Neurological Critical Care
Brian Sumner, MD
Critical Care Fellow - Mount Sinai Health System
Chair, EMRA Critical Care Committee
Special thanks to our 2nd edition writing team
Abdullah Bakhsh, MBBS, FAAEM
Yanika Wolfe, MD
Special thanks to our 2nd edition faculty editor
Evie G. Marcolini, MD, FACEP, FAAEM, FCCM
Description of the specialty
Neurointensivists are physicians who are board-certified in neurology, neurosurgery, internal medicine, emergency medicine, surgery, pediatrics, or anesthesia and complete additional fellowship training to provide comprehensive multisystem care to the critically ill neurologic patient. The neurointensivist’s unique niche is the interaction between the brain and all other organ systems in the critically ill patient.
The number of dedicated neuroscience intensive care units (NICUs) is increasing, especially with advancing technology to diagnose and treat stroke patients and the proliferation of primary and comprehensive stroke centers. Dedicated neuroscience ICUs with specialty-trained intensivists and nurses have also been demonstrated to improve patient outcomes. Neurointensivists use and interpret data from advanced specialty-specific neuromonitoring tools, including continuous electroencephalogram (EEG), transcranial doppler, intracranial pressure and tissue oxygenation monitors, and microdialysis catheters. One of the unique aspects of neurocritical care is that the patients and families are living through a crisis of cognitive identity. The neurocritically ill patient has not only sustained injury to an organ system, but in many cases to the one organ system that defines personhood. This has a different set of implications than injury to the heart, lungs, or any other organ. In this sense, the neurointensivist has a very important role in helping patients and families grapple with issues around end of life, goals of care, loss of identity, and the bioethical principles that underlie each of these issues. The opportunity to help a patient and family through the worst imaginable crisis is simultaneously a privilege and a challenge.
History of the specialty/fellowship pathway
The Neurocritical Care Society (NCS) was formed in 2003. Board-certification pathway first opened in October 2005 and has always been open to EM physicians. EM residents can become neurocritical care certified by passing the exam after completing a 2-year fellowship in neurocritical care following completion of residency training, or completing a 1-year neurocritical care fellowship following the completion of a general critical care fellowship.
Why residents choose to follow this career path
Neurocritical care has always been a multidisciplinary specialty and has actively sought involvement of EM physicians. Outcomes for neurocritically ill patients presenting to the emergency department (ED) are dependent upon initial care, and EM-trained neurointensivists are uniquely positioned to optimally bridge this transition of care from one setting to the next. Neurocritical care-trained EM physicians represent a small, but growing, niche and as such have significant specialty value to many organizations from both an EM and neurocritical care perspective. For those interested in understanding and manipulating physiology, neurologically injured patients may have significantly more variables and subtleties than other critical care patients. For those interested in research, neurocritical care is a young and dynamic field, particularly regarding therapies during the first few hours, and as such there are still large areas for defining/refining care and making significant academic contributions.
How do I know if this path is right for me?
If you find yourself wanting to know more about the downstream implications of the choices you make when caring for neurologically-injured patients in the ED, (traumatic brain injury, subarachnoid hemorrhage, ischemic and hemorrhagic stroke, status epilepticus, etc.), are interested in a developing a deeper understanding of systemic and cerebral physiology, and want a second practice environment in which you provide care outside of the acute ED setting for critically ill patients, this fellowship is for you. If you enjoy the complex interactions with patients and family around issues of critical illness, personhood, brain death, palliative care and ethics, this field will provide many opportunities for clinical and academic pursuits. Completion of this fellowship will also open a wide variety of career options and leadership roles in both fields after fellowship. Because this specialty, and particularly its intersection with EM is young, you may have both the opportunity and necessity of defining your own career path. Therefore, it is optimal to give significant thought to your career and practice goals prior to pursuing this fellowship training.
Career options after fellowship
There are opportunities for practice either in community practice or academics. Smaller community and even academic centers may be lacking in resources for a dedicated NICU, so assisting in the creation of one or at least taking a leadership role in education of other providers in a mixed ICU may be possible. If you continue to provide care in the ED as well, you may also become the de facto “stroke expert” and possibly even general critical care expert for your colleagues and/or trainees. Research opportunities and consulting/working with industry regarding device development, monitoring techniques, and computer-aided interpretation of the tremendous amounts of data generated by multimodality real-time monitoring are all possibilities as well. Even at large academic centers, there will likely be a variety of quality improvement projects in the ED-based care of neurocritically ill patients.
Splitting clinical time between departments
As with many EM physicians with critical care training, you will be able to split time between two departments, and many choose different ratios of clinical time depending on individual interest and departmental staffing needs. Depending on the degree of cross-training you receive during your fellowship (as programs differ significantly) and the structure/patient mix in various ICUs, you and your institution may also have interest in splitting time between general medical and trauma/neurosurgical ICUs. This is also an area of negotiation between you and your department chair(s) and there is no one right answer. Generally speaking, spending time in both for the start of your career may be valuable to clarify interests and to leave options open. There are many different models of dividing your clinical time, and much of this will depend on which department holds your primary appointment (EM or Neurology). Consider that some institutions contract with groups for ED coverage rather than employing all physicians, which may complicate or benefit schedule splitting between multiple departments.
Academic vs. community positions
This is a personal decision, but before starting fellowship it is wise to consider that while the number of NICUs is growing rapidly, a certain patient volume is required to maintain adequate support staff and services (neuro IR, continuous EEG, real-time MRI availability). As such, a fully capable NICU may require a larger volume hospital to support it. Clearly, all the usual considerations regarding tradeoffs between academic and community positions, including salary, workload, liability, research opportunity, etc., still apply to neurointensivists.
IN-DEPTH FELLOWSHIP INFORMATION
Differences between programs
Because it is a newer specialty, there is in general greater program-to-program variability in neurocritical care (NCC) than in other critical care specialties, although all meet accreditation requirements. One of the most important considerations is where emergency medicine falls in their conceptualization of neurocritical care. Most fellowships are open to neurology, EM, internal medicine, anesthesia, pediatrics, surgery and neurosurgery-trained applicants.
Neurocritical fellowships often fall into one of several categories. Some have a strong history of training EM providers and therefore may be better equipped to recognize your unique needs (i.e., less procedural/resuscitation training and more focus on neuroimaging, neuromonitoring, etc.). Some do not have a strong history of EM involvement, but recognize the unique strengths and viewpoints of EM-trained providers and are excited/actively recruiting EM applicants. Some are fairly rigid and accept largely neurology applicants. These are still excellent programs, but you will have to make your career interests and needs very clear early in the process to ensure they are understood and will be met.
While there may be an initial bias toward going somewhere more “EM-friendly”, it is important to also recognize that this runs the risk of less detailed training in neurology-specific topics. Ideally you want a program where you are a respected team member (not viewed as a lesser-trained physician with respect to neurology), but also one that pushes you to excel in neurology/neurosurgery specific topics. If you don’t feel “behind” in some areas when you start, the program probably isn’t pushing these areas hard enough (since you will be competing with people who have spent several years learning these topics).
Other differences between programs to consider:
- Open vs. closed vs. cooperative ICUs
- Extent of cross-disciplinary training
- Acuity of patients in NICU
- Ownership of “joint” patients, for example traumatic brain injury patients (trauma ICU vs. neuro ICU). Do you get to manage medical/surgically sick patients in your neuro ICU or in other ICUs during training?
- Degree to which you will be involved in “routine”/less acute cases such as low-risk perioperative monitoring, small strokes, neuro-intact IPH, etc.
- Extent of procedural training/availability (i.e., does neuro ICU do bronchoscopy, chest tubes, and intubations? Or do you maintain currency with these procedures elsewhere?)
- Availability of moonlighting, primarily for skill maintenance as you will be out of the ED for a prolonged period of time.
- Role on non-NICU blocks (ie, primary fellow vs. observer)
- Role of fellow: supervisory or hands-on
Length of time required to complete fellowship
Skills acquired during fellowship
The skills you will hone include (but are certainly not limited to):
- Neurocritical care patient management
- Implications of cardiovascular and ventilator management on intracranial pressure/cerebral perfusion pressure/cerebral metabolism
- Understanding indications for procedural vs. operative vs. medical management of neurologic and neurosurgical patients, including those presenting to the ED
- Managing infectious and cardiac complications of NICU patients
- Understanding of multiple therapies to manage intracranial pressure and optimize cerebral perfusion
- External ventricular drain (EVD) management
- Antiepileptic management
- Management of multiple neurologic conditions rarely discussed in EM curriculum, including uncommon central nervous system infections, motor neuron disease, etc.
- Diagnostic skills
- Continuous EEG
- Transcranial Doppler use and interpretation
- Multimodality monitoring interpretation
- Varying degrees of ultrasound usage
- Procedural skills
- General critical care skills (variable by program): airway management, bronchoscopy, venous access (most NICUs prefer subclavian central lines and many require central access for administration of hypertonic saline, providing a large volume of these procedures), chest tubes
- Neuro-specific procedures, such as ventriculostomy/parenchymal monitor placement, are uncommonly taught to neurointensivists. Most attendings do not find maintaining credentialing and liability coverage to be financially viable based on volume and prefer that neurosurgery perform these procedures, although some programs will teach them to neurocritical care fellows. Often insertion of modified central lines for targeted temperature management will be taught, although some institutions prefer surface cooling only.
Contact individual programs for details; rotations are highly variable, especially regarding non-NICU blocks and the amount of clinical/ICU vs. research/elective time.
Board certification afterwards?
Board certification in NCC is available to ABEM-certified physicians who meet eligibility criteria and pass the NCC subspecialty exam. ABEM co-sponsors the NCC subspecialty with the American Board of Psychiatry and Neurology (ABPN), the American Board of Anesthesiology (ABA) and the American Board of Neurological Surgery (ABNS).1
For more information on board certification in neurocritical care through ABEM, please visit ABEM.org
Average salary during fellowship
PGY4 and 5 vs. 5 and 6 (as per your number of resident years already completed)
PREPARING TO APPLY
How competitive is the fellowship application process?
There are often a few unfilled spots in the country, although not many. Some programs prefer neurology resident applicants and consequently applying from EM is quite competitive, while others are actively recruiting EM applicants and therefore much more open.
Requirements to apply
There are no specific requirements other than completion of training in one of the approved specialties (EM, IM, neurology, neurosurgery, surgery, pediatrics, anesthesiology). Each program has individual requirements and should be contacted directly (many will require USMLE Step 3, for example).
There are no formal research requirements, but clearly research is beneficial to your application, particularly if in an area that spans the intersection of emergency medicine and neurocritical care.
Suggested elective rotations to take during residency
This will be dependent on your total amount of elective time, but rotations to consider include:
- Neurological Intensive Care Unit (NICU) – an absolute must!
- Other critical care rotations for broad critical care skill base
- Helpful more neuro-based rotations: EEG/neurophysiology monitoring, stroke, epilepsy – in general, these are very useful for rounding out your education and demonstrating interest, but consider them only if you have time.
Suggestions on how to excel during these elective rotations
Keep an open mind. Remember that in general you will be learning from a specialist in an area in which you have fairly limited experience and information; pay attention to what they’re saying, and if they are managing patients differently than you might choose to, try to understand why.
As usual, show up on time, know your patients, read about your patients, and try to gain more in-depth knowledge regarding the specialties involved (epilepsy, for example).
Learn the personalities and communication styles/preferences of your various consultants. This will also benefit you greatly in the future for learning the type and order of information that different consultants (interventional neurology, for example) would like.
Should I complete an away rotation?
Depending on the quality of your home NICU (if it exists), this may or may not be beneficial. If your home NICU is less developed, then an away rotation is a must. If you already have a NICU block in your residency training, then your elective time would be better spent on more neuro-focused activities and not “another” NICU month, since you will be doing many of these in your fellowship and ideally should already have excelled in your month at your home institution. Take into consideration that letters of recommendation are an important part of the application process, and a letter from an established and well-respected neurointensivist is highly valuable.
What can I do to stand out from the crowd?
The usual activities: join professional societies, go to conferences, and essentially demonstrate both that you have specific exposure to the field (so you know what you’re involving yourself in) and a commitment to it. Get involved in the Neurocritical Care Society; there are plenty of opportunities to get involved in projects to increase your exposure to neurocritical care and to get to know some of the leaders in the field.
Should I join a hospital committee?
Joining hospital committees, in particular those focused on ICU-based topics like ethics, palliative care, and especially brain death and organ donation may be helpful if you are interested. Certainly, stroke committees may be helpful as well.
Publications other than research
Publications other than research, such as opinion pieces, are always helpful as well.
How many recommendations should I get? Who should write these recommendations?
Generally, most programs require 3 letters, and many will accept additional letters. One will come from your program director, and ideally one should come from the director of your NICU month (whether that be home or away rotation). Additional letters can come from a faculty mentor, research advisor, or an EM-based intensivists or stroke team liaison. As stated earlier, letters of recommendation are an important part of the application process, and a letter from an established and well-respected neurointensivist is highly valuable.
What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
This depends on the length of time spent as an attending and what you do during that time. The goal should be to demonstrate your time was spent on neurocritical care-related activities and fits into an overall career plan, including what you want to do post-fellowship. It shouldn’t look like you’re applying for a fellowship position because you’re bored/frustrated with your current position. That said, fellowship can be a valuable road back into academics for those who have been practicing in the community and find themselves less competitive for academic positions. If you are returning to fellowship training after being an EM attending, spend free time with projects, research, committee-work with neurologists, neurosurgeons, and neurointensivists at your hospital. Letters attesting to your growth and contributions to neurocritical care as faculty are important.
What if my medical degree is from an osteopathic program?
According to ABEM.org, the ACGME-accredited fellowship training pathway for NCC eligibility pertains to ABEM- or AOBEM-certified physicians who enter ACGME-accredited programs.
What if I am an international applicant?
Visa issues may become a concern and this will again be very program-specific. However, similar to its history of significant interest in multidisciplinary contributions, NCS has a strong history of international involvement and is historically very welcoming of those with significant contributions to make.
How many applications should I submit?
Generally, you should try to find as much information as possible regarding specific programs, and then apply only to the ones in which you have significant interest. Attendings from your home program, either EM or neurology, may be able to help you with this. Unlike some critical care specialties, most spots in neurocritical care are filled using a “match” process through SF Match similar to residency. It is unlikely that you will be offered on-the-spot jobs, and having too many interviews isn’t necessarily a problem, but don’t waste time and effort applying to places you would not want to attend. As with any match process, gauge the number of applications to the strength of your application: the stronger your application, the fewer programs you will need to consider.
How do I pick the right program for me?
Figure out your career goals and then try to match them with a program. The personalities of the people in the program are very important. How well do you feel you fit in with them? Are they supportive of your goals? Do they understand your goals and why someone from EM would be applying? Fellowships in general and in neurocritical care in particular are much smaller than residencies, so your interactions, positive or negative, with a handful of attendings will define your experience to a significant extent. This may be a difficult assessment to make in the brief time of an interview day, so returning to spend some clinical time with the program, if that is an option, may be helpful. It cannot be overstated that the tenor of the program and relationships with your attendings and coworkers is one of the components of fellowship that can make it an excellent experience or a challenging and frustrating one.
It also may be valuable to ask program directors what they want to see their graduates doing or what they have done in the past to determine how well the program’s priorities match yours. Ensure that you have read the papers and research by some of the key faculty you are interviewing with, as this will determine the slant of the department and skew of their clinical exposure and connections within neurocritical care.
Common mistakes during the application process
Applicants who try to change their goals or personality to match a program. Even if this gets you in, it will not make you happy. There will be constant friction, and neither you nor your institution will have their needs met during your 2 years. Do not accept an offer from a program that doesn’t offer what you want and won’t be flexible.
Being overly positive or negative about your EM background. Remember, this puts you in a significant minority as compared to most applicants, but you have unique strengths and weaknesses. Don’t see yourself as a less-well-trained candidate, but also don’t underestimate the amount of neuro/critical care background that you lack. See yourself as a differently-trained candidate. Make sure the program knows you see yourself as this.
Asking obvious questions. If the answer to your question is on the website, it proves you haven’t bothered to do even basic research into the program.
Asking small-picture questions.
You are investing half a million dollars of lost income and 2 years of your life into furthering your career. Ask big-picture questions regarding your training and the future. Questions such as what the call schedule is like or how many weeks of vacation you have are not appropriate attending-level questions and really don’t matter on this scope. However, discussing these questions with the fellows during dinner is fine.
Not attending a pre- or post-interview dinner. Meeting the existing fellows in an informal setting to gauge their personalities and goals and determine whether you could see yourself as one of them. Remember that it’s informal but still part of the interview process – on both sides.
Not treating administrative personnel with respect and graciousness. Fellowship coordinators are the backbone of a program – and they will offer their opinion as to how they were treated by applicants during the process. If you can’t treat administrative or other staff well (nursing, techs, etc.), that is a clear red flag that you will have problems with teamwork and communication.
Not showing interest in the process during the interview. This should not need to be said, but texting or answering your phone during any part of the interview where somebody is speaking with you or presenting information shows a lack of respect for the presenter or interviewer and stands out in spades. Remember that your academic achievements and CV got you to the interview, and the interview day is mostly to gauge whether or not your personality will be a good fit.
All programs participate in SF Match. Registration is early! For example, you would have started registering in January 2023 to match for a July 2024 position (no, this is not a typo – 18 months!) Match results are available in August (7 months after application opens). The application timetable can be obtained from the SF Match website.
Tips for writing your personal statement
Be genuine. Make it clear why you are interested in doing what you want to do. Legitimate interest and passion is usually obvious in your statement. Many program directors will recognize genuine interest and passion which will carry you through difficult months and make you successful in the long term.
Include and highlight relevant interests or activities that aren’t already on your CV. This is your chance to express yourself as an interested, committed, and thoughtful person.
Your personal statement is also a great chance to make it clear what strengths you bring to the table as an EM applicant. Express in writing why an EM applicant is interested in this career path.
In general, do not embellish on your application. Be honest about your accomplishments; being caught in a fabrication reflects a lack of character and will likely put you to the bottom of the list if not earn you the classification of “do not rank”.
Is this a match process?
Yes, through SF Match.
What happens if I don’t obtain a fellowship position?
Your options include finding one of the spots that are available after the match (there usually are a few), applying again for the next cycle (ideally while working on enhancing your CV in the interim), or working as an emergency medicine attending (which can also be quite rewarding). If you have a strong interest in neurology, critical care, and neurocritical care, you can often supplement that through informal training and still position yourself, particularly at medium-sized institutions, as the local “expert” in the topics that interest you.
How do I stand out from the crowd?
Make sure you read your personal statement before your interview and use the interview as a way to highlight important points/make points that are related or supportive. Don’t contradict your personal statement or make it seem irrelevant!
Make it clear what you bring to the table for the organization rather than focusing on things from your perspective. Many may have only a vague idea of the skills you have obtained during residency but would be interested in topics such as general critical care/resuscitation skills, as well as general knowledge of how to make neurocritical care concepts “work” in a real-life/chaotic ED to improve the care of patients closer to their injuries. EM providers often also have ultrasound training of interest to neurocritical care departments.
Be as knowledgeable as you can about the neurocritical care specialty. Read about the history of its development and most importantly be able to articulate what your niche interest is within neurocritical care, such as brain death, epilepsy, intracranial pressure (ICP) management, etc. Don’t make this up on the fly – give this a lot of thought and have conversations with your EM or neurology attendings who have a stake in neurocritical care to gauge whether your areas of interest are feasible, practical, and/or need some refinement. The applicant who has a good sense of the neurocritical care landscape and where he/she wants to fit into it presents as someone who has goals and has been thoughtful about planning a career path. This doesn’t mean you can’t change direction during or after fellowship but it shows that you have been thoughtful and insightful about the process.
What types of questions are typically asked?
You will get all the standard questions for any interview, but overall the most prevalent one is why an emergency medicine physician would want to be a neurointensivist. Have a true/passionate answer ready and don’t react defensively. People are genuinely interested and curious! They are spending two years of time training you to be their colleague, and they expect that some portion of your practice should be alongside other neurointensivists.
How many interviews should I go on?
Many people try to maximize their total number of interviews, but often stratifying may be a better strategy. Interview with a couple programs from each tier. Your home institution or a trusted mentor may be able to provide insight on how competitive of a candidate you are. Often this may come from your neurology department, not your emergency department, to further fine-tune this number.
PREPARING FOR FELLOWSHIP
Textbooks to consider reading
You will know early enough – again, greater than a year in advance – where you will be matching that it is probably best to directly contact your future program director and find out what you should be reading. That said, any general neurocritical care textbook would be valuable. If you have extra time, background reading of a general hospital neurology textbook may be helpful to better understand some of the neurology “zebras.”
Important skills to practice while in residency to prepare for fellowship
- General critical care skills, both procedural and cognitive
- Neurology exam: This will probably not be as detailed as a real “neurologist” neurology exam – and often can’t be due to patients’ clinical status or acuity of their condition – but you should gain an understanding of how to examine patients who are intubated/critically neurologically injured. Focus on things like cranial nerves, brainstem reflexes, and abnormal posturing. Understanding of the NIHSS as well as a good posterior circulation exam is also a must for EM neurointensivists. Subtle findings in seizures and understanding of clinical localization of lesions in critically ill patients are also helpful.
Tips on how to succeed as a fellow
The biggest factor is a significant change in mindset from traditional emergency medicine thinking. In addition to correcting problems, critical care is partially about anticipating and preventing them with a good understanding of a patient’s longitudinal course. This requires greater attention to detail. Many patients have more complex interrelated issues that may not be emergencies but still must be addressed to productively move their care forward.
The critical care arena also often involves significant adjustment to the presence of additional consultants with their own, differing opinions. In the Emergency Department, consultants usually do not come unless you ask them to, however, in neurocritical care they may be following the patient longitudinally or have been consulted by a previous team. This increases the number of political issues which you may need to manage. This is particularly true regarding neurosurgical patients; once an attending has operated on a patient, he/she has opinions on care and a vested interest in seeing that the patient does well, regardless of whether the attending of record at your institution is the neurosurgeon or neurointensivist.
All the usual residency skills regarding being on time, courteous, professional, and having good communication skills certainly still apply.
Do not stop learning, both through reading and especially through discussions with your consultants. There will be a large amount of neurology and neurosurgery literature with which you are unfamiliar. Seeking out information and opinions from the (many) consultants with whom you interact is incredibly valuable.
Seek out mentorship and career advice. This potentially includes those outside of your institution, particularly if you do not have attendings from an EM background. Your neurology-trained attendings will have very valuable advice for you, but are likely less familiar with the competing priorities you will need to manage for the EM half of your career (assuming you plan to retain clinical time/appointments in the ED).
The first part of your fellowship is the time to lay low, get a feel for the landscape and practice diplomacy. Be the leader of a team. Develop excellent relationships with your nursing staff; they can make you or break you. Choose your battles later. Come out of the gate being confident, collaborative and willing to learn from everyone. Building a team around you will save you in times of crisis. If the nurses consider you trustworthy, dependable and accessible, they will keep you informed. If not, they will go around you and this will erode your position. This is key to knowing what is going on with every aspect of your team and patients.
Remember that your fellowship director, medical director and attendings will be writing you letters and helping you get your next job. Be thorough, detail-oriented and diligent about follow-through. Be attentive to each attending and his/her preferences. Don’t be frustrated by different attending preferences or styles – it is to your benefit to see many different styles as you develop your own.
Take time to teach medical students and residents. This is recognized and speaks volumes about your dedication. Your role encompasses not only patient care, but family communications, trainee education and consultant collaboration.
- Neurocritical Care Society publication Neurocritical Care
- Any journals specific to your area of interest (traumatic brain injury, stroke, cardiac arrest, etc.)
NCS (Neurocritical Care Society)
SCCM (Society of Critical Care Medicine)
ACEP (American College of Emergency Physicians) Scientific Assembly
AAN (American Academy of Neurology) - especially if interested in more “neuro” as opposed to neurocritical care topics
SAEM (Society for Academic Emergency Medicine) Critical Care Interest Group
AAEM (American Academy of Emergency Medicine)
How to find a mentor
Ask anybody and everybody you know! EM neurointensivists are a small but rapidly growing group – and as such are hard to find, but are very interested in expanding and increasing their numbers. Do not forget this specialty exists all on its own but spans neuro, critical care, and EM. Valuable mentors and professional contacts may exist in any of those departments, plus in basic neuroscience non-clinical specialties if you have a particular interest in research.