Neurocritical care?

[Interveno]

Hey guys,
Is it worth it to do a one year critical care after CCM?

I hope someone shares any feedback about the specialty.

---

Members don't see this ad.

 

[deleted547339]

Hey guys,
Is it worth it to do a one year critical care after CCM?

I hope someone shares any feedback about the specialty.

Ha. No.

 

[Interveno]

Ha. No.

That's easy answer. Lol

 

[aafisahar]

maintaing a rock garden = neuro critical care

 

[deleted547339]

maintaing a rock garden = neuro critical care

With bad vent management.

 

[CCM-MD]

Salt overload everyone. Poor overall critical care and medical management. Heavy reliance on medical consultants.

 

[Interveno]

With bad vent management.

Wow!
I never thought it would be that bad to pursue it.
Then, what is the point of this fellowship?

 

[aafisahar]

Wow!
I never thought it would be that bad to pursue it.
Then, what is the point of this fellowship?

Cheap labor

 

[gro2001]

I am a Neurocritical care fellow. I don't think this will change anyone's mind, but here is my perspective.

First of all, to answer your question about whether it is worth it to add a year of Neurocrit on top of CCM: I don't know. Probably not. There is probably going to be an increase in the demand for Neurocrit trained folks over the next few years as more places start/expand their mechanical thrombectomy capabilities for large vessel strokes. How exactly this will translate into specific job opportunities that would not be available without NCC training is unclear. I'd say do it if you are interested in working with TBI, SAH, or cardiac arrest prognostication, otherwise it would probably be not worth it. Even then, it would be a year of lost attending income, so you could say this would cost you like $250k in life time earnings, so that's something to weigh in the pros/cons.

The joke about NSICU being an ICU with salt overload and poor general critical care management has a grain of truth to it. But so does the converse of other ICUs having terrible neuro care. And unfortunately the actual patient impact is not likely in favor of CCM in this comparison (ie my patients are relatively healthy from the neck down, so my poor vent management/poor Crit Care doesn't do that much harm; but you end up withdrawing care prematurely on post cardiac arrest patients because you didn't recognize NCSE or misunderstood what myoclonus means in that setting/can't differentiate it from Lance Adams syndrome, or failed to appreciate the significance of the location of the insult to prognostication, etc etc). At my institution we do consults in other ICUs for cardiac arrest prognostication and some other issues like ICP management, and well... let's just say CCM folks don't know what they don't know.

Jokes aside, this whole thing about Neurocrit being a 'vegetable garden' is kinda outdated and shows a lack of understanding of the literature on long term cognitive outcomes. Poor long term neurologic outcomes are a lot more common in the general ICU population than a lot of CCM practitioners seem to think, and are a lot better in the neuro world than you'd think (mostly have to look out far enough; for example, most survivors of out of hospital cardiac arrest actually do great neurologically if you follow them out for a year, and most of the bad outcome is attributable to mRS = 6 (ie death)). Difference is, we actually target our therapy for that, which is a lot more patient centered IMHO.

Anyway, most good fellowships both in CCM and Neurocrit are multidisciplinary with multiple months of either spent in other ICUs (CCM fellows at some institutions spend several months in the neuro ICU, Neurocrit fellows spend several months in the MICU/SICU). Some of the comments on this thread make me think that maybe these folks didn't get as well rounded a training as would be considered good these days, which is unfortunate. But hey, nobody is perfect.

 

[Interveno]

I am a Neurocritical care fellow. I don't think this will change anyone's mind, but here is my perspective.

First of all, to answer your question about whether it is worth it to add a year of Neurocrit on top of CCM: I don't know. Probably not. There is probably going to be an increase in the demand for Neurocrit trained folks over the next few years as more places start/expand their mechanical thrombectomy capabilities for large vessel strokes. How exactly this will translate into specific job opportunities that would not be available without NCC training is unclear. I'd say do it if you are interested in working with TBI, SAH, or cardiac arrest prognostication, otherwise it would probably be not worth it. Even then, it would be a year of lost attending income, so you could say this would cost you like $250k in life time earnings, so that's something to weigh in the pros/cons.

The joke about NSICU being an ICU with salt overload and poor general critical care management has a grain of truth to it. But so does the converse of other ICUs having terrible neuro care. And unfortunately the actual patient impact is not likely in favor of CCM in this comparison (ie my patients are relatively healthy from the neck down, so my poor vent management/poor Crit Care doesn't do that much harm; but you end up withdrawing care prematurely on post cardiac arrest patients because you didn't recognize NCSE or misunderstood what myoclonus means in that setting/can't differentiate it from Lance Adams syndrome, or failed to appreciate the significance of the location of the insult to prognostication, etc etc). At my institution we do consults in other ICUs for cardiac arrest prognostication and some other issues like ICP management, and well... let's just say CCM folks don't know what they don't know.

Jokes aside, this whole thing about Neurocrit being a 'vegetable garden' is kinda outdated and shows a lack of understanding of the literature on long term cognitive outcomes. Poor long term neurologic outcomes are a lot more common in the general ICU population than a lot of CCM practitioners seem to think, and are a lot better in the neuro world than you'd think (mostly have to look out far enough; for example, most survivors of out of hospital cardiac arrest actually do great neurologically if you follow them out for a year, and most of the bad outcome is attributable to mRS = 6 (ie death)). Difference is, we actually target our therapy for that, which is a lot more patient centered IMHO.

Anyway, most good fellowships both in CCM and Neurocrit are multidisciplinary with multiple months of either spent in other ICUs (CCM fellows at some institutions spend several months in the neuro ICU, Neurocrit fellows spend several months in the MICU/SICU). Some of the comments on this thread make me think that maybe these folks didn't get as well rounded a training as would be considered good these days, which is unfortunate. But hey, nobody is perfect.

This is really helpful. Is there is interventional aspect in NCC other than the usual procedures in CCM. For example, mechanical thrombectomy?

 

[bigtuna]

Had to look up lance adams syndrome. Less than 150 cases reported - I don't feel so bad

 

[deleted547339]

I am a Neurocritical care fellow. I don't think this will change anyone's mind, but here is my perspective.

First of all, to answer your question about whether it is worth it to add a year of Neurocrit on top of CCM: I don't know. Probably not. There is probably going to be an increase in the demand for Neurocrit trained folks over the next few years as more places start/expand their mechanical thrombectomy capabilities for large vessel strokes. How exactly this will translate into specific job opportunities that would not be available without NCC training is unclear. I'd say do it if you are interested in working with TBI, SAH, or cardiac arrest prognostication, otherwise it would probably be not worth it. Even then, it would be a year of lost attending income, so you could say this would cost you like $250k in life time earnings, so that's something to weigh in the pros/cons.

The joke about NSICU being an ICU with salt overload and poor general critical care management has a grain of truth to it. But so does the converse of other ICUs having terrible neuro care. And unfortunately the actual patient impact is not likely in favor of CCM in this comparison (ie my patients are relatively healthy from the neck down, so my poor vent management/poor Crit Care doesn't do that much harm; but you end up withdrawing care prematurely on post cardiac arrest patients because you didn't recognize NCSE or misunderstood what myoclonus means in that setting/can't differentiate it from Lance Adams syndrome, or failed to appreciate the significance of the location of the insult to prognostication, etc etc). At my institution we do consults in other ICUs for cardiac arrest prognostication and some other issues like ICP management, and well... let's just say CCM folks don't know what they don't know.

Jokes aside, this whole thing about Neurocrit being a 'vegetable garden' is kinda outdated and shows a lack of understanding of the literature on long term cognitive outcomes. Poor long term neurologic outcomes are a lot more common in the general ICU population than a lot of CCM practitioners seem to think, and are a lot better in the neuro world than you'd think (mostly have to look out far enough; for example, most survivors of out of hospital cardiac arrest actually do great neurologically if you follow them out for a year, and most of the bad outcome is attributable to mRS = 6 (ie death)). Difference is, we actually target our therapy for that, which is a lot more patient centered IMHO.

Anyway, most good fellowships both in CCM and Neurocrit are multidisciplinary with multiple months of either spent in other ICUs (CCM fellows at some institutions spend several months in the neuro ICU, Neurocrit fellows spend several months in the MICU/SICU). Some of the comments on this thread make me think that maybe these folks didn't get as well rounded a training as would be considered good these days, which is unfortunate. But hey, nobody is perfect.

Please don’t take this personally (based on your previous history on the board, I’m sure you won’t), but I have a big problem with neuro-ccm (or any subspecialty icu board). I really believe ccm should be an integrated board. Are there specific intricacies of NICU, or CTICU, or MICU? Sure. But vents are vents, antibiotics are antibiotics and transfusions are transfusions. Do you give more antibiotics in the Micu, more hypertonic in the nicu, more blood in the SICU and do more TEEs in the CTICU? Of course. But I think a good CCM program should train you to do any of that. I think that if you want to work in a CTICU, you should be able to spend your second year electives doing CT-OR, TEE and a couple extra months in a CTICU and CCU. If you’re going to do Neuro ICU, you should be able to spend a couple extra months in the NICU, a few weeks with neuro-rads and doing EEG, etc. Will there be some on the job learning as faculty? Of course, but that’s true regardless. Spending an extra year for a merit badge is a huge money suck that seems to not have the learners interest above the hospital’s goals. I think the same for the rare CT-ICU superfellowships.

 

[Hamhock]

(mostly have to look out far enough; for example, most survivors of out of hospital cardiac arrest actually do great neurologically if you follow them out for a year, and most of the bad outcome is attributable to mRS = 6 (ie death)).

I have many thoughts on your response. Yet, I seem unable to reply without first considering this claim further.

Are you able to provide a reference for this? On what data are you making this assertion? Is your statement incorporating survivorship bias and other selection biases?

{note, I acknowledge there are some premature transitions to "comfort care" that also alter data}

Thanks, HH

 

[Interveno]

Will it be valuable to do tele NICU to expand your practice since you deal with cases such acute stroke to triage for thrombectomy? I think CCM intensivist cannot authorize this.

 

[gro2001]

Had to look up lance adams syndrome. Less than 150 cases reported - I don't feel so bad

It's actually not that uncommon. Just often not recognized/confused with myoclonic status epilepticus (previously believed to be a 100% specific sign of bad outcome after cardiac arrest; now believed to have a false positive rate of as high as 20%. So if you use it to withdraw care... as I said, you don't know what you don't know).

 

[gro2001]

Please don’t take this personally (based on your previous history on the board, I’m sure you won’t), but I have a big problem with neuro-ccm (or any subspecialty icu board). I really believe ccm should be an integrated board. Are there specific intricacies of NICU, or CTICU, or MICU? Sure. But vents are vents, antibiotics are antibiotics and transfusions are transfusions. Do you give more antibiotics in the Micu, more hypertonic in the nicu, more blood in the SICU and do more TEEs in the CTICU? Of course. But I think a good CCM program should train you to do any of that. I think that if you want to work in a CTICU, you should be able to spend your second year electives doing CT-OR, TEE and a couple extra months in a CTICU and CCU. If you’re going to do Neuro ICU, you should be able to spend a couple extra months in the NICU, a few weeks with neuro-rads and doing EEG, etc. Will there be some on the job learning as faculty? Of course, but that’s true regardless. Spending an extra year for a merit badge is a huge money suck that seems to not have the learners interest above the hospital’s goals. I think the same for the rare CT-ICU superfellowships.

I agree with you. I think you probably need more than a couple of extra months to learn the intricacies of some of the more specialized ICUs (like the neuro ICU), but in principal I agree with you. I think ideally something like the first year should be spent learning foundations of critical care, and the second year finding your niche/doing electives tailored to what you want your career to be like.

I also agree that an additional year of Neurocrit training for most CCM people doesn't make sense (which is what I also said in the first paragraph of my post).

 

[gro2001]

I have many thoughts on your response. Yet, I seem unable to reply without first considering this claim further.

Are you able to provide a reference for this? On what data are you making this assertion? Is your statement incorporating survivorship bias and other selection biases?

{note, I acknowledge there are some premature transitions to "comfort care" that also alter data}

Thanks, HH

Well, first of all the cardiac arrest literature is a mess, for many reason. The ideal study where we don't withdraw on anyone for months and follow them up for more than a year out from discharge doesn't exist, and will probably never exist.

However, this is what we find in the best studies:

Consider the Nielsen et all 2013 TTM paper (the 33 vs 36 one). I'd start with that because it reflects what I feel is standard practice at most good institutions for out of hospital cardiac arrest of presumed cardiac cause (not just shockable rhythms). At my institution we cool to 33 unless there is a good contraindication, in which case we will cool to 36.

Specifically look at table 3, which breaks down outcomes on follow up at 180 days. CPC category 1 is solidly good (conscious, alert, able to work, might have mild deficits). CPC 5 is death/brain death.

42% are CPC 1 (able to work)
49% are CPC 5 (dead/brain dead)
Only 10% are in between

This is replicated in recent studies. Nakstad et al in Resususcitation in 2020: CPC 1-2 was 49% at 6 months and 42% at 5 years.

This should make us optimistic.

Now if you want to feel a little anxious consider the Perman et al paper from CCM in 2012. They looked back at patients who had documented "poor prognosis" (mostly by CCM attendings) but on whom families refused to withdraw care. Around 20% ended up having good outcome (CPC 1). Now, this was mostly because people were prognosticating way too early, which I thought we've learned in the last 8 years not to do. Then again, I had a discussion just recently with someone on this forum who was insisting that they could accurately prognosticate at 24 hours.

I don't know, maybe I just have a different value system, but it seems to me if 20% of people I was willing to withdraw on ended up having good enough neurological outcomes to go back to work, I'd start to worry that maybe the 'vegetable farmers' knew something I didn't.

 

[gro2001]

This is really helpful. Is there is interventional aspect in NCC other than the usual procedures in CCM. For example, mechanical thrombectomy?

There really isn't, it's mostly typical ICU procedures. A small subset of Neurocrit people end up also doing an interventional fellowship, but it's not like there is an easy way to combine that practice without splitting time. You can't be available to both be in the ICU and also to be on call for thrombectomy. Most people practice either/or. Interventional can make more money, but life is better for intensivists.

Another small subset of neurointensivists due some invasive stuff like insert EVDs, but this is not common.

 

[CCM-MD]

There really isn't, it's mostly typical ICU procedures. A small subset of Neurocrit people end up also doing an interventional fellowship, but it's not like there is an easy way to combine that practice without splitting time. You can't be available to both be in the ICU and also to be on call for thrombectomy. Most people practice either/or. Interventional can make more money, but life is better for intensivists.

Another small subset of neurointensivists due some invasive stuff like insert EVDs, but this is not common.

OP is likely not a neurologist since he is asking about adding neuroCC to CCM. Can’t do neuroIR if you’re not a neurologist

 

[Interveno]

OP is likely not a neurologist since he is asking about adding neuroCC to CCM. Can’t do neuroIR if you’re not a neurologist

I see.
So in summary, this specialty makes more sense for a neurologist who wants to practice in ICU; has no potential increment on income for someone who is CCM specialist; and no way to become a neuro IR if you are an IM-CCM based specialist.

 

[CCM-MD]

I see.
So in summary, this specialty makes more sense for a neurologist who wants to practice in ICU; has no potential increment on income for someone who is CCM specialist; and no way to become a neuro IR if you are an IM-CCM based specialist.

Maybe. Most non-academic institutions don’t have dedicated neuro ICUs. Those that do often primarily use it as a post op neurosurgical parking lot. I work at a tertiary community hospital that’s a stroke center. We have a “neuro ICU” too. It’s nothing like the one I trained in and it probably doesn’t warrant a neurointensivist. That reminds me about the other thing I hate about the neuro ICU: neurosurgeons.

 

[gro2001]

OP is likely not a neurologist since he is asking about adding neuroCC to CCM. Can’t do neuroIR if you’re not a neurologist

Correct. You'd have to be a neurologist, neurosurgeon, or radiologist.

I meant some of the folks with a neuro background do both, but very few for the reasons I mentioned above.

 

[aafisahar]

Well, first of all the cardiac arrest literature is a mess, for many reason. The ideal study where we don't withdraw on anyone for months and follow them up for more than a year out from discharge doesn't exist, and will probably never exist.

However, this is what we find in the best studies:

Consider the Nielsen et all 2013 TTM paper (the 33 vs 36 one). I'd start with that because it reflects what I feel is standard practice at most good institutions for out of hospital cardiac arrest of presumed cardiac cause (not just shockable rhythms). At my institution we cool to 33 unless there is a good contraindication, in which case we will cool to 36.

Specifically look at table 3, which breaks down outcomes on follow up at 180 days. CPC category 1 is solidly good (conscious, alert, able to work, might have mild deficits). CPC 5 is death/brain death.

42% are CPC 1 (able to work)
49% are CPC 5 (dead/brain dead)
Only 10% are in between

This is replicated in recent studies. Nakstad et al in Resususcitation in 2020: CPC 1-2 was 49% at 6 months and 42% at 5 years.

This should make us optimistic.

Now if you want to feel a little anxious consider the Perman et al paper from CCM in 2012. They looked back at patients who had documented "poor prognosis" (mostly by CCM attendings) but on whom families refused to withdraw care. Around 20% ended up having good outcome (CPC 1). Now, this was mostly because people were prognosticating way too early, which I thought we've learned in the last 8 years not to do. Then again, I had a discussion just recently with someone on this forum who was insisting that they could accurately prognosticate at 24 hours.

I don't know, maybe I just have a different value system, but it seems to me if 20% of people I was willing to withdraw on ended up having good enough neurological outcomes to go back to work, I'd start to worry that maybe the 'vegetable farmers' knew something I didn't.

Perman, et al, 2012 -> retrospective review of 60 patients. mean age 58. Didn't really comment on the survivors etiology. We all know that cardiac cause of cardiac arrest (eg VT/VF) carries a much better prognosis than PEA or asystole. Moreover, this study is very nebulous on how it defined "pre TH and post TH" prognostication. We all know grandma who was getting cpr by her husband (who had to stop to take puffs of oxygen from his O2 tank) for 20 minutes before EMS arrived, who has ESRD and missed dialysis 5 days in a row, along with severe AS, metastatic NSCLC, is going to have a poor prognosis vs the 55 year old who had a witnessed VF and out-of-hospital shock revealing anterior STEMI. Without breaking it down, we have no idea who was prognosticated on.

In Nakstad -> re-iterates this in the discussion " The strongest pre-hospital predictors for poor outcome were unwitnessed arrest, non-shockable rhythms, and no-bystander CPR, with FPRs from 0.05 to 0.13, whereas time to ROSC > 25 min had FPR 0.32 (0.240.42) " Nothing we don't know. If you have a shockable rhythm, you do better. Again, look at the characteristics on who has a good outcome -> VT/VF, shockable, cath lab, bystander CPR. Sure, you can do all this ancillary testing to see which gomer is going to have a good outcome that otherwise might not have, but in reality, I don't think we are missing much in the US where we have aggressive families and huge amounts of medical liability. I can count on one hand on the number of times I was surprised that an arrest that was a goner turned out to have a good outcome. It's just not that common.

We all hear the mantra -> "they aren't dead until they are warm and dead".

 

[Radetzky]

It's actually not that uncommon. Just often not recognized/confused with myoclonic status epilepticus (previously believed to be a 100% specific sign of bad outcome after cardiac arrest; now believed to have a false positive rate of as high as 20%. So if you use it to withdraw care... as I said, you don't know what you don't know).

People often confuse Myoclonic jerks with Myoclonic status. But are you suggesting Myoclonic Status may have a 20% FPR??

Any literature on that you can provide (because I’m curious to know more).

 

[gro2001]

Perman, et al, 2012 -> retrospective review of 60 patients. mean age 58. Didn't really comment on the survivors etiology. We all know that cardiac cause of cardiac arrest (eg VT/VF) carries a much better prognosis than PEA or asystole. Moreover, this study is very nebulous on how it defined "pre TH and post TH" prognostication. We all know grandma who was getting cpr by her husband (who had to stop to take puffs of oxygen from his O2 tank) for 20 minutes before EMS arrived, who has ESRD and missed dialysis 5 days in a row, along with severe AS, metastatic NSCLC, is going to have a poor prognosis vs the 55 year old who had a witnessed VF and out-of-hospital shock revealing anterior STEMI. Without breaking it down, we have no idea who was prognosticated on.

In Nakstad -> re-iterates this in the discussion " The strongest pre-hospital predictors for poor outcome were unwitnessed arrest, non-shockable rhythms, and no-bystander CPR, with FPRs from 0.05 to 0.13, whereas time to ROSC > 25 min had FPR 0.32 (0.240.42) " Nothing we don't know. If you have a shockable rhythm, you do better. Again, look at the characteristics on who has a good outcome -> VT/VF, shockable, cath lab, bystander CPR. Sure, you can do all this ancillary testing to see which gomer is going to have a good outcome that otherwise might not have, but in reality, I don't think we are missing much in the US where we have aggressive families and huge amounts of medical liability. I can count on one hand on the number of times I was surprised that an arrest that was a goner turned out to have a good outcome. It's just not that common.

We all hear the mantra -> "they aren't dead until they are warm and dead".

Ok, clearly you are as unteachable as the folks in the Perman paper, who had a 20% good outcome rate among patients they recommended to withdraw on. Must be nice to be so confident.

We have a literature base where out of the survivors 45% end up walking out of the hospital, 45% end up dying, and like only 10% survive with bad outcome. Where is the somewhat sick middle? We are either predicting almost everyone perfectly and everyone is choosing to withdraw accordingly (I doubt that's the case), or we are withdrawing on a whole bunch of people who we shouldn't. The study that would prove this can't exist, cause we would have to not withdraw on anyone for a long time to see what happens. When it happens accidentally, like in the Perman paper, we see a 20% error rate. I don't know what to tell you. This should make you uncomfortable with the degree of your certainty.

 

[gro2001]

People often confuse Myoclonic jerks with Myoclonic status. But are you suggesting Myoclonic Status may have a 20% FPR??

Any literature on that you can provide (because I’m curious to know more).

I may have overstated this a bit (misremembered the upper limit of a confidence interval). It's more accurate to say it's believed to have a false positive rate of like 4-7%. Biggest problem with it is the self fulfilling prophecy of it. Everyone thinks it has a FPR of 0, so everyone withdraws.

Freund and Kaplan (PMID: 29225535) is a good review. The studies they list are all over the place, but it's worth reading and going through the references.

The most interesting ones are:

1. Elmer et al. Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest. Annals of Neurology 2016. 5% of patients with early myoclonus survived with good neurologic outcome (all in one of the patterns they described).
2. Reynolds et al. Early myoclonus following anoxic brain injury. Neurology 2018. Probably largest subset in the literature, 111 patients. 74% died, compared to 61% of patients without, but like 13% of survivors were discharged with good outcome, compared to 54% of patients without myoclonus.
3. Rossetti et al. Predictors of awakening from post anoxic status epilepticus after therapeutic hypothermia. Neurology 2009. Report of 6 patients who did well after myoclonic status.
4. Rossetti et al. Prognostication after Cardiac Arrest and Hypothermia: a Prospective Study. Annals of Neurology 2007. 7% FPR.

Youn et al in Resuscitation 2017 had a 4.5 FPR (upper limit of confidence interval was 22.8, which is where I misremembered this from), but to be fair that was from 1 patient who did well despite MSE.

Otherwise it's mostly case reports.

Again, I don't think MSE is great, just that it's not 100% death sentence it was believed previously to be. And this is despite the self fulfilling prophecy aspect of things. I think in real life you have people with like a myoclonic jerk being withdrawn on because someone read the 2006 recommendations.

 

[deleted547339]

Maybe. Most non-academic institutions don’t have dedicated neuro ICUs. Those that do often primarily use it as a post op neurosurgical parking lot. I work at a tertiary community hospital that’s a stroke center. We have a “neuro ICU” too. It’s nothing like the one I trained in and it probably doesn’t warrant a neurointensivist. That reminds me about the other thing I hate about the neuro ICU: neurosurgeons.

There is a corollary that approximates my distaste for cardiac surgical ICUs.

 

[ACSurgeon]

I am a Neurocritical care fellow. I don't think this will change anyone's mind, but here is my perspective.

First of all, to answer your question about whether it is worth it to add a year of Neurocrit on top of CCM: I don't know. Probably not. There is probably going to be an increase in the demand for Neurocrit trained folks over the next few years as more places start/expand their mechanical thrombectomy capabilities for large vessel strokes. How exactly this will translate into specific job opportunities that would not be available without NCC training is unclear. I'd say do it if you are interested in working with TBI, SAH, or cardiac arrest prognostication, otherwise it would probably be not worth it. Even then, it would be a year of lost attending income, so you could say this would cost you like $250k in life time earnings, so that's something to weigh in the pros/cons.

The joke about NSICU being an ICU with salt overload and poor general critical care management has a grain of truth to it. But so does the converse of other ICUs having terrible neuro care. And unfortunately the actual patient impact is not likely in favor of CCM in this comparison (ie my patients are relatively healthy from the neck down, so my poor vent management/poor Crit Care doesn't do that much harm; but you end up withdrawing care prematurely on post cardiac arrest patients because you didn't recognize NCSE or misunderstood what myoclonus means in that setting/can't differentiate it from Lance Adams syndrome, or failed to appreciate the significance of the location of the insult to prognostication, etc etc). At my institution we do consults in other ICUs for cardiac arrest prognostication and some other issues like ICP management, and well... let's just say CCM folks don't know what they don't know.

Jokes aside, this whole thing about Neurocrit being a 'vegetable garden' is kinda outdated and shows a lack of understanding of the literature on long term cognitive outcomes. Poor long term neurologic outcomes are a lot more common in the general ICU population than a lot of CCM practitioners seem to think, and are a lot better in the neuro world than you'd think (mostly have to look out far enough; for example, most survivors of out of hospital cardiac arrest actually do great neurologically if you follow them out for a year, and most of the bad outcome is attributable to mRS = 6 (ie death)). Difference is, we actually target our therapy for that, which is a lot more patient centered IMHO.

Anyway, most good fellowships both in CCM and Neurocrit are multidisciplinary with multiple months of either spent in other ICUs (CCM fellows at some institutions spend several months in the neuro ICU, Neurocrit fellows spend several months in the MICU/SICU). Some of the comments on this thread make me think that maybe these folks didn't get as well rounded a training as would be considered good these days, which is unfortunate. But hey, nobody is perfect.

As a surgical critical care doctor, I really appreciate what a good neurointensivist does for patients and for cross covering physicians in the way of anticipatory guidance.

For the OP, the critical care market is hot currently, and the neuroCC market is even hotter. If you maintain broad medical CC experience in addition to neuro, you’ll have good options for your entire career. I can see where someone who does only neuro might burn out or feel ill prepared to work at a smaller hospital with a mixed unit, but the OP would be medicineCC trained so should be versatile.

If you have interest, try to do an elective in fellowship before committing to the extra training. If you like it, it’s just one extra year. People routinely prolong their training a year or longer for much more trivial matters. Even if it doesn’t translate into higher pay (although I think it does), it’ll likely translate into more job prospects, leverage and potentially job satisfaction.

 

[CCM-MD]

As a surgical critical care doctor, I really appreciate what a good neurointensivist does for patients and for cross covering physicians in the way of anticipatory guidance.

For the OP, the critical care market is hot currently, and the neuroCC market is even hotter. If you maintain broad medical CC experience in addition to neuro, you’ll have good options for your entire career. I can see where someone who does only neuro might burn out or feel ill prepared to work at a smaller hospital with a mixed unit, but the OP would be medicineCC trained so should be versatile.

If you have interest, try to do an elective in fellowship before committing to the extra training. If you like it, it’s just one extra year. People routinely prolong their training a year or longer for much more trivial matters. Even if it doesn’t translate into higher pay (although I think it does), it’ll likely translate into more job prospects, leverage and potentially job satisfaction.

You are very mistaken about about the neurocritical care job market and its pay. There is a reason why so many of these fellowship positions stay empty.

 

[ACSurgeon]

You are very mistaken about about the neurocritical care job market and its pay. There is a reason why so many of these fellowship positions stay empty.

Maybe I’m projecting our recruitment experience. Also, I don’t know what the job market is for pure neuroCC, but if you can do that well In addition to medicineCC, that’s a nice skill set.

 

[CCM-MD]

Maybe I’m projecting our recruitment experience. Also, I don’t know what the job market is for pure neuroCC, but if you can do that well In addition to medicineCC, that’s a nice skill set.

Largely limited to academia and large flagship community hospitals which is where most dedicated neuroICUs are present. I looked on PracticeLink out of pure curiosity and there are 19 advertised positions: some of which are mistakenly placed in the incorrect category and are looking for neurohospitalists or something entirely different. For reference, there are close to 300 advertised CC-Intensivist jobs. Sure CCM+neuroCC could be a nice combo IF one likes neuroCC (big IF). Investing an entire year after already being already trained in CCM, with the hopes of potential improvement in income is probably not smart.

 

[jthedestroyr]

I liked our NICU as a fellow. The game always was where was the stroke, was it Left MCA or right and how much aphasia.

Depending on insult area, IE left versus right, they get right up to the day you want to PEG and trach otherwise PEG/trach then LTAC. Obviously more complex then that, but vast cases.

My fellowship was one of largest neuro ICU and we saw a ton of cool pathology (tertiary syphilis x2 I saw as a fellow).