
Neurocritical Care at a Suburban Regional Medical Center:
From the Perspective of a Recently Graduated Neurointensivist
By Kinjal Desai, MBBS, MD, MPH
“Virtually nothing is impossible in this world
if you just put your mind to it and maintain a
positive attitude,” says Lou Holtz.
NCS and the field of neurocritical care
have come a long way in terms of how
multidisciplinary care is delivered to
complex life threatening neurologic
emergencies. There are two main paths for
the majority of trainees after completion of an NCC fellowship:
1) joining an academic medical center as a junior neurocritical
faculty, or 2) taking a leadership role and being involved in
developing or staffing a newly formed neurocritical care unit in
a suburban, usually a non-academic or partly academic center.
Although there are no scientific papers on the proportion of
graduates who end up in academic medical centers versus nonacademic
centers, there are only so many positions to fill at any
major academic medical center. This is in fact one of the toughest
decisions in life and depends on lots of factors, such as interests in
teaching, conducting cutting-edge research, being a part of famed
institution, salary and having a good work-life balance, etc.
I have always wanted to be part of a growing organization. This
is a challenge I gladly embrace every day since joining Clearlake
Regional Medical Center (CLRMC) in Webster, Texas. CLRMC is
a comprehensive stroke center and a level 2 trauma center. The
current setup at CLRMC’s Neuroscience Division includes a 16-bed
telemetry stroke unit and a six-bed Neurotrauma ICU (NTICU),
which is staffed primarily by trauma surgery and patients being comanaged
by Critical Care, Trauma, Neurosurgery and Neurology/
Neurocritical care. My role apart from being the stroke director at
CLRMC and its sister facility Mainland Medical Center includes
providing neurocritical care consultative services in the ICU
(neuro-ICU, CCU, MICU, SICU) and stroke unit.
I interviewed at 18 academic institutions for my neurocritical
care fellowship prior to matching at Baylor College of Medicine.
Although all the current training programs in neurocritical care are
UCNS certified, there are still subtle differences among these. Some
programs being critical care/procedure heavy, others being research
heavy and the rest a mixed bag of both. Programs also vary based
on whether these provide training for the fellows in neurotrauma.
The majority of the UCNS accredited training programs train the
fellows to successfully run and manage patients in a well-established
neurocritical care unit. Building a neuro-ICU requires leadership
skills, management skills and negotiation skills to be able to justify
the primary role of a neurointensivists not only from a patient
management but also a financial perspective to an institution.
Fellowship training in neuro-ICU at Baylor College of Medicine
was vastly different from current neurohospitalist/neurocritical
care consulting role at CLRMC. The primary difference being
that of an academic neuro-ICU versus a non-academic neuro-
ICU. Academic neuro-ICUs, as most of our readers are aware
of, has been built from the ground up by practicing academic
neurointensivists with set protocols and patient management
strategies, in addition to ongoing clinical research trials and
studies. The responsibility of building these at suburban/rural
medical centers rest on our shoulders, thereby addressing the
fresh graduating crew from the neurocritical care fellowship. The
neurointensivists of today are more than prepared to take care of
these sick patients; however, creating a neuro-ICU requires a huge
culture shift. This involves understanding the local politics of who
has most stakes in the ICU and convincing the administration and
departments of anesthesia/trauma/intensivists, the positive impact
of a neuro-ICU being staffed by a neurointensivist.
Being a part of the local community and providing educational
outreach, increasing awareness of risk factors for varied
neurological diseases and providing neurocritical care services
are some of my roles. The challenges, however, are many in terms
of increasing awareness within the hospital as to what we do as
neurointensivists and what a neurocritical care unit is. Beginning
clinical research projects, developing registries and databases
without any dedicated personnel to help is another mountain to
climb and does make progress slow. The biggest hurdle for me
currently is to justify my potential role to the administration of a
primary neurointensivist staffing the NTICU and how this would
help provide comprehensive and multidisciplinary care to patients
by practicing evidence-based medicine. This is despite multiple
global research studies explaining the better outcomes of patients
suffering from ICH, SAH and ischemic stroke when managed by a
primary neurointensivist in a neuro-ICU.
Despite the challenges I face every day, being able to take care of
wide variety of patients in a consultative role does provides solace.
Since more and more institutions across the country in suburban
and rural areas strive to achieve comprehensive stroke status,
the need to build neurocritical care units will continue to rise.
As more senior members of the neurocritical care society come
toward the end of their tenure, it is our responsibility as young
neurointensivists to take these responsibilities and learn the steps
of successfully building a neurocritical care unit. Formal training
opportunities of leadership, program development skills and an
in-depth understanding
of various political factors
that play a role in an
organization/neuro-
ICU are still a “work in
progress “for the current
fellowship training
programs.
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