Leading Insights

Stefanie P. Cappucci, MD Neurology Resident Beth Israel Deaconess Medical Center Corey R. Fehnel, MD, MPH Assistant Professor of Neurology Beth Israel Deaconess Medical Center Harvard Medical School Section Editor: Michael Reznik, MD Assistant Professor of Neurology & Neurosurgery Brown University/Alpert Medical School       “A year ago, I was thrilled to survive…and looked forward to what the future would bring. I would have never imagined a year from that day I would be getting ready to go to ...

By Mary Presciutti, NP, CCRN, CNRN, Mount Sinai Hospital, Department of Neurosurgery Weeks before deployment, my fellow advanced care providers (APP) and I were told that our New York City hospital was in the process of rearranging healthcare personnel to meet the impending surge of patients with COVID-19. Like most of us, I was filled with anxiety and many questions:  How will things be? What will our path be moving forward? Two weeks later, I received my schedule and learned that I had been assigned to the COVID-ICU. Prior to my current position ...

Taking a Closer Look into Neurocritical Care Mechanical Ventilation During the COVID19 Pandemic and the Use of Anesthesia Machines in the Neuro ICU By Shaun Golden, MSN, RN; and Sarah Beth Thomas, MSN, RN, CCRN, CNRN, SCRN Since the beginning of the COVID-19 global pandemic, ventilators have been at the forefront of public discourse. Discussions on social media, stories in various news outlets and even sound bites offered by prominent politicians in Washington and beyond have made ventilators a new buzzword for the American public.  ...

By Francisco Gomez, MD 1 ; Alyssa Polliti 1 ; and Fawaz Al-Mufti, MD 2   1 Deparment of Neurology, University of Pennsylvania 1 Department of Neurology, Rutgers - New Jersey Medical School 2 Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College   The authors have no actual or potential conflict of interest in relation to the topics discussed in this column. This article may discuss non-FDA approved devices and “off-label” uses. The NCS and Currents do not endorse any particular ...

By Jeong-Ho Hong, MD, PhD, Department of Neurology, Keimyung University School of Medicine, Daegu, Korea Recently, I was working as a neurointensivist at one of the hub-hospitals treating COVID-19 patients, Daegu Dongsan Hospital (branch hospital) and one of tertiary hospitals, Keimyung Univerisity Dongsan Hospital (main hospital), in Daegu, South Korea. Daegu is the center of South Korea’s expanding COVID-19 outbreak. Government-designated Hub-hospital for Only COVID-19 Patients vs. General Tertiary Hospital: A Neurointensivist’s Point of ...

Cardiac Arrest and Cooling Out-of-hospital cardiac arrest (OHCA) has an incidence of about 110.8 per 100,000 in all ages, while in-hospital cardiac arrest (IHCA) has an estimated incidence of about 292,000 cases per year in the United States.   In view of the recent HYPERION trial, finding for the effectiveness of targeted temperature management (TTM) in non-shockable rhythm arrest, TTM is again at the forefront of discussion and remains the standard of care for acute management of all unresponsive post-cardiac arrest patients. Several modalities ...

Yingying Su COVID-19: Difficulties and Countermeasures in the Prevention and Control of Neuro ICU Infection and Medical Quality Control in China By Yingying Su From February to March 2020, the epidemic of COVID-19 peaked in China. The situations for neuro ICU were as follows: In addition to some medical staff sent to the designated hospital or ward of COVID-19 to combat the epidemic, most of them were still on duty at their local neuro ICU, routinely guarding against the outbreak of COVID-19, taking responsibility of quality and safety in the ...

By Alexis Steinberg, MD; Matthew R. Leach, MD; Angela Hays Shapshak, MD; and Lori Shutter, MD The Covid-19 pandemic has dramatically changed the practice of critical care, and neurocritical care has not been immune to these changes.  As ICUs across the country experience a swell in COVID-positive patients, neurointensivists have been called upon to practice outside their normal scope, dealing with increased patient volumes and greater proportions of general critical care patients, despite ongoing acute neurologic emergencies.  We interviewed attending ...

By Stephen Trevick, MD  I am writing from Chicago on March 20. I feel this is important to share as the COVID-19 pandemic is developing so rapidly that some concerns that I discuss here may be less relevant by the time you read this. There is an incredible amount of uncertainty in the pathophysiology, epidemiology and social impact of this disease. The eyes of the world are on healthcare providers now, and we have all become leaders of our communities. We will be called upon not only to provide medical care and information, but, ideally, to help guide ...

The ongoing pandemic of Coronavirus Disease 2019 (COVID-19) is unprecedented in scale, with devastating effects seen in the economic and social spheres of society. The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020, after the number of cases outside of China skyrocketed 13-fold since late February.  The micro-organism causative of COVID-19 infection is a β-Coronavirus, an enveloped positive sense single-stranded RNA virus, which shares the same family as severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and ...

By Alberto Hernandez, MD, PhD, DESA, Director, Anaesthesia & ICU, Grupo Policlinica, Ibiza, Spain; and Peter J. Papadakos, MD, FCCM, FAARC. Director, Critical Care Medicine, Professor Anesthesia, Surgery, Neurology and Neurosurgery, University of Rochester, New York, US.   These days, there are multiple papers emerging daily about COVID-19 management, protocols, guidelines, etc. Many research protocols are in play, but c urrent management of COVID-19 still remains supportive .   We were intially told the virus would only seriously affect older ...

By Lauren Koffman DO, MS Months ago, I had plans for a weekend trip with a friend, and despite my multiple reassurances, she cancelled. She had family and friends in China and had deep concerns about the COVID-19 situation evolving. She would tell me about the horrific scenes unfolding as hospitals were overwhelmed and under prepared.  Thinking back two or three months ago, the virus and its casualties on another continent felt like an isolated health crisis. Now, not much time has passed, and COVID-19 is here.  While we as intensivists are ...

By Peter J. Papadakos, MD, FCCM, FAARC As an individual who studies the effect of technology on the practice of medicine, one of the most amazing aspects of this terrible pandemic is how the medical community around the world has joined together as one to share protocols, guidelines and disaster plans with each other. I have a broad network of colleagues in both trauma critical care and neurocritical care, and it’s been outstanding how rapidly we all joined together via e-mail, WhatsApp forums, Zoom conferences and others to share our patient care ...

By Peter J. Papadakos, MD, FCCM, FAARC  As neurocritical care providers, we are confronted with an increased number of individuals who are on blood thinners who are involved in falls during the winter months.  Many will become neurocritical care patients with major subdural hematomas (SDH). Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006.  The mortality associated with acute subdural hematomas has been reported to range from 36-79%, with many survivors not regaining previous levels of functioning, especially after ...

By Erika Bassett, PA-C and Alexis Steinberg, MD  When graduating from a nurse practitioner or physician assistant program, an advance practice provider (APP) can launch themselves into a broad range of specialties and subspecialties.  So why enter the world of neurology, and specifically, why neurocritical care?  Throughout the years, we have seen APPs come and go in our neurological ICUs (NICU). Some enter neurocritical care, learn the nuances of neurological patients, but ultimately leave and transition themselves into a different subspecialty. ...

By Wade Smith, MD, PhD, FNCC I have practiced neurocritical care since 1994. As a fellow in 1993, I engaged in the first case of donation after cardiac death (DCD) in California. This experience, coupled with prior ethics consultation experience as a resident, initiated a career-long interest in organ donation. However, I have had several struggles with the organ procurement process throughout my career, and I am writing this article to ask if others have had similar or dissimilar experiences. A few years ago, I was taking call for ethics when I ...

By Kristi Tucker, MD   Trainees are taught how to communicate with patients and how to behave professionally during patient interactions, but sadly there is much less emphasis placed on effective communication with medical colleagues.  In residency programs, there is little, if any, formal instruction and most of the learning comes from observation.  However, mastery of these skills is an important part of providing consultation services.  Also, notably, two of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies ...

To most, Sunday, April 7, 2019, does not stir up strong emotions or even spark a distant memory. The most popular tweet of the day was “Keep your emotions off the internet” from NFL player JuJu Smith-Schuster; Old Town Road by Lil Nas X jumped 14 spots to No. 1 on the Billboard Hot 100; front page news introduced Candida auris to the public; and in just 24 hours, the Virginia Cavaliers would face the Texas Tech Red Raiders in the NCAA college basketball national championship game. But that day was a big one for Kertisha “Tisha” Brabson and her battle ...

By Brittny Medenwald, PharmD, with acknowledgements to Katleen Chester, PharmD, BCCCP, BCGP and Sunita Dergalust, PharmD, BCPS At 19 years old, my best friend was involved a motorcycle crash. Her severe TBI caused her to stay in the neurocritical care (NCC) unit for 13 days. That experience started my path toward practicing in NCC. As a first-year pharmacy resident, I had a strong desire to be back in the NCC unit. I chose my rotations hoping to manage NCC patients. I was disheartened that despite rotating through various adult and pediatric critical ...

By Jens Nee 1 , Erich Schmutzhard 2 , Raimund Helbok 3   Medical Department, Divison of Nephrology and Intensive Care Medicine - Circulatory Arrest Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany. Department of Neurology, Neurocritical Care, Medical University of Innsbruck, Innsbruck, Austria. Department of Neurology, Neurocritical Care, Medical University of Innsbruck, Innsbruck, Austria.  The first Berlin Circulatory Arrest Symposium took place in November 2019. The goal of this symposium was to discuss ...

By Lauren Koffman, DO and Starane Shepherd, MD Through a partnership with the Rush University Global Health Department, a local nonprofit organization, Community Empowerment and the Feltrex Foundation, Lauren Koffman and Starane Shepherd were welcomed back to Santo Domingo in the Dominican Republic for the second time in August 2019. In 2018, they were the keynote speakers at two events and conducted a half-day workshop for residents, but this year there was a different format. It was an action-packed day in Santo Domingo, with the day starting off ...

There was a trail of blood around the house that led to the basement. He recalls pacing back and forth, trying to take care of a wound. He had blacked out at some point, but he remembers his dog vigorously licking him to get up and answer the door.   Christopher’s memory and speech still aren’t what they used to be, but they’ve been steadily getting better. He turned 21 years old in 2019, and the year has been one of recovery and rebirth. He continues to make constant progress, and he hopes that someday soon he may yet return to his electrician’s apprenticeship ...

The Currents Editorial Board is seeking Stories of Hope submissions for 2020. Stories of Hope tells the stories of patients who have fought their way to recovery and the experiences of their family and/or medical providers. By sharing these stories, we remind each other of what we are all working for and reinforce each other’s resilience and hope. Do you have a story to share? Email your idea as a brief paragraph to krehan@neurocriticalcare.org  with the subject line “Stories of Hope.” #LeadingInsights ​

Emily Grodinsky, MD (left), Edith Graham, MD Neurology Residents (center), David Walker, MD (center), Lauren Koffman, DO, MS Assistant Professor of Neurological Sciences (right) Aaron Smith is the kind of guy you want to be around. He is 20 years old, with maturity and wisdom beyond his years — forged from having lost his mother at a young age. As a result of his loss, he has grown closer to his father and other relatives, and has developed into someone who is “gentle, reserved, hardworking, loving, and hilarious” according to his niece, Tyler.  ...

By Jody Manners Dr. Cherylee Chang was born on Kauai, Hawaii and raised in Los Angeles from an early age. She graduated from Stanford University and completed medical school and her internship year at the University of California at San Diego. She returned to Stanford for her neurology residency. She returned to UCSD to complete an internal medicine residency before traveling to Charlottesville where she completed fellowships in internal medicine critical care and neurological critical care at the University of Virginia. She now serves as the Medical ...

By Amr A. Akl, BMSc, Medical Student, Kuwait University (left); Brouj Miskin, BMSc, Medical Student and Biomedical Sciences MSc Student, Kuwait University (center); Azzah A. Alrashidi, BMSc, Medical Student, Kuwait University (center); Hamad J. AlKhader, BMSc, Medical Student, Kuwait University (right) Stroke is one of the most common healthcare-related diseases in modern day medicine. It is ranked as the second most common cause of death and third cause of disability worldwide. Temporal changes in stroke incidence were reported over the previous ...

By P.J. Papadakos, MD, FCCM, FAARC, Director Critical Care Medicine University of Rochester and police surgeon for the New York State Police  It should be the goal of every neurocritical care unit to provide community health education in conditions such as stroke and traumatic brain injury. One of the most successful ways to reach this goal is to partner and work closely with first responders in your city or town. First responders have a long history of being at the forefront of community education at schools, religious centers, community centers, ...

By Megan E. Barra, PharmD, BCPS, BCCCP, Brian L. Edlow, MD   The efficacy of pharmacologic stimulant therapy in patients with severe traumatic brain injury (TBI) was demonstrated in a 2012 randomized controlled trial that provided Level I evidence for using amantadine to accelerate subacute recovery. 1 Amantadine therapy is now recommended for patients with post-traumatic disorders of consciousness in the 2018 Disorders of Consciousness management guideline. 2  Although prescribing trends in stimulant use after the 2012 amantadine trial have yet ...

By: (from left to right) Sydney Moseley, MD, Hussein Alshammari, MD, Scott Woolf, DO, Fawaz Al-Mufti, MD 1 1 Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College The authors have no actual or potential conflict of interest in relation to the topics discussed in this column. This article may discuss non-FDA approved devices and “off-label” uses. The NCS and Currents do not endorse any particular device. Many neurological insults require close monitoring of intracranial pressure (ICP) and simultaneous ...

By:  Danielle Marut, PharmD (left), Jessica Traeger, PharmD, BCCCP (right) The use of oral factor Xa inhibitors, including rivaroxaban and apixaban, has increased over the last several years. Historically, strategies for the treatment of bleeding patients taking these agents included supportive care (due to the drugs’ short half-lives) or prothrombin complex concentrates (PCC), which are not FDA-approved for the reversal of factor Xa inhibitors. Drug-specific anti-Xa levels for rivaroxaban and apixaban are not FDA-approved or widely available, leading ...

By Bnar Shawki, MD, MBChB, F.I.C.M.S, FIPP, Head of Anesthesia Department in RozhHalat Emergency Hospital, Erbil, Iraq (left); Firas Abdulmajeed, MBChB, Assistant Professor of Critical Care Medicine and Neurology, University of Pittsburgh, USA (right) The population of Iraq is 37,203,000, according to WHO data from 2016. Life expectancy at birth in that year was 68/72 (male/female). The probability of dying between 15 and 60 years of age per 1,000 people in 2016 was 213/133 (male/female). Although we were not able to observe up-to-date accurate published ...

By Ariana Barkley, MD (left); Jonathan Medina-Beckwith DNP, ARNP, NP-C (center); Abhijit Lele, MBBS, MD, MS, FNCS (right)   Neurocritical care educational initiatives for staff at two hospitals in Phnom Penh, Cambodia emerged as a capacity development initiative that native healthcare providers enthusiastically voiced when a survey was conducted in October 2018. The Emergency Neurological Life Support Course (ENLS) serves as a paradigm of organized neurocritical care education and exists on a platform that allows dissemination of educational resources ...

By: Daniel B. Rubin, MD, PhD (left); Henrikas Vaitkevicius, MD (right)   As the field of neurocritical care becomes increasingly recognized as essential to the care of patients with serious neurologic injury, we are necessarily encountering a more complex and diverse patient population. As a consequence, neurointensivists must learn how to use new treatment modalities and understand the risks associated with them. Effective collaboration with other specialists has become increasingly necessary to provide comprehensive and effective care, to keep up ...