UTHSCSA Neurocritical Care Rotation: Fellows

Faculty Rotation Director: Rachel Garvin, MD ([email protected]) Additional Faculty: Ali Seifi, MD Location: NeuroICU, 8th floor Sky Tower, University Hospital 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 neurologic injury. Some of the encountered conditions in the neuroICU include traumatic brain injury, strokes and seizures. Fellows 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. Fellows 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, fellows also gain experience with ICP monitors, EEGs, neuroimaging and the specifics of the neurologic exam. The experience in the neuroICU demonstrates the complicated and unique issues that brain injury/dysfunction bring to managing a critically ill patient.

Team Organization: The core neurocritical care team is composed of the attending physician trained in neurocritical care, a neurosurgery intern, other off-service intern, nurse practitioner (NP) and/or physician assistant (PA), 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.

How the Team works: The majority of our patients are admitted through neurosurgery or neurology. Some also come from the trauma service. We provide a full spectrum of care for all of our patients addressing each organ system and its interaction with the central nervous system. When patients are admitted to the NeuroICU, neurocritical care is the primary team. We do however work closely with neurosurgery and neurology and communicate with them daily on their patients. We also provide a consult service for those requesting neurocritical care expertise. For those patients we give recommendations only unless they ask us to place orders. Anatomy of a day on the unit: 6-8:30: Pre-round on ICU patients 8:30-12/1: Round with ICU team 2:30: Daily team huddle 1-4: Procedures, family meetings, teaching sessions 5pm: Afternoon rounds with ICU team

Call/Schedule: *Fellows take home call and are the first call for any issues on the unit. Home call is for then entire rotation month except for 2 weekends/month (Friday night/Saturday/Sunday) off. The other 2 weekends the fellow is on call, he/she is also expected to be present for rounds. We ask that vacation time not be taken during the rotation if possible and that schedule requests be submitted at least 1 month ahead of time.

*Surigcal/trauma ICU fellows – requirement MICU fellows – recommendation

Educational Material: Resources on neurocritical care are available on our website: http://neurosurgery.uthscsa.edu/ncc_rotation.php

Requirements and Evaluations: Fellows are expected to help run rounds and teach on par with their level of training. At the end of the month, a didactic session is required as a topic or case presentation. 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. For medical ICU and surgical ICU fellows, the goal is to gain experience caring for critically brain-injured patients and understanding the complexity involved in this unique patient population.

Patient Care: a. Conduct an assessment of the patient’s multi-system issues and formulate a systems-based plan b. Perform and/or supervise the following procedures Central venous access, including dialysis catheters if indicated Arterial line placement Orotracheal intubation Bronchoscopy Lumbar puncture c. Demonstrate ability to communicate effectively and compassionately with patients and their family members d. Review and interpret diagnostic studies including laboratory tests, xrays, CT scans, MRI’s,

Medical Knowledge: a. Demonstrate understanding of the pathophysiology and management of diseases specific to neurocritical care including, but not limited to: subarachnoid hemorrhage, traumatic brain injury, stroke , spinal cord injury, status epilepticus b. Demonstrate understanding of pathophysiology and management of conditions common to critically ill patients including, but not limited to: acute respiratory failure, sepsis, ARDS, acute kidney injury, electrolyte abnormalities, shock, cardiac dysrhythmias, STEMI/NSTEMI, coagulopathy

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. Hone 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 and teach appropriate methods to discuss end-of-life and care planning issues with patients and families

Professionalism a. Act as a role model for other trainees b. Demonstrate respect with patients, families and colleagues 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 required in the neuroICU c. Demonstrate the ability to mobilize and integrate multi-disciplinary care into the care plan for the neuroICU patient

Updated 7/16