(DM) As a surgery resident, I saw trauma cases at St.
Joseph’s medical center. We worked closely with
neurosurgery residents from Barrow, and I really enjoyed
critical care and neurotrauma management. I always
wanted to do critical care, but thought I would do cardiac
critical care. However, during my fellowship, the sole
Neuro ICU attending was leaving and there was an
opportunity to run and develop the Neuro ICU. I had
always been interested in the neurological cases, and I
think I had a natural aptitude for it. I’ve loved it ever since!
(CS) I initially planned to specialize in Epilepsy, but after
five months of ICU rotations during my Pediatric
preliminary years, I realized my passion for working with
critically ill patients. I also appreciate the large number of
neurocritically ill pediatric patients. My two months in
the Neuro ICU ultimately sealed the deal. I loved the
intersection of neurology, acute care, and palliative care,
plus ample opportunities to pursue research in quality
improvement and implementation. I had exceptional
mentors who saw the value of training neurointensivists
who could care for patients of all ages.
3. What can be done to attract more people from your field to
neurocritical care? Is there an optimal time during training
to expose and recruit them to neurocritical care?
(FA) a) Reach out to residency programs with
information about neurocritical care fellowships; b)
market ENLS so it becomes a part of IM residency
educational material; c) put out statistics of neurointensivists
with internal medicine backgrounds to
encourage residents to apply.
(MD) The neurosciences can seem intimidating to an
emergency medicine resident, who is taught to handle
anything that comes in, but can’t possibly learn the
details of every field. Supportive fellowship leaders are
essential for recruiting fellows with non-neurology
backgrounds. I wouldn’t have been successful if my
training wasn’t tailored to the strengths and weaknesses I
possessed. Welcoming individuals from a variety of
training backgrounds adds complexity to training, but we
are a stronger field because of this diversity.
(JE) In EM residency, trainees are exposed to brief
snippets of patients who go to the Neuro ICU, but they
don’t realize that all the interesting stuff in neuro patients
like MCA strokes and subarachnoid hemorrhage happens
after leaving the emergency room. Thus, having EM
residents rotate through the Neuro ICU like they do in
the MICU and SICU would help show residents the
importance of critical care in acute neurologic disease.
(JM) Neurosurgery residents should ideally be exposed to
neurocritical care in PGY 2 or 3. Many programs have
PGY-1 residents rotate through the Neuro ICU, but this is
too early for them to appreciate how to best manage these
patients. One major barrier for neurosurgeons is the
financial gap between earnings in the OR and Neuro ICU.
A neurosurgeon has to do neurocritical care because he or
she loves it and realizes its importance in the complete
care of their patients.
(DM) Anesthesia residents need to spend time in Neuro
ICUs, ideally in mid-level residency. Anesthesiologists are in a
unique position to follow a patient from the OR to the ICU
to clinic, offering vertical patient care. An anesthesia resident
can either do a two-year neurocritical care fellowship, or a
year of critical care plus a year of neurocritical care, the latter
option allowing the resident to be anesthesia-critical care
certified. I think it is a huge advantage to get trained by
experts from different fields. It gives them a better
understanding of neuroanatomy and neurophysiology,
allowing them to perform better in the OR.
(CS) Pediatric, in addition to adult, neurology residents
should have meaningful exposure to the Neuro ICU. I
also think it is very important for both neurocritical care
and child neurology faculty to support child neurology
residents. Most Neuro ICUs are adult-based, likely
contributing to some apprehension by child neurology
residents, but with appropriate supervision and
supportive faculty, fellows, and co-residents, child
neurology residents can thrive. It is also mutually
beneficial for both adult and pediatric providers to learn
from one another, to enhance the practice of neurocritical
care across all age groups.
4. What were the biggest challenges you faced when beginning
work in this field? How could these challenges be avoided
for others?
(FA) There were two challenges when I started my
fellowship: (1) Earning the trust of neurosurgery and
neurology programs (they looked at me differently, since
I was not a neurologist), and (2) Finding a job. I thought
that Neuro ICUs run by neurology departments might
not hire a non-neurologist, so I started looking for Neuro
ICUs run by critical care departments or large
multidisciplinary private critical care groups.
(MD) Neurointensivists remain pioneers. Neurocritical
Care Units are continuing to open for the first time at
many hospitals and the role that neurointensivists will
play in the new Neuro ICUs is still being defined. There
is wide variation in the positions available, and they will
evolve as the field matures, demanding flexibility and
determination to forge new paths.
(JE) I think that neurocritical care is great for
multidisciplinary backgrounds. While I was better than
others at managing rapid afib and doing intubations, I
knew a lot less about neurology and neuroanatomy. I
think having a program director who can help fellows
foster their strengths and focus education around their
weaknesses is key for successfully training a diversity of
fellows.
(JM) Every neurosurgeon feels they know how to do
neurocritical care because it’s part of their training. They
need to realize it is its own subspecialty, just like vascular
or tumor neurosurgery and requires its own additional
training. The best solution is to have more exposure not
just to neuro but managing disorders of other body
systems (e.g., ARDS, liver disease). Additionally, NCS
should recognize other specialty certifications beyond
UCNS to encourage member involvement and
consideration for FNCS induction.
(DM) My biggest challenge was developing personal
relationships with neurosurgery, nursing, and neurology,
but it was also the most rewarding. As an anesthesiologist
it is initially challenging to get people to view your
knowledge base beyond ventilator management. As
people recognize your capabilities, they trust you more
and that is key in neurocritical care. It is important to
establish protocols as well so that you are making good,
consistent decisions, in alignment with other doctors.
(CS) I thankfully had two local role models of Child
Neurology trained neurointensivists to discuss career
development opportunities. One of the greatest
challenges is finding a practice model with a good fit.
Many pediatric ICUs require pediatric ICU fellowship
regardless of neurocritical care training. However, many
successful programs have pediatric neurocritical care
specialists serving in a consultative role. I personally
wanted a hybrid model, to practice as a primary
neurointensivist in a dedicated (adult) Neuro ICU and as
a pediatric neurocritical care and stroke consultant.
During my job search, some institutions could not
support this model, but thankfully, many institutions
recognized the value of a clinician with adult and
pediatric neurocritical care expertise.
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