Leading Insights

By Sachin Agarwal, MD, MPH 1 (pictured); Alex Presciutti, MA 1 ; Deepti Anbarasan, MD 2 ; Linda S. Golding, MA BCC 3 ; and Marykay Pavol PhD 4 1 Division of Neurocritical Care, Department of Neurology 2 Division of Epilepsy, Department of Neurology 3 Pastoral Services, New York Presbyterian Hospital 4 Division of Neuropsychology, Department of Neurology Columbia University College of Physicians & Surgeons, New York Presbyterian Hospital Goals and Vision of the Program Life after cardiac arrest is like “walking around without a net.” 1 ...

By Andrew M. Naidech, MD, MSPH Randomized clinical trials (RCTs) are a keystone of modern medicine and considered the gold standard for determining if an intervention produces better patient outcomes in a variety of critical care and acute care settings. While observational data (e.g., registries, cohorts, databases) are valuable and advance knowledge, there are often measured and unmeasured confounders between the intervention and the patient outcome, such as uncontrolled factors that affect both the cause and apparent effect of an intervention. RCTs, ...

By Audrey Paulson, DNP Electroencephalograms (EEGs) are usually placed on the patient by the EEG tech, and the process takes at least 30 minutes. It is then read by the neurologist, occasionally in real time but often after the fact. This results in the diagnosis of a seizure long after the seizure is over. Nursing typically does not play a huge role in this process except to alert the physician if they see any type of seizure activity. One FDA-approved product available on the market is Ceribell™. It is a device that can change how nursing functions ...

By Chandrika R Garner, MD, FASE 1 (not pictured); Rohesh J Fernando, MD 1 (left); Aarti Sarwal, MD, FNCS, FAAN 2 (center); and Jose L. Diaz-Gomez, MD, FCCM, FASE 3 (right) Wake Forest School of Medicine, Department of Anesthesiology, Section on Cardiac Anesthesiology Wake Forest School of Medicine, Department of Neurology, Section on Neurocritical Care Mayo Clinic, Jacksonville, Fla., Departments of Critical Care Medicine, Anesthesiology & Perioperative Medicine, and Neurologic Surgery The use of point of care ultrasound (POCUS) or focused ...

By Katherine Salisbury (left) and Aarti Sarwal, MD (right) Traumatic brain injuries (TBI) are a major cause of hospitalization and death in the United States, with an estimated 1.7 million people sustaining TBIs annually and 52,000 of those dying from TBI-related factors 1 . While the hemodynamic and neurological responses depend upon severity, patient risk for significant injury does not conclude after primary impact. Modern TBI management centers around the need to reduce risk associated with secondary brain injuries resulting from a variety of ...

By Fawaz Al-Mufti, MD 1 ; Francisco Gomez, MD 2 ; Corey Scurlock, MD, MBA 1 ; and Chad Cole, MD, MSc 1 Westchester Medical Center at New York Medical College University of Pennsylvania Editor’s Note : 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. NCS and Currents do not endorse any particular device.  As the population ages, critical care needs will increase proportionally and health systems will need ...

By (from left to right) Simona Ferioli, MD; Brandon Foreman, MD; and Kelly Rath, ACNP, University of Cincinnati, Department of Neurocritical Care Section Editor : Michael Reznik, MD, Brown University, Alpert Medical School, Rhode Island Hospital It was the Christmas season, which for Mary and Mark meant a time for reflection and making plans. Mark would retire, they agreed, while Mary would continue working her job as an operations specialist at Delta. They would continue to travel and enjoy living the American dream. And why not? Mary had just ...

Contributor: Leighton Mohl, MD, Neurology Resident University of Minnesota (left); Contributor: Christopher Streib, MD, MS, Assistant Professor of Neurology, Program Director, Vascular Neurology Fellowship Stroke Director, University of Minnesota (center); Section Editor: Michael Reznik, MD, Assistant Professor of Neurology & Neurosurgery, Alpert Medical School, Brown University/Rhode Island Hospital (right) After finishing work and returning home one day, Sten Anderson was on his way to the gym — “dreading working out, as most people do,” he recalls, ...

By Francisco Gomez (left), MD, Mohammad El-Ghanem (center), MD and Fawaz Al-Mufti, MD (right) 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. A significant portion of critically ill patients admitted to the ICU will eventually exhibit severe loss of strength and muscle mass, a phenomenon which has been termed ICU Acquired Weakness (ICUAW). ICUAW ...

By Caroline Der Nigoghossan, PharmD, BCCCP, and Shivani Ghoshal, MD (pictured) Intravenous crystalloid administration is one of the most common interventions performed in critically ill patients. However, during the last decade, a growing body of literature suggests potential harm with 0.9 percent sodium chloride (also known as normal saline) and its associated hyperchloremia, most notably in the critically ill. In actuality, the adjective “normal” is a misnomer; 0.9 percent sodium chloride solution contains a supraphysiologic chloride concentration ...

By Jennifer A. Kim While career advice is often geared toward the training and early job stages, the roadmap to success throughout the remainder of one’s career is often not much clearer. Here, Dr. Wendy Wright, director of the Neuroscience Intensive Care Unit at Emory University and chair of the Fellow of Neurocritical Care Committee, provides insight into making the most of your mid-career, getting promoted, taking on leadership roles and becoming a Fellow of Neurocritical Care (FNCS). Even for those of us early in our careers, Dr. Wright provides ...

By Jennifer A. Kim Securing one’s first job as an attending is an exciting time! The first few years of being an attending form a crucial foundation for success throughout the remainder of your career. For those who choose to enter academics, we interviewed Dr. Thomas Bleck, founding chair of the Neurocritical Care Society and director of clinical neurophysiology at Rush University Medical Center; Dr. Jonathan Rosand, chief of neurocritical care and emergency neurology at Massachusetts General Hospital; and Dr. Jose Suarez, director of neurosciences ...

By Jennifer A. Kim After putting in so many years of studying, then blood, sweat and tears into residency and fellowship, it’s finally time to apply for a job! But, having only experienced life transitions in applications and matches, the job search process is daunting. Despite having extensive training, the logistics and “business” of job hunting can feel mysterious. To help alleviate those anxieties, Dr. Karen Hirsch, medical director of neurocritiacal care at Stanford, shares her advice. (Note: The interview has been paraphrased for brevity.) ...

By Anand Venkatraman and Alexis Steinberg Applying for your fellowship can be one of the most stressful times during residency. If it weren’t hard enough to have to navigate a busy program, family life and keeping up with your reading, now you have to send out emails, set up interviews and book flights around the country. The process of fellowship applications has certainly become easier since NCC joined SF Match. A match provides structure, while also taking out the stress of deciding when to accept an offer. That said, it is still a process that ...

By Jennifer A. Kim In this issue of Currents, I am very excited to share a four-article series offering career advice, from applying to fellowship to becoming a leader in neurocritical care. With the assistance of guest writers Dr. Anand Venkatraman, fellow at Massachusetts General Hospital, and Dr. Alexis Steinberg, resident at University of Pittsburgh Medical Center, we have had the great opportunity to interview a few of the leaders in our field, who offer advice to physicians in training and throughout their careers. 1. Forging Ahead: Tips ...

By Piotr Tekiela (left), Lauren Ottenhoff (center) and Michael Schneck (right), Loyola University Chicago, Stritch School of Medicine With the steady rise of high acuity complex cases, physicians are increasingly finding themselves navigating the legal system about decisional capacity. Decision-making authority can vary in the United States by individual state (as discussed in the one of the recent ethics papers in Currents) but can also vary internationally, depending on resources, societal norms and community relationships. The areas of consent, ...

By Briana Witherspoon, DNP, ACNP, and Karen March, MN, RN, CCRN In 2012, the American Board of Internal Medicine (ABIM) Foundation partnered with Consumer Reports to create Choosing Wisely®, an initiative focused on reducing the number of unnecessary tests and procedures performed during a hospital admission or clinic appointment. The overall goal of Choosing Wisely® is to encourage dialogue between patients, families and healthcare staff to ensure that patients are receiving care that is not only evidenced-based but also a necessary component of their ...

By Alexandra Reynolds, MD (left), and Michael Reznik, MD (right) In 2004, Caroline (name changed for privacy), a 19-year-old Bulgarian-American woman, was hit by a car while crossing the street in Manhattan, suffering a severe traumatic brain injury as a result. She had cerebral edema on presentation to the hospital, along with a large subdural hematoma, which required an emergent left hemicraniectomy and evacuation. Postoperatively she was kept intubated and sedated in Cornell’s Neuro ICU, and she proceeded to have a prolonged recovery. Despite her ...

By Francisco Gomez, MD, Jessy Walla, MD, and Fawaz Al-Mufti, MD  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. NCS and Cur-rents do not endorse any particular device. With the recent expansion in the endovascular treatment window for ischemic stroke, the need for improved triaging on all levels has become most apparent. In order to maximize benefit for our patients, the utmost celerity and accuracy must be sought. ...

By Gabriel Prada, MD 1 (left); Jose L. Diaz-Gomez, MD 1,2 ; and Aarti Sarwal, MD 3 (right) Affiliations: 1 Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida; 2 Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; 2 Departments of Neurology and Critical Care, Wake Forest School of Medicine, Winston Salem, North Carolina. Point-of-care ultrasound (POCUS) is ultrasonography performed by the provider in real time at the bedside to help clinical decision making. POCUS is increasingly being implemented ...

By Catherine Albin, MD, and Deepa Malaiyandi, MD Simulation in critical care training has exploded over the last decade, but its application to neurocritical care has been met with some skepticism. High-fidelity simulation aims to create safe learning environments that mimic real-life scenarios. This involves accounting for the actions or elements to be learned, the interactions between them, and key environmental factors.  Employing high-fidelity simulation to train physicians in the management of neurological illness is not a new concept. It dates ...

Section Editor: Michael Reznik, MD Contributor: Aleksandra Yakhkind, MD, Neurology Resident Alpert Medical School, Brown University/Rhode Island Hospital It is late morning on New Year’s Day, and Kathi has just left her home to go to the local supermarket, where she works as a cashier. She had just spent the previous evening together with her family celebrating New Year’s, reminiscing about 2017 and looking forward to 2018. Kathi is 19, works two jobs and eventually hopes to go to nursing school — a big deal for her family, who are from Guatemala. ...

By Pedro Kurtz, MD, PhD Paulo Niemeyer State Brain Institute (IECPN) was inaugurated in 2013 as Brazil’s first public hospital/institute entirely dedicated to the treatment of patients with neurological and neurosurgical diseases, and to research and teaching in the field. The hospital’s infrastructure includes state-of-the-art operating rooms, two MRIs (including one inside the OR), two CT scans (one “mobile” for brain CT of severe patients), a neurovascular laboratory and a 44-bed neuro ICU, including eight beds of pediatric neuro ICU. Its privileged ...

By PJ Papadakos, MD, FCCM, FAARC Over the last decade, electronic medical records (EMRs) have rapidly become the adapted documentation standard in part due to federal and insurance regulations. Hospitals and practices have spent billions of dollars on these systems and the hardware needed to support them. Along with the rapid access to data and automated systems for documentation and billing have come unforeseen problems. Caregivers and patients have noted that there is now more interaction with the screen than with patients and families. A term, ...

By Ryan Hakimi, DO, MS (Division of Neurology, Department of Medicine, University of South Carolina-Greenville Health System, Greenville, SC) on behalf of the American Society of Neuroimaging; David S Liebeskind, MD (Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA); Tatjana Rundek, MD, PhD (Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL); and Andrei V. Alexandrov, MD (Department of Neurology, University of Tennessee Health Science Center, Memphis, TN) The mortality rate associated ...