COMMENTARY

Being a Neurointensivist

Andrew N. Wilner, MD; Tenbit Emiru, MD, PhD

Disclosures

September 06, 2017

Andrew N. Wilner, MD: Hello. I am Dr Andrew Wilner, and today I am at Hennepin County Medical Center in Minneapolis, Minnesota, with Dr Tenbit Emiru, chief of neurology and director of neurocritical care here. Welcome, Dr Emiru.

Tenbit Emiru, MD, PhD: Thank you.

Dr Wilner: The neurology intensive care unit (ICU) is a distinct service. What are the special needs of neurology patients who require ICU services, and which special skills must neuro ICU physicians possess in order to take care of them?

Dr Emiru: The patients in the neuro ICU have life-threatening neurologic and neurosurgical conditions such as very large strokes, bleeding in the brain, respiratory failure from a neuromuscular disease, brain tumors, brain trauma, and spinal cord injury. Neurointensivists must be experts in acute brain and spinal cord disorders, the impact of these disorders on the other organ systems, and the impact of other medical illnesses on the brain and spinal cord. They also have to be knowledgeable about the management of most of the conditions we encounter in the ICU, including hemodynamic instability; respiratory failure; infections; and liver, kidney, and other organ failures.

Dr Wilner: How does one learn to become a neurointensivist?

Dr Emiru: There is a neuro critical care fellowship that is accredited by the United Council for Neurologic Subspecialties. The accredited fellowships are 2 years long. You can go into this fellowship with a background in neurology, after having completed a neurology residency. You also can go into it after completing internal medicine, emergency medicine, anesthesiology, or neurosurgical residencies. This subspecialty is not limited to neurologists; often, our colleagues come from an internal medicine background. Becoming a neurointensivist is accessible to a variety of physicians with different backgrounds.

Dr Wilner: You must work very closely with the neurosurgeons in this setting, and the ICU used to be primarily their territory. How does that go?

Dr Emiru: A long time ago, the neurointensivist who was my mentor told me that neuro critical care was started by a neurologist who took care of patients with respiratory failure caused by neurologic disorders. Then we neurologists dropped the ball and let others take over the care of the critically ill neurologic and neurosurgical patients. It is true that neurosurgeons have been the predominant caregivers in the neuro ICU; therefore, we work with them very closely. Indeed, most of our patients are also receiving neurosurgical care, especially in units that have a lot of trauma patients. A successful neurocritical care program requires a close collaboration with a variety of physicians, including neurosurgeons, trauma surgeons, pulmonary critical care physicians, and cardiologists. It is truly a multidisciplinary service.

Dr Wilner: Why did you choose to be a neuro critical care physician?

Dr Emiru: As you may know, the first year of a neurology residency is, essentially, all internal medicine. When I began my residency, I was rotating through different hospitals on my internal medicine rotations and I found that I quite enjoyed this area. I loved learning about management of infections and pneumonias, renal failure, and heart failure, and I found those problems to be very interesting, knowing that I was going to spend the next 3 years of my neuro residency just learning about the brain. As I moved on into the neurology part of my training, I found ways in which I could incorporate the internal medicine training I had during my first year of residency. When I had the opportunity to rotate through a neuro ICU, everything came together for me. This was where I could bring some of my internal medicine interests into taking care of a neurologically ill patient.

In addition to that, I like the way the day is structured in the neuro ICU, or in any ICU. Rounds are often attended by the intensivists, multiple different specialty residents, the physical and occupational therapy folks, the nutritionist, the dietician, the palliative care medicine specialist, and many other consultants, all coming together to take care of one patient. This often also includes the bedside nurse, the charge nurse of the ICU, and the pharmacist, who is also an integral part of that team. That large team and the multidisciplinary approach enticed me to become an intensivist. The only choice I had at that point was to become a neurointensivist. Everything came together for me there.

Dr Wilner: As a board-certified internist and neurologist, I believe that the care of the whole patient is a very attractive proposition. Do we have any modern tools in the neuro ICU? Electroencephalography (EEG) is an old tool, but are we using it differently? Or hypothermia, for example. Are these helpful?

Dr Emiru: Absolutely. We rely on many monitoring techniques. EEG is one of them, and even though it has been around for about 75 years or so, it is still a very useful tool, especially in the neuro ICU. We use it for more than detecting seizures. Most of our comatose patients will have an EEG at some point. That continues to be an integral part of neuro ICU monitoring. We also use the routine monitoring modalities that are used in other ICUs: the continuous blood pressure monitoring, ventilators, ventriculostomies, continuous intracranial pressure monitors, PbO2 monitors (or what we call brain tissue oxygenation monitors), and Licox® monitors that measure the brain pressure oxygenation and brain temperature. These are new multimodality monitors. We also commonly use cardiac output monitors. We basically use everything that is used in other ICUs plus others for the brain.

Dr Wilner: Dr Emiru, it sounds as though the neuro ICU is a very exciting place to work and a great place to be a patient if you have a life-threatening neurologic disease. Thank you very much for sharing your experience with Medscape.

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