Picking the Brain in Neurology and Neurocritical Care

Session 190

Dr. Marc-Alain Babi is a neurology resident and fellowship director. We talked about what the path is like, the different myths, and why neurocritical care is important.

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[01:13] Interest In Neurology and Neurocritical Care

'Neurocritical care is a specialty that deals with the management of acute neurological and neurosurgical emergencies.'Click To Tweet

Neurocritical care is involved in treating severe neurological disorders, severe seizure, massive ischemic stroke, severe brain trauma, as well as brain infections that require life support. It is a hybrid subset of both neurology, neurosurgery and critical care medicine and surgical critical care.

And it was throughout his second or third year where he was intrigued by the acute parts of neurology.

While the patients can be very challenging or difficult to manage, it also can be very rewarding when you can make a difference in patient outcome.

Marc applied for fellowship training with additional subspecialty training after residency. He spent two years of neurocritical care training at Duke University Hospital. After fellowship, he moved to University of Florida as his first job after a long phase of medical training, medical school residency, and fellowships. A year later, he established the neurocritical care fellowship program, where they now train future specialists in neurocritical care.

[03:28] Traits that Lead to Being a Good Neuro Intensivist

Neurointensivist is a little bit different from a general neurologist that handles some outpatient, inpatient, epilepsy, and headaches.

“With neurocritical care, things are very fast paced. You have to make very quick decisions. You have to be decisive, very firm, and evidence-based.”Click To Tweet

In neurocritical care, excellent communication skills, a fast paced environment, and dealing with high acuity settings are important. You also have to be very collaborative as they work very closely with neurosurgeons, stroke neurologists, and with trauma surgeons.

[04:40] The Biggest Myths or Misconceptions About Neurocritical Care

Marc explains that it’s not just pursuing such a field because of a lifestyle, but because you’re committed to that practice.

'We have to be really careful not to have misconceptions early on in the course of patient disease because there are a lot of variables.'Click To Tweet

There are different neurological resuscitation and different new neurosurgical techniques on how they treat a lot of neurological and neurosurgical emergencies.

The key is to always teach resident fellows the first few days of a neurological emergency to take a step back, evaluate the situation. That way, the decision-making is based on objective facts, not just based on opinions.

Marc also adds that for the most part, they already have the diagnosis of the patients. And so, they’re more involved with treating the secondary complications. Whether it’s brain swelling, severe seizure, respiratory failure, or cardiac dysfunction related to brain injury.

For the most part, they are now able to figure out what caused a stroke or what goes on. For example, in the case of brain trauma, it’s very clear cut where they already know the history of trauma. And now the patient has secondary complications related to their severe brain injury. They’re not able to breathe on their own or their cardiac function is depressed because they have a severe brain injury that affected their heart function and so forth. And so, the next step is how to manage that complication?

[08:12] Typical Day

Marc says he’s on call and responsible for Neuro ICU 24/7. They alternate with a partner that rotate with them throughout the week. Typically, they’re going to work at the neuro ICU between six and seven in the morning.

Their team is working day and night 12-hour shifts and breaks them down among their advanced practice provider residents and fellows. They do the rounds as a team together with the fellows, residents, nutritionists, pharmacists, respiratory therapists, and nurses.

They also treat respiratory issues, renal issues, infectious issues, etc. which takes them about three to four hours to go through between 10 to 12 patients. And then around between six and seven, it’s going to be now the handoff from the day to night team. If the emergency happened overnight, they will have to go back to the hospital. They would support the team that is physically present in the ICU and addressing whatever medical emergency.

[11:05] Types of Procedures

In neurocritical care, they do all the standard critical care procedures. This includes intubation, placing life support raising tubes for patients, and fiber optic bronchoscopy.

Other procedures include placing the drain into the brain when blood pressure builds up, and brainwave recording. They also do transcranial Doppler, cardiac ultrasound, chest tube placement, central venous catheter placement, arterial line placements, lumbar puncture.

[12:06] Life Outside of the Hospital

Marc says he has life outside of the hospital and that means being able to find your own balance. He is an avid spear fisherman and does a lot of free diving, spearfishing, and kite surfing. And then whenever he has a longer stretch off, he travels out of state, and does hiking and skiing depending on the season. Marc is an avid outdoorsman and has two little kids.

Resilience is another important trait they look for. Burnout is quite high in their field so it’s very important for them to be resilient.

[14:19] The Training Path

Neurology is a four-year residency training. They do that first year as medicine rotation and then the next few years as neurology and neurology subspecialty rotation. For neurocritical care, this depends on what pathways of residency the applicant comes from.

They take candidates from neurology, anesthesiology, neurosurgery, internal medicine, and anesthesiology or those who have completed previously critical care specialty training.

So if a candidate has completed neurology and general medicine, or anesthesiology, it’s a two-year duration of training. If a candidate has previously completed neurosurgery, which is mostly 6 years, and 7 years for a few other programs, the neurosurgical care training is one year.

About 40% of neurocritical care fellows and practitioners from their program are of Neurology background. 20-25% are of Internal Medicine background, 10-15% of anesthesiology background, 5-10% percent emergency medicine background, and 5-10% percent neurosurgery background.

[15:53] Overcoming the Bias Against DOs

Marc speaks specifically for his program and he claims that they don’t distinguish between DO and MD. They have a holistic approach in their program where they look at all factors altogether. That includes the letters of recommendation, the extracurricular activities, etc. They also look at USMLE scores or board or COMLEX scores all combined together.

During the interview process, they factor all of those in together. They also look at the fact if an individual is of underrepresented minority or minority background.

He adds that they have a committee of faculty who interview prospective fellows. And then after the interview season, they meet again collectively to go through the file of each candidate and then submit their rank list.

[17:33] Job Opportunities

Marc explains how the models out there can be very varied by institution, by the platform, and by that infrastructure. There are about 3-4 places that offer neuro intensive care units in community or hospital employed settings.

There are closed models out there where the patient would be admitted under the neuro intensivists. The patient would be admitted under a neurosurgeon for stroke neurology. So their role is more of a consultant to support the elder team in managing secondary complications like airway complication, cardiovascular complication, hemodynamic, and so forth.

'There are varied models out there in the community. Job market is very diverse as well.'Click To Tweet

Marc estimates that it will take at least five to seven years to saturate the field because it’s a relatively young field that only started in mid 2000. And it was only in the early 2010 when it became much more recognized.

Moreover, telehealth consulting is very common especially in large institutions that have spoken out models of outreach to smaller hospitals. Spoken out model is when you have a major academic center or a large hospital contracted with a smaller regional hospital or rural hospital. The major health hospital may not be able to admit everyone from outside hospitals as they fill in their bed. They have their individual physician specialists at the telehealth consultation to whatever scope of practice of expertise they’re on.

[20:39] What He Wished He Knew Before

Marc would have wished he knew how it was a demanding field because it puts a lot of both physical and intellectual tasks on an individual.

Physically, you’re working 12 to 14 hours doing procedures and taking a certain manual skill set. Intellectually, you have to be on top of your knowledge that is ever changing. That means keeping up with the guideline protocols, etc. So you have to be on top of your knowledge. That being said, as much as it’s taxing, it’s also very rewarding as a specialty.

[21:25] The Most and Least Liked Things

What Marc likes the most about the field is the deep connection you form with patients and their family. And having the honor and the privilege to take care of the sickest of the sickest in the hospital. They’re given the privilege and honor of managing neurological emergencies and neurological catastrophes where it’s up to them how to manage that.

'It's extremely rewarding to see how we can make a difference to the patients in terms of the outcome you see.'Click To Tweet

The other part that’s very rewarding is being able to train future specialists in that field. When they train fellows, residents or advanced practice providers, they see how they likely branch out down the road and go to other hospitals.

On the other hand, he couldn’t find anything that he disliked about the field, especially that insurance is irrelevant to his specific practice.

[23:41] Major Changes Coming Into the Field

A lot of changes are happening in the field as they’re getting more technologically advanced.

Historically, for a lot of procedures, a patient needs to go through a major brain surgery. They take out the scar, they take out the skull, retract brain tissue, and then address whatever brain issue is there.

Now, a lot of what they do is through endovascular approach. Their surgeon would go directly to the blood vessel.

[24:41] Final Words of Wisdom

If he had to do it all over again, Marc says he still would have chosen the same field.

Finally, to those interested in neurocritical care, Marc once agains stresses how it’s a great field and how it’s very distinct from all the other fields in Neurology. They’re in a unique position

'It's very distinct from all the other fields of Neurology. It's more of a hybrid between neurosurgery, acute care neurology, stroke neurology and Critical Care Medicine.'Click To Tweet

The most rewarding part in critical care is seeing the positive impact you can make toward patients and their family, as well as training the future generation of specialists.