Curriculum

We will provide advanced training in general and neurocritical care, encompassing guidelines developed by the UCNS, Neurocritical Care Society, and Society of Critical Care Medicine. Graduating fellows will be competent in managing complex patients with a broad spectrum critical and neurocritical care disorders within a collaborative environment. They will also be competent in core critical care procedures (listed below) as well as the economic aspects of modern medical practice. They will lead family discussions and provide compassionate patient-centered care (including end-of-life and palliative care). At the start of fellowship they will receive extensive orientation and supervised training in core procedural and ACLS/ENLS competencies (educational link). We will train them to become responsible and competent independent neuro-intensivists who can lead a busy Neuro-ICU in their second year. They will stay current and be able to appraise the evolving critical care literature critically through regular didactic lectures and mentored journal clubs (conference schedule). They will attend our regular Process Improvement meetings and participate in PI/QI projects. They will receive feedback through semi-annual evaluations which will include 360º feedback and review of their academic productivity. They will also be afforded the opportunity to give feedback on the program as we constantly strive to improve the educational experiences offered to our fellows.

The disease states and procedures are outlined below, highlighting the high volume and variety of disorders encountered in our busy unit (complemented by additional exposure in other ICUs).

Neurological disease states (approx. number of patients seen in the Neuro-ICU each year):

  1. Cerebrovascular disorders (400/year):
    1. Ischemic cerebrovascular diseases (50): including malignant hemispheric infarction, basilar artery occlusion and vasculopathies (e.g. moya-moya, RCVS), MELAS
    2. Intracerebral hemorrhage (200): including supratentorial and cerebellar/brainstem ICH, IVH (administration of intraventricular fibrinolytics)
    3. Subarachnoid hemorrhage(100) including management of delayed cerebral ischemia
    4. Cerebral venous sinus thrombosis (10)
  2. Neurotrauma (200/year):
    1. Severe closed head injury (60): with ICP monitoring
    2. Penetrating head injury (10)
    3. Subdural hematomas (100)
    4. Spinal cord injuries (20)
  3. Status Epilepticus (40) including refractory and super-refractory status epilepticus, use of anesthetic agents, hypothermia, and other interventions
  4. Neuromuscular Disorders (30): including myasthenia gravis crisis, Guillain-Barre syndrome, ALS
  5. CNS Infections (60): including encephalitis, meningitis and brain/spinal abscesses
  6. CNS Inflammatory disorders (20): including neurosarcoidosis, ADEM
  7. Neuroendocrine disorders (40) including pituitary apoplexy , panhypopituitarism and DI
  8. Neuro-oncology (80): including primary tumors and metastases, carcinomatous meningitis and paraneoplastic syndromes
  9. Miscellaneous encephalopathies (50): including PRS, eclampsia, anoxic encephalopathy
  10. Clinical syndromes including hydrocephalus (100), herniation (50), brain death (50), severe dysautonomia / ‘surging’ (35)
  11. Perioperative neurosurgical care (over 200/year) including craniotomy, third ventriculostomy, major spinal procedures
  12. Brain death (60): evaluation of catastrophic brain injury, diagnosis of brain death including apnea testing (coverage for entire hospital) and management of the potential organ donor

General critical care:

  1. Cardiovascular: including management of shock, myocardial ischemia (including stunned myocardium), arrhythmias, pulmonary edema, hypertensive emergencies
    1. Use of hemodynamic monitors such as esophageal Doppler, pulse contour analysis (for stroke volume and pulse pressure variation)
  2. Respiratory: including hypoxemic and hypercapnic respiratory failure, ARDS, pneumonia, COPD
    1. Management of mechanical ventilation, BiPAP and criteria for intubation/extubation
    2. Pulmonary embolism: we have developed a novel screening tool for PE in the ICU
    3. Neurogenic breathing patterns
    4. Management of chest tubes and pleural catheters
    5. Chest x-ray interpretation
  3. Renal: including fluid, electrolytes, renal failure, indications for and approach to dialysis (and other modes of renal replacement therapy), drug dosing in renal failure
    1. Management of rhabdomyolysis
    2. Neurogenic disorders of sodium/water regulation including hyponatremia from SIADH, cerebral salt wasting, diabetes insipidus
  4. Infectious: management of hospital-acquired infections, selection of antimicrobials (incl. resistance patterns), evaluation of central fever
    1. Sepsis: management of sepsis and septic shock
    2. Physiologic severity scales including APACHE and SOFA
  5. Hematologic:
    1. Reversal of coagulopathies including anticoagulation, use of PCC
    2. Venous thromboembolism prophylaxis and treatment
  6. Administrative and Ethical aspects of care:
    1. Billing in critical care, use of EHR, charting
    2. Process/Quality improvement
    3. Triage and resource allocation (fellows function as primary triage for ICU)
    4. Collaboration with multidisciplinary team and consultative service
    5. End-of-life care including palliative care, death and dying, terminal extubation
  7. Academic:
    1. Study design and biostatistics
    2. Protocol design and IRB approval
    3. Scientific writing – submission of manuscript, presentation of posters

Procedural Competencies (with approx. number per year for fellow experience)

  1. Central venous catheter placement (including dialysis catheters) ~ 100/year
  2. Arterial catheter placement ~ 150/year
  3. PICC line placement (taught by NPs) ~ 150/year
  4. Endotracheal intubation (Direct Laryngoscopy and Glidescope) ~ 100/year
  5. Lumbar puncture ~ 50/year
  6. Therapeutic hypothermia ~ 50/year
  7. Bronchoscopy: in NNICU as well as other ICU rotations ~ 20-30/year
  8. Thoracentesis and tube thoracostomy (also on SICU rotation) ~ 10-20/year
  9. Bedside ultrasonography and echocardiography: 200-300 cases/year
  10. Hemodynamic monitoring including non-invasive (esophageal Doppler) and pulmonary artery catheterization (few per year)
  11. CPR / ACLS (20-30/year)
  12. Continuous EEG monitoring ~ 150/year
  13. Jugular bulb monitor placement and monitoring (few/year)
  14. Conscious sedation and barbiturate anesthesia
  15. Plasmapharesis and IVIG ~ 30/year
  16. Renal replacement therapies (in conjunction with nephrology service) ~ 30/year

Off-Service Rotations:

Mandatory rotations

  1. Anesthesia/airway: 2-4 weeks in the first few months of first year
  2. Medical ICU: 2-4 weeks in the first half of first year (option for another 4 weeks in year 2)
  3. Surgical ICU: 4 weeks in year 2

Electives

  1. Cardiothoracic ICU (4 weeks)
  2. Stroke: function as fellow on vascular in-patient service (2-4 weeks)
  3. EEG: review in-patient and continuous EEGs with epilepsy attendings (2-4 weeks)
  4. Emergency Ultrasound: (2-4 weeks) plus twice annual half-day critical care U/S course
  5. Cerebral angiography (2-4 weeks)
  6. Neurosurgery (2-4 weeks)
  7. Interventional Pulmonary (2-4 weeks) with exposure to percutaneous tracheostomy

Benefits:

Vacation – 3 weeks/year
Educational fund – $2000/year for conference travel, books and other expenses

CONFERENCE SCHEDULE:

Monday Tuesday Wednesday Thursday Friday
Stroke Conference NNICU Journal Club
Multidisciplinary Critical Care Conf
Neurology
Grand Rounds
PI Meeting
NNICU Journal Club
Multidisciplinary CC Conference
Professor’s Rounds (Dr. Diringer) Neurology
Grand Rounds
Stroke Conference NNICU Research Meeting
Multidisciplinary CC Conference
Neurology
Grand Rounds
NNICU M&M
Multidisciplinary CC Conference
Professor’s Rounds (Dr. Diringer) Neurology
Grand Rounds