UTHSCSA Neurocritical Care Rotation: Residents

Rotation Director:
Ali Seifi, M.D., FNCS, FCCM

Additional Faculty:
Shaheryar Hafeez, MD, Director of Fellowship

Firas Kaddouh, MD

Rotation Assistant:
Trisha Frick,  frickt@uthscsa.edu

Neurosurgery ICU, 8th floor Sky tower University Hospital of San Antonio


The specialty of neurocritical care is a combination of Neuroscience and the Critical care.  Neurointensivists are specially trained intensivists with backgrounds ranging from neurology to Anesthesiology, Internal Medicine or emergency medicine, that do a 2 year fellowship in order to care for critically ill patients with a wide range of neurologic dysfunction.  Some of the encountered conditions in the Neuro ICU include traumatic brain injury, Intracranial hemorrhage, strokes, seizures and brain death. Residents in the neuro 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.  Residents also have the opportunity for numerous procedures including:  placement of central venous lines and arterial lines, lumbar punctures, intubations, chest tube, peritoneocentesis and bronchoscopy.  In addition, because of the unique nature of neurocritical care patients, residents also gain experience with ICP monitors, evaluating EEGs and learning the specifics of the neurologic exam.  The experience in the neuro ICU 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, Fellows ( Neuro CC, Pulmo CC, Surgery CC, Anesthesia CC) , residents ( neurosurgery, neurology, anesthesia, emergency medicine, 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:
Neurocritical care is a primary service and all other services are as consultants.  The majority of our patients are admitted through neurosurgery or neurology. However, we provide a full spectrum of care for all of our patients addressing each organ system and its interaction with the central nervous system.

Anatomy of a Day on the Unit: {Weekends Off}
6am:  Round with neurosurgery team
7-8:30:  Pre-round on ICU patients
8:30-12/1:  Round with ICU team
Lunch break
1-4:  Procedures, note writing, family meetings
5pm:  Sign-out with neurosurgery residents

Expectations for the Rotation:
a.  Arrive on time
b.  Round on a minimum of 3 patients, doing an assessment and plan on every patient
c.  Lay hands on your patients when you round
d.  Ask questions:  otherwise it will be assumed that you understand everything
e.  Make time to read

Requirements and Evaluations:
At the end of the rotation you will be required to do either a case presentation or a journal article presentation on a topic relevant to neurocritical care, to be presented to the neurocritical care team.  Each presentation will be around 20 minutes in length with the date and time TBD.
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.

Patient Care:

1.  Perform a thorough history and physical exam, including a detailed neurologic exam

2.  Conduct an assessment of the patient’s multi-system issues and formulate a systems-based plan

3.  Observe and/or perform the following procedures

  • Central venous access placement
  • Arterial line placement
  • Orotracheal intubation
  • Bronchoscopy
  • Lumbar puncture

4.   Demonstrate ability to communicate effectively and compassionately with patients and their family members

Medical Knowledge:

1.     Demonstrate understanding of categories of traumatic brain injury (TBI).

2.     Demonstrate understanding of pathophysiology behind intracranial hypertension and methods for monitoring and treatment

3.     Describe the common etiologies of ICH, diagnosis and management goals

4.     Demonstrate understanding of presentation of subarachnoid hemorrhage (SAH), imaging used to diagnose, neurosurgical interventions, medical management

5.     Demonstrate understanding of vasospasm etiology, monitoring, diagnosis and treatment.

6.     Describe differences among types of seizure activity and risk factors for seizures

7.     Be able to understand differences between normal and abnormal EEG in the ICU

8.     Describe different modes of conventional mechanical ventilation

9.     Understand grading and management of spinal cord injury

10.  Describe nutritional needs of ICU patients

11.  Demonstrate etiology and management of the following common neuroICU conditions:  altered mental status, respiratory failure, shock, sepsis, ARDS, acute kidney injury, metabolic derangements (hyponatremia, hypomagnesemia, hypocalcemia, hyperglycemia),

12.  Describe the differences between cerebral salt wasting and SIADH

Practice-Based Learning and Improvement:

1.    Identify gaps in knowledge base and use resources to increase understanding

2.    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.  Start to identify 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 appropriate methods to discuss end-of-life issues with patients and families

a.  Maintain an appropriate appearance
b.  Employ and enforce a respectful attitude
c.  Maintain patient confidentiality
d.  Demonstrate sensitivity to cultural differences

Systems-Based Practice
a.  Describe the role of neurocritical care as a team within the larger hospital system
b.  Identify cost-effective strategies that allow for the detailed care in the neuro ICU
c.  Demonstrate the ability to mobilize and integrate multi-disciplinary care into the care plan for the neuro ICU patient