probably the most reliable way to have your neurocritical care experience  kind of brought out to the rest of the country.  I agree with Rosie. I think that the most important thing is the experience and it doesn't really matter how you've trained as long as you have that experience.  But I think- Let me add to this specifically. Both of you agree that you need experience, but, and let's say, it's my opinion that experience comes  if you are exposed to the patient population. So for me, the most important thing from the get-go is to have the volume of patients.  You have a large volume of patients,  you have a large volume of patients, you're forced to become more experienced. You don't have the high volume of patients in this specific patient population,  it will take you much, much more time to really become good at it. So having that in mind, having the volume of patients, can you kind of reframe that again?  If you have in a small hospital with only one or two strokes every couple of weeks versus a stroke every day,  do you insist again and have a specialist to be there for that? Or do you do the telemedicine or the PIN consultation?  Yeah, you bring up a good point because let's say it's a subarachnoid hemorrhage patient, that patient is going to need coelombilization and evaluation to secure the aneurysm,  which would require neurointerventionalists, neurosurgery subspecialty. So in a smaller community hospital, those patients are probably being flown out to a tertiary care center.  And in which case you probably wouldn't need someone to continuously manage those consultants and the care of that subarachnoid patient. So in that case, you probably wouldn't need  someone super experienced.  A trauma center though, traumatic brain injuries,  that's gonna be a higher level of care and you need to be able to not just have trauma surgeons there, but you need support staff.  So like I mentioned, to care for a subarachnoid patient,  you need several different physicians and several different subspecialties. So it's not just that a neurointensivist is the one sweeping in and doing all the work.  It's definitely several subspecialties. So in a smaller community hospital where maybe it's just ischemic strokes, hemorrhagic strokes, the studies do show that you're fine  with just a neuro ICU with protocols, but it's more of the infratentorial bleeds and the subarachnoid hemorrhages where we see the big difference with neuro trained intensivists.  So very good point. So a specialization goal with the complexity of the disease and you just name it, that SAH is a systemic disease.  It's very complex and you need probably more support. Thank you, that's very valuable point. Dr. Reynolds. Yeah, I mean, I'll say that I think experience matters  even in neurologists. So if a general neurologist is the consultant helping with prognostication after cardiac arrest at a small hospital where they haven't done a lot,  I think that person is probably not more qualified to have that conversation with a family than the general intensivist who sees a lot more of it.  So in some ways, I think that your background training may not even be all that helpful if you are up on the literature, you've read the latest papers coming out on prognostication  and you see every cardiac arrest that comes into your hospital. So I think that's the only reason why I would say that the experience sometimes, even if it's not experienced  with neurocritical care specifically, I think intensivists are capable of understanding the literature, seeing the patients and then reaching out for help,  even if it's telemedicine help, if there's a question or concern. So what you're saying is you have a critical care trainee that did his fellowship or her fellowship somewhere else  and gained some good experience in a community hospital that the bottom is not that high, it still can apply those concepts  that learned during fellowship and be good, is that right? Yeah, I mean, a headache neurologist who is doing their two weeks of inpatient consults  isn't gonna necessarily have much more to add to a general intensivist who saw this in training. Good point. Actually, I will start just now bringing  some of these wonderful questions we have. This question comes from a Pulmonary Critical Care Fellow here actually in my shop, Dr. Garner.  He's asking, should critical care medicine programs offer tracks for further specialization? For instance, Internal Medicine Critical Care Training Fellow  chooses their second year of training to be the majority critical care or transplant or ECMO. What would you think about tailoring critical care to a specific specialty?  That's a very interesting question.  That's a very good question. I've never really thought about that,  but I guess if you're in an institution that has all of those options, you probably don't need to do a subspecialty track. I did two years of critical care fellowship at Mount Sinai  and it was the surgical ICU, the neurosurgical ICU. We did a lot of liver transplant medicine, neurocritical care, obviously. And at the end of my training,  I felt prepared enough to do everything. One thing that I didn't get a lot of experience in is ECMO, but when I trained, it was just really starting out at NYU VV ECMO.  And if I wanted to, I would probably just have one of my colleagues train me right now. So I don't think it's necessary right now. And I think what we've seen in this pandemic  is that all intensivists need the ability to pivot very quickly to be able to fill in gaps.  So even like our anesthesia colleagues who maybe are primarily in CTICUs, we've moved them around and neuro-intensivists are taking care of these severe ARDS patients.  So I'm not sure that's completely necessary right now because past fellowship, I think you almost get like an apprenticeship at wherever you're getting your first job  and the other senior intensivists would probably train you in whatever other skills that you need. SCCM, ACCP, there's always these live learning classes  if you want to further get some more training like advanced airways, point of care ultrasound, all these different things are available for continued learning.  That's a great point. And actually, I'm not sure whether you were able to see Dr. Sarkar this morning in his, the new year health commissioner in his talk,  but he stated something that honestly, just basically made me feel so inspired moving forward. He says that we in critical care always need to actually engage the risk,  but that risk and not having enough data has to be based on the best ability to have alien-based medicine. So right now, I'm an ECMO practitioner,  but oftentimes I struggle taking decisions on ECMO patient who is a candidate, who's not a candidate. And part of the reason is because we don't have  solid evidence-based medicine to do that. So how you want to really change your critical care curricula on some aspects of our practice that do not have  definitive evidence-based medicine. So it's a very interesting position, but you probably have heard from our society that actually there are some proponents  that we should do just alternating critical care medicine without any background. So, and other people are asking, there are folks doing one extra year of fellowship in ECMO.  And I think this will be something in evolution. It's just too premature, I guess, to say in a specific recommendation at this time. Dr. Reynolds.  I mean, I think that the big secret is that the end of fellowship doesn't mean the end of learning.  And certainly I'm in my third year of being in attending and I'm still learning every day.  We do in our neurocritical care fellowship, we do offer a six month track to subspecialize even further. And so if you're particularly interested  in cerebrovascular or continuous EEG, you are given that opportunity to basically use your elective time on something very specific.  And I think that's a reasonable way of approaching it as a fellow, if you are really convinced that you want more background in a specific subspecialty.  But as you said, Jose, I think, you never really know, you're a neurocritical care physician one day and then the next day you're an ECMO aficionado  and you kind of have to be flexible and you never really know as an intensivist where your life is gonna take you. So being comfortable with the fundamentals,  I think is probably the most important so that when you're thrown into a new situation, you can handle it, which I think we've all seen with COVID. Thank you.  Dr. Ramesh is asking this question. As mentioned in this presentation, neurocritical care training programs, neuro-ICU are mostly at the coast, both coast.  Training will therefore differ based on where you are trained. How can visibility, knowledge and training in neurocritical care be made more universal?  I think right now we can convey a message so far we have discussed.  Well, the neurocritical care profession in general is newer. So the UCNS board certification was just established in 2007. So I think it's gonna take time  because those of us who were trained on the coast are slowly moving inward. So, and then starting programs ourself or helping our colleagues with some of the finer details.  So I think it'll just take time because 2007 is very young fields and there's still a lot of data that we're exploring. And that's one of the reasons why I love it.  There's still that art of medicine within neurocritical care, where like you mentioned before, Jose, it's like this, if the evidence isn't there,  you're sort of using your best clinical judgment and best evidence-based practice.  So I have this question  by my Congress co-chair Dr. Emlett from Pittsburgh. This is a generalist versus specialist intensivist question. I know intensivists who have changed mid-career  from transplant to cardiothoracic. As an additional mechanical circulatory devices and applications grow, we all must continue our learning and practice.  If we believe we are lifelong learners, then we must also believe that we can share knowledge and become proficient even mid-career. What suggestions do all the speakers suggest  for allowing more neurocritical care knowledge by all? How can we impact mid-career individuals to those fundamentals go up there for the mid-career people?  Well, I think... Go ahead. No, go ahead. No, no, no, go ahead. I forgot what it's called, but there's a little... Oh, ENLS.  That's sort of like a mini training if you wanted to expand on that, Alex. Yeah, so emergency neurological life support. It's a neuro version of ACLS.  And you can do it online.  And I think it's a really nice way of giving you the fundamentals of neurological emergencies. Again, I mean, technology is changing every day.  And so I think the ability to just stay  attuned to what the newest literature shows is important.  But I think it really comes down to fundamentals. And my perception, at least of neuro, is that as a neurologist, is that everyone either loves it or hates it. And if you hate it,  you do your best in training to avoid it  because neuroanatomy is terrifying to a lot of people and probably not taught properly starting in your medical school career. And so I think just being open  to understanding the fundamentals  when you're a trainee is super important because you can always build on that. And it's not, well, it's not neurosurgery. It's not rocket science.  But I think there's this general fear of the brain because it's so complex. And so I think just trying to learn from people who can break it down  and from your peers is always a good start.  Thank you. Alex, that's such a good point because one thing that I have seen consistently, even in academic centers, is that doing a neurological exam on an intubated patient  is still like that basic fundamental skill. And many fellows don't know how to do it. They often see triple flexion as true flexion  and their neurological exams are inaccurate. And you're right. It just takes someone to train you and teach you those basic concepts.  Let me share with you a little bit of kind of like  leadership perspective on the ENLS. On those centers that are stroke certified centers and there is no 24 seven presence of neurointensivist, it's a good selling point to propose  to the general intensivist who is in-house to actually have this kind of certification on the ENLS. Then you have a visit. And then by CMS and you say,  okay, something happened at 3 a.m. in the morning, how would you respond to the crisis this patient has been reading to be? It's a stroke patient.  Just showing that your team have that ENLS is a good way to demonstrate that a general intensivist have that fundamental core of neurocritical care.  But again, that's something I wanted to share with you.  There is actually a question by one of our leaders in the country, Dr. Chan,  said basically the hope is that all critical care medicine training programs will have rotation through the neuro ICU just as neurointensivists rotate through the MICU and CQ.  Is that right? Can we attest that? That all critical care medicine trainees in the United States need to rotate as well like the neuro ICU trainees rotate to the MICU and CQ,  vice versa. The other non-neurocritical care trainees should have exposure to neurocritical care. Does everybody get on that? I want your point, Dr. Reynolds and Chan.  Yeah, I mean, I agree. I think none of this is particularly complicated and if we can expect a neurologist to learn how to intubate or how to change a ventilator setting,  then I think we can also expect an internal medicine trained person to do a neuro exam and know how to treat status. And I don't think,  I think it should just be fundamental learning. The brain is, I'm gonna say it's the most important organ, but it's certainly up there with the heart and the lungs.  And so I think that it should be a part of everyone's kind of core learning.  Dr. Chan? My understanding is the ACGME critical care fellowship requirements are only four weeks, which I guess what the curriculum isn't too bad.  Some centers will increase that up to six weeks, but one thing I noticed anecdotally at my previous academic institution is that the first year fellows  would rotate through the neuro ICU with me, complete their six weeks in their first year. But then I felt like in second and third year,  they had forgotten what they had learned in first year because there's just so much to absorb in your first year of fellowship. So I think spreading out that long term  spreading out that learning, adding in didactics. And then this question was asked previously, like, should we start having tracks? But Dr. Reynolds also mentioned this  where you can fill in your elective time. And that's actually exactly what I did at Mount Sinai. I bugged my program director, Dr. Orofello  to give me all of my elective time in the neuro ICU. And so I guess I did my own mini track.  But it's definitely, it's required, but I think only four weeks is required at this time. Great. We have another of our neuro critical peer leaders in the country, Dr. Sharal.  And she's asking, can the speakers address if tele-ICU will influence such discussions into a special expertise?  I want Alex to go first.  Yeah, I agree.  Just repeat the last part of the question. If tele-ICU- If tele-ICU will influence such discussion on such specialty expertise. You think that the way I interpret this is that  tele-ICU will be the solution to this discussion on such specialty expertise. Like, can we solve all this issue with just tele-ICU?  Basically, are you a proponent that tele-ICU is the way- I mean, I think it's a start. I think it's a good start for the, but there, I think there,  again, this depends on whether you think that every neuro patient needs a neuro critical care person. And I don't know that I necessarily feel that way,  but there are certainly high risk patients all over the country that probably don't have access to a neuro critical care physician. And so I think that just for equity sake,  it's probably a start, but I don't think that's the only thing that will help. I think that we have to educate our general critical care trainees  to be able to handle the neurological patient. And I think that most places do a good job. It's just a matter of trying to triage which patients are so high risk  that they need to be taken care of by a neuro critical care physician. And certainly that's, to some degree,  that's done because oftentimes we're shipping those patients to places where they need a neurosurgeon. So at least there is a neurosurgeon  who's comfortable with the underlying pathophysiology, like in Dr. Khan's example, hopefully the posterior fossa ICH patient is taken care of in a place where there's a neurosurgeon  who knows about upward herniation.  But I think that trying to understand  which patients would benefit the most when there is a very short supply of neuro critical care  is probably going to be just as important as telemedicine. Thank you.  Dr. Khan, anything? You know, I don't have any tele experience, whether it's MICU or neuro. So my understanding is that you would call in  a tele consultant typically when there's already a problem. And I think that a lot of really good neuro critical care comes and critical care comes  from preventing catastrophic events. You know, every day we do small little things, you know, to prevent, you know, cardiac arrest and brain damage.  So like the more subtle neurological changes like somnolence could be the first signs of herniation. And I'm concerned that the pupillary reflexes  showing signs of herniation, that's when it's almost a little too late to get on the phone with a tele consultant. So. Thank you. And once again, from the leadership perspective,  keep in mind that business model you are jumping in  because this technology is not for free. And when you need to have engaged administrators with this,  you better know what you're talking about. My experience in the past and other healthcare systems, these investments can be in the middle of dollar ranges.  So it's not easy to justify initial investment upfront.  It has to be a really savvy person, how to present this thing. But it's definitely something we should keep in mind, especially for those remote areas.  I think there is no question that, you know, there is somebody there.  I want to continue, you know, moderating these questions. There's a question from Dr. Corsic. Is there not an argument here for regionalized specialty ICU programs  that are built based on evidence and located in one hospital patient catchment area  rather than numerous hospitals healthcare system a few blocks or miles apart, trying to develop these kinds of specialized ICUs?  So I guess how's your perspective here with regionalized specialty ICU programs  built on evidence and located in one hospital versus many numerous hospitals with a few blocks or miles apart trying to develop this kind of specialized ICUs?  Yeah, that's, I'm, you know, I'm born and raised in New York City where there are uncountable number of neuro ICUs, including multiple in the same hospital system.  And you could probably walk yourself with a neurological disorder from one neuro ICU to another. I think that certainly the idea  of having a neurosciences hospital that is maybe even hospital system agnostic so as to prevent the competition of different hospitals wanting to keep the patients  and not send them to a different hospital system is a really intriguing one.  I think that in the more rural areas where there's a large catchment area for a particular regional hospital system, that's probably a tertiary care center  that probably would just be housed in that tertiary care center.  The question is one of accessibility by plane or by ambulance. And I think that's kind of an issue that I'm probably not as familiar with having been an East coaster my entire life.  Dr. Khan, do you have anything to add?  Yeah, I think you've touched on it a little bit, Alex. And I think for the first time in the United States, we're starting to see this sort of silos break down  because hospitals are businesses,  whether they're profit, nonprofit doesn't matter. I think in the past, like you said, that systems would like to keep the patients within that system.  And there's very little sharing. I think during the pandemic, some of those walls were broken down, but I mean, regionally in the Los Angeles area, I've seen this for years  where you have three major hospital centers with every subspecialty, Cedars-Sinai, USC, UCLA. And there's very little sharing and referrals that go back and forth  because we do have all the subspecialties within there. And then we don't know about like the little nuances with other centers where it might be beneficial.  And so in a utopian world, we would love to have these different hospitals that are nearby each other where we can just send certain patients to a particular hospital,  and they have a lot of neurocritical care. But as a business model in the United States,  that model will work. But we'll see what happens because people started sharing ventilators this year, which was something that we weren't doing before.  So I'm really excited to see what happens with this breakdown of the silo model and businesses  and sort of resource sharing. Thank you. So I have some news for you from Dr. Chang. She's saying, there is some discussion at the SCCM level  to discuss harmonizing critical care medicine curriculum  throughout all the ACGME critical care training programs for AVMS specialties offering critical care medicine. We'll see. So she's a wonderful leader.  I'm pretty sure more to follow up on that. So we have three minutes left. I want each of you in 60 seconds to kind of take, have expressed your take home messages  for our wonderful membership.  My take home message would be that if you can get neurocritical care expertise  in your fellowship training with additional electives, I think that's such an invaluable skill that will follow you no matter where you go in your career.  And if you are not in your fellowship training, I think utilizing these further learning models like ANLS, CME based courses on neurocritical care  would be really, really valuable to just add more skills to your toolbox.  That's pretty good. It's gonna be hard to follow that.  The brain is not that scary and try your best to learn the fundamentals and be continually learning from your consultants and the other people that can help you.  Neurosurgeons are kind of scary, but they can also be a helpful resource if you're co-managing a patient with them.  And the Neurocritical Care Society does have a lot of educational opportunities as well.  And we're always happy to kind of exchange information. And we learn a lot from the general intensivist. So continue those conversations.  Thank you. So I will make a few comments. Number one, when you were saying about the brain is the most important organ, I do believe that. Being an anesthesiologist,  taking care of surgical patients,  we know that most of the surgeons have a big ego, but those instances where I remember that that ego is on the floor is when brain catastrophe happened.  And seeing that in plastic surgeons, chiropractic surgeons, all kinds of surgeons, if the patient developed an intracranial hemorrhage or a back stroke, I'm telling you,  I'll say, well, how can we help my patient? And that actually made me feel so inspired to actually be good on those fundamentals and serve in that capacity.  But please do not forget, we need to help our neurointensivists that are super, super academic, like Dr. Chan, Dr. Saurabh. We need to help them with more,  more, I will say, situations or scenarios that they can push that research agenda. They need us and we need them. The way I look at it with the SCCM,  all these neurointensives are very generous. They're very welcoming people. You can establish some relation with the Neurocritical Care Society.  But what an ambition here is a stronger presence  of neurointensives in the SCCM. So we learn more from them, but at the same time, they will understand more what is our setting and how they can help us as well.  So in the last five seconds, I just want to thank you for attending to this wonderful session by Dr. Chan and Reynolds. Thank you.  Thank you. Thank you so much.

Video Summary

The session titled "Do You Need a Neurointubesivist?" discussed the role of neurointubesivists in the ICU and whether they are necessary for all neurologic and neurosurgical conditions. The speakers, Dr. Roseira Kan and Dr. Alexandra Reynolds, presented arguments for and against the need for neurointubesivists. Dr. Kan argued that neurointubesivists are necessary for certain complex neurologic conditions, such as subarachnoid hemorrhages and infratentorial bleeds. She emphasized the importance of experience and specialized training in neurocritical care. On the other hand, Dr. Reynolds argued that general intensivists can effectively manage neurologic patients with the help of protocols and consults with neurologists or other subspecialties when needed. She emphasized the importance of multidisciplinary care and the use of protocols in the ICU. The discussion also touched on the need for more neurointubesivists to meet the demand and the possible use of tele-ICU for neurocritical care expertise. The speakers agreed that experience and ongoing learning are crucial for providing the best care for neurologically ill patients. The session ended with a discussion on the potential for regionalized specialty ICU programs and the importance of harmonizing critical care medicine curriculum across all specialties. Overall, the session provided an informative and nuanced discussion on the role of neurointubesivists in the ICU.

Asset Subtitle

Neuroscience, Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe different diseases across neurologic and neurosurgical pathologies that need continuous evaluation by neurocritical care specialists
Recognize which critical care patients have neurologic conditions that may be better served in medical/surgical ICUs and neurology consults on a case-by-case basis
Review the advantages that neurocritical training confers on clinicians who must care for patients with neurologic or neurosurgical conditions

Pro: Do You Need a Neurointensivist?
Roozehra Khan

Con: Do You Need a Neurointensivist? Nope!
Alexandra S. Reynolds

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Area Quality and Patient Safety

Knowledge Level Advanced

Membership Level Select

Tag Stroke

Tag Evidence Based Medicine

Year 2021

Keywords

Neurointubesivist

ICU

neurologic conditions

neurosurgical conditions

complex neurologic conditions

subarachnoid hemorrhages

infratentorial bleeds

neurocritical care

general intensivists

multidisciplinary care

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