Neurocritical Care Fellowship

Background

The ACGME-accredited UCLA Neurocritical Care Fellowship is a nationally recognized clinical training program in Neurocritical care. The program is a 2 year program. This is one of a few recognized training programs in the United States and has been in existence since 1999. The Neurocritical Care Society and the American Academy of Neurology Section of Emergency and Critical Care Neurology have recently recognized UCLA as a premier example training program which encompasses and exceeds all fellowship requirements in neurocritical care. We have trained many fellows who have gone on to academic and clinical careers since our inception.

How UCLA is Unique

The UCLA program is unique in several respects.

The program is formally housed within the Departments of Neurosurgery and Neurology and is under the directorship of the neurocritical care program director. Our program is separate from but intersects deeply with the UCLA stroke program. All patients with any type of neurological or neurosurgical critical illness from the entire UCLA Health Network come to the NeuroICU.
A focused expertise on minimally invasive neurosurgical techniques is a unique goal of the fellowship. Fellows are trained multiple invasive procedures and other brain diagnostic testing (EEG and TCD).
The fellow is the main ICU doctor for all of the patients in the Neuro-ICU and has primary responsibility for the treatment of these patients.
The program features several state of the art technologies including cerebral microdialysis, brain oximetry, and a comprehensive electronic ICU featuring EPIC, GCQ® and a In-touch Health Robotic Telepresence®. Telemedicine expertise for acute stroke and other neurological emergencies is featured in our program.
The program features an advanced ICU based research environment.
Critical Care education is integrated across disciplines and there is a large number of multidisciplinary faculty in critical care including medicine, anesthesia, surgery, pediatrics, and neuroscience who teach and mentor the fellows.

Team Complement

The current program consists of four fellows, two ICU NPS, and 10 board certified attending physicians including: Dr. Paul Vespa, Dr. Manuel Buitrago Blanco, Dr. Yince Loh, Dr. Robert Shpiner, Dr. Joseph Meltzer, Dr. Rajan Saggar, Dr. Anahat Dhillon, Dr. Tisha Wang, Dr. David Boldt, Dr. Vadim Gudzenko. We also have a multidisciplinary team of dedicated Pharm Ds, Respiratory Technologists, and Nursing leaders. The fellow is the main ICU doctor for all of the patients in the Neuro-ICU and has primary responsibility for the treatment of these patients. Neurology and Neurosurgery residents rotate in the ICU on a monthly basis.

In addition to the clinical team, the research team consists of basic science research faculty members (PhDs - Dr. David Hovda, Dr. David McArthur, Dr. Thomas Glenn, Dr. Benjamin Ellingson, Dr. Matthew Wright, Dr. Martin Monti, Dr. Jack Van Horn), lab techs, a senior nurse research coordinator (Ms. Courtney Real) and two seniour lab assistants/researchers. The research team members are actively engaged in mentoring the fellows in experimental design, experimental methods, statistical training, and grantsmanship activities.

Fellowship Candidates

The candidates must be ABMS board eligible or certified in Neurology, Neurosurgery, Internal Medicine, Anesthesiology or other critical care ABMS specialty, and are independently licensed or fible for licensure through the state of California. The fellowship consists of a 2 year period of time of dedicated clinical training and research.

UCLA is the NeuroICU of the Future

The UCLA Neuro-ICU is a state of the art intensive care unit that is leading the world in patient care, technology, and research. We have moved into our new, dedicated 24 bed ICU in the new Ronald Reagan UCLA Medical Center. We have a total of 106 ICU beds at UCLA and a team of 40 intensivists house wide. We average 2000 admissions/year. UCLA NeuroICU fellows are exposed to a large volume of clinical material and experience. All neurological emergencies and critical care cases are admitted to the ICU with an equal balance of stroke, trauma, neuromuscular disease, status epilepticus, subarachnoid hemorrhage, intracerebral hemorrhage, brain tumors, myasathenia gravis, Guillain-Barre syndrome, cardiac arrest, and spinal cord injury/surgery admitted each year. We triage and treat every cardiac arrest patient in any ICU at UCLA.

UCLA Neurocritical Care is a Leader in Research

Basic and clinical science research are strongly supported through NIH funded research programs in brain trauma, intracerebral hemorrhage, and stroke. Fellows are expected to conduct a closely mentored research project, publish abstracts and full-length manuscripts and participate in ongoing research efforts. The ICU environment is strongly oriented towards innovation and cutting edge approaches and research. We are funded by several sources including an NIH Program Project Grant, NIH SPROTRIAS grant, NIH K08 grant, NOH RO1 grants, Department of Defense, The State of California Neurotrauma Initiative Grant and several industry sponsored trials. Each fellow participates in the 2 year NIH K 30 Clinical Translational Research Program that is offered at UCLA in conjunction with the NIH. UCLA features the Clinical and Translational Science Institute (https://ctsi.ucla.edu/) which facilitates interdisciplinary research across much of the distributed UCLA campus.

UCLA Neurocritical Care is Internationally Acclaimed

The UCLA Neurocritical Care program is well regarded among neurointensivists. We have trained over a dozen graduates. These graduates of the program have matriculated to University Faculty Appointments in Neurocritical Care. Dr. Vespa is a Fellow of the American College of Critical Care Medicine, a founding member of the board of directors of the Neurocritical Care Society, and an Editorial Board Member of Critical Care Medicine, Neurocritical Care, Surgical Neurology, and The International Journal of Critical Care. Dr. Vespa is a member of the UCNS Board of Directors and was named Chair of the UCNS in August 2009. He is also a guest editor for several additional journals including Critical Care, Current Opinion in Critical Care, Journal of Cerebral Blood Flow and Metabolism, Neurology, Annals of Neurology. Dr. Vespa has served as a faculty educator for numerous national and international conferences.

Goals and Expectations for Fellows

Fellows are very cherished in our program and one of the fundamental reasons for the existence of our program. The expectations for fellows are that each fellow matriculate into a premier position as a clinician-scientist and be positioned to make a significant contribution to the field. The job market continues to increase for neurointensivists and our candidates are encouraged to seek outstanding career opportunities. We expect fellows to pass the UCNS Neurocritical Care Board Examination within 1 year of completion of the fellowship training and be certified in Neurocritical Care. Fellows average 56 hours/week of work, well below the 80 hour work limit.

Benefits

The pay scale and full benefits package are superior with starting salary at the PGY appropriate level (PGY 5 for year 1, PGY6 for year 2) according to the UCLA PGY pay scale and cost of living adjustment for Los Angeles. The salary is competitive and comfortable. In addition, there is an annual Educational Stipend of $1,200 and an annual travel allowance to one major national meeting. There is 2 weeks paid vacation.

Recommended 1 Week Visitor Rotation at UCLA

Since the selection of fellowship is a significant decision, we recommend that serious candidates spend a 1 week elective rotation with us at UCLA. This is an observer rotation that permits the fellow to familiarize one with our program.

Neurocritical Care Fellowship Curriculum and Core Schedule

Overview

2 year fellowship in Neurocritical care with goals in 3 areas: Critical Care, Research, Brain Metabolism

Critical Care

Clinical skills
Cognitive skills
ICU procedures
ICU administration

Research

NIH K 30 Program
Literature knowledge
Methods skill sets
Clinical trial design
Meeting presentation
Scientific publiciations
Grant-writing training

Brain Metabolism

EEG
Microdialysis
Brain oximetry
TCD
Xenon CBF
PET, MRI, MRS

Progressive plan of academic development over 2 years incorporating the 3 spheres of knowledge. This progression is outlined below:

Year 1

Basic critical care skills are learned including invasive procedures: Central Line, Arterial line, Pulmonary Artery Catheterization, ventriculostomy, microdialysis catheterization, intubation, bronchoscopy, percutaneous tracheostomy, thoracostomy chest tubes, plasmapheresis treatments.
Basic patient assessment and case-based learning of critical care principles and practices. Fellow observes attending integrating information and making treatment decisions.
Didactic lectures in neurocritical care core principals and topics (see curriculum on page 4) are given on a weekly basis, Mondays at 2 PM.
A research project is identified and agreed upon by the fellow and mentor, background reading is done, the project is designed and data accrual begins in year 1. A 1 month statistics course (Statistics for Clinician Scientists) is given during month 8 of the fellowship.
One national meeting, such as Critical Care Medicine or Neurocritical Care Society Meetings.

Year 2

Critical Care principals and skills are applied to patients with attending physician oversight (fellow gains independence from attending gradually).
Fellow develops academic skills in teaching and administration: basic neurocritical lectures to students/interns, service on quality assurance reviews, writes/modifies ICU treatment protocols.
Completion of training in Neurosonology and Neurophysiology (with the potential to sit for certification examinations).
Lectures, practical workshops, and clinical expertise assessments in neurophysiology are completed. The goal is for the fellow to become competent in performing and interpreting these studies at the end of year 2.
Completion of research project with manuscript (months 20-24). Statistics course continues until month 20 of the fellowship. Grant application writing is done during months 12-16.
Attend one national meeting on Neurocritical Care or similar topic.

Weekly Duty Schedule

Fellows are on-service for one week at a time, alternating with research week for one week at a time.

Routine Clinical Schedule

06:00 - ICU work rounds with the neurosurgery residents
08:00 - ICU Attending teaching rounds with residents and fellows
11:00 - ICU work and procedures
12:00 - ICU topic mini-conference
13:00 - Family meetings, TCD and other test review sessions
17:00 - Evening ICU rounds with neurosurgery residents
18:00 - Nights and weekend call duty (call by telemedicine/phone)

Conference Schedule

Monday

14:00 - Neurocritical Care Fellows Conference

Wednesday

07:15 - Neurosurgery Grand Rounds
09:00 - Neurology Grand Rounds
14:00 - Neurocritical Care Teaching Conference
17:00 -Neurocritical Care/Neurosurgery Guest Speaker Series

Friday

07:30 - Stroke/Vascular/Interventional Case Conference
14:00 - Neurocritical Care Residents Conference

Research Schedule

08:00-11:00 - Fellow Data Review or data accrual
11:00 - Meeting with Mentor to review progress
13:00 - Meeting for statistical review and analysis
17:00 - Research day ends

Call is not taken during the research week, and flex-time is encouraged in order to promote a balanced lifestyle. Most of the research projects involve clinical research using human subjects.

Call Schedule

The schedule consists of a one week on and one week off program. This typically will require fellows to be in house from 6AM until 8 AM the next morning during the long call weeks. A detailed on call schedule is available upon request.

Central Mission

The fellow will be trained as neurointensivists/critical care neurologists under a pathway that will enable them to matriculate as academic neurointensivists with specialized training and expertise in critical care.

Team Structure Design

The neurointensivist is the primary attending for on all ICU patients. The fellow serves as the main ICU physician for the patient and is responsible for treatment decisions as a "primary team" member. The nurse practitioners or neurology residents function as the unit resident. The fellowship is structured to not displace any resident from completing the ICU portion of their training, but to provide service for an unmet patient care need. The fellowship is balanced towards providing the fellow the opportunity to be hands-on and gain first-hand experience in treating critically ill patients, while providing time for education, reading and thoughtful contemplation. An integrated approach where the neurology and neurosurgery residents, fellows and attendings are on one team is our approach. Neurosurgery residents benefit from the interaction with the fellows in terms of learning classical neurology principles in the areas of stroke, seizures, coma etc. Fellows benefit from interaction with senior neurosurgery residents who provide surgical knowledge and expertise.

Academic Training

Grant Writing Skills Workshop: During the course of each academic year, the fellow will attend a formal grant writing skills workshop.
Grant Writing: The fellow will write a formal research grant application during his/her second year of fellowship, in order to begin one's academic career.

Reading List

UCLA Neurocritical Care Manual of Key Articles
Handbook of Neurocritical Care-Bhardwaj
Ropper's Neurocritical care textbook
Critical Care Neurology and Neurosurgery-Suarez
The Clinical Practice of Critical Care Neurology-Wijdicks
Critical Care Medicine-ed Parrillo and Bone: We will do selected chapters during the initial 6 months.
Transcranial Doppler Textbook-Ayad
Traumatic Brain Injury-Narayan, Willberger, Povlishock
Book chapters will be presented monthly by the fellows.
Journal Club: An article will be discussed once per week from one of these journals: Neurocritical Care Journal, Stroke, J of Neurotrauma, Neurology, Critical Care Medicine, Critical Care, and J of Neurosurgery, NEJM, Lancet.

Educational Curriculum for the UCLA ICU Fellow

The fellowship program directors of the Neurocritical Care Society under the auspices of the UCNS have formulated a suggested curriculum for all programs in neurocritical care. Please see the UCNS website for complete details. We meet and exceed the suggested curriculum guidelines. The following serves to outline the core concepts.

Core Competencies of Fellows and Areas of Study/Training

Airway and mechanical ventilator skills and knowledge
Coma examination and etiology
Prognosis of critically ill patients
ICU encephalopathy
Subarchnoid hemorrhage and aneurysms
Status epilepticus and Burst-Suppression treatment
Intracerebral hemorrhage
Neuromuscular illness: Guillain Barre syndrome and myasthenia
Encephalitis and CNS infections
Brain death
Traumatic brain injury
ICP physiology and management
Transcranial Doppler ultrasound and CBF competency
Spinal cord trauma and acute spinal compression syndromes
Fluid management principals in critical illness
Antibiotics and antiviral agents in critical illness
Electrolyte abnormalities in neurologic patients (hyponatremia)
Sepsis and multiple organ failure
Hemodynamic Monitoring and management of hypertension
Ethics in intensive care
Basics of clinical research protocols in intensive care
Renal Failure, treatment and hemodialysis
Critical care nutrition and metabolic testing
Mechanical ventilator management and ARDS
Intensive care unit triage and administration
Anesthetics and sedation agents in intensive care
Expertise in continuous EEG monitoring
Invasive procedure methods and management principals
- Procedural Skills that will be mastered: central venous line, pulmonary artery catheter, arterial line, chest tubes, bronchospcopy, intubation, percutaneous tracheostomy, percutaneous gastrostomy, cerebral microdialysis, brain tissue oxygen probe, jugular venous oximetry, ICP monitor, cerebral microdialysis, and ventriculostomy).
- Fellows usually perform > 40 of each procedure during the fellowship.

Documentation Logs

Each fellow will keep a log of all patients admitted to the ICU with dates, diagnoses, complications. A procedure log will be kept and will include the patient's name, type of procedure, and complications. Logs will be surveyed every 3 months. Fellows will need to perform a defined number of procedures in order to complete the fellowship satisfactorily.

Research

12 months of protected time dedicated to research that is divided between the first and second year. Neuroscience-ICU based clinical investigation in SAH, TBI, ICH. Basic science laboratory research in Neurotrauma lab or Interventional neuroradiology basic laboratory. Fellow is expected to write at least one manuscript and one grant proposal during the 24 month fellowship. The fellow is expected to generate several abstracts and manuscripts during the fellowship, and is closely mentored by a PhD in statistics, as well as the other PhD and MD researchers in the neurocritical care program.

ICU Clinical Guest Rotations

Guest 1 month rotations in anesthesia and other ICUs are available. An introduction into interventional radiology is also available.

Travel to Academic Meetings

Yearly attendance at one of these meetings: NCS, SCCM, AHA International Stroke Conference or AAN annual meetings. The costs of travel and registration for the meeting will be paid for fellows who are presenting novel research in the form of a scientific abstract.

Vacation

2 weeks vacation / year.

Academic Time

Time available for presentations and board preparation at the discretion of program director.