UT Health San Antonio Neuro ICU Rotation: Fellows
Ali Seifi, M.D., FNCS, FCCM
Shaheryar Hafeez, MD, Director of Fellowship
Firas Kaddouh, MD
Location: Neuro-ICU, 8th floor Sky Tower, University Hospital
Length of Rotation: 4 weeks
Link to the call schedule: https://conexus.uthscsa.edu/ncc/rotation/
Fellows in the neuro ICU are exposed to patients with a wide range of neurologic injury including severe traumatic brain injury, stroke, status epilepticus and spinal cord injury. These patients also have critical illness in addition to their neurologic dysfunction including respiratory failure, renal failure, metabolic derangements, cardiac dysfunction, sepsis and ARDS. Fellows 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, evaluating 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.
The core neurocritical care team is composed of the attending physician fellowship trained in neurocritical care, a neurosurgery intern, other off-service interns, emergency medicine second year resident, nurse practitioner (NP) and/or physician assistant (PA), critical care pharmacist and the ICU nurses. Additionally, there are respiratory therapists, dieticians, physical and occupational therapists, social workers and case managers.
How the Team Works:
When patients are admitted to the Neuro-ICU, neurocritical care is the primary team and neurology or neurosurgery are required consultants.
We also provide a consult service for those requesting neurocritical care expertise outside of our ICU. For consult patients, we give recommendations only, unless the primary team ask us to place orders (such as for hypertonic saline or cEEG monitoring).
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 Sign out and rounds with ICU team
Schedule and Expectations:
- Fellows are requested to act in a full fellow role, not as an observer. They are requested to be present daily and 1-3 weekend days per month unless their call schedule dictates otherwise. We will make sure that they don’t exceed the duty hrs.
- Fellows will be asked to be available overnight by phone, when the in-house residents have a question or need help.
- The fellows should be familiar with all the patients on the unit
- We ask that vacation time not be taken during the rotation if possible and that schedule requests be submitted at least 1 month prior to their rotation start date.
Resources on neurocritical care are available on our website:
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, an informal 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.
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.
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
- Lumbar puncture
- Bedside ultrasound
- Chest tube placement
c. Demonstrate ability to communicate effectively and compassionately with patients and their family members
d. Review and interpret diagnostic studies including laboratory tests, x-rays, CT scans, MRIs,
- 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
- 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:
- Identify gaps in knowledge base and use resources to increase understanding
- 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
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
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