Neurocritical Care

I think for many critical care intensivists, neurology is the most challenging knowledge to master. The anesthesiologists are comfortable with cardiac physiology, vasopressor pharmacology, and ventilator management. The internists and pulmonologists are great at reading X-rays, formulating antibiotic regimens, and managing renal insufficiency. But a surprising amount of critical care is neurologic in nature. While like most intensivists, I am comfortable managing analgesics, sedatives, and other neurologic drugs, there's a lot I wish I were better at. I have a great respect for neurologists who are proficient in critical care and those who do two years to subspecialize in the field.

Even in a community hospital, I see so many variations on altered mental status in the intensive care unit. A patient with a history of seizures has jerking motions; the treating physician gives too much benzodiazepine and the patient is so somnolent she is intubated. She has significant liver and kidney disease, and in the ensuing few days, we have to tease out whether her persistent somnolence is nonconvulsive seizures or residual anti-seizure medication. After an emergency surgery for a bowel perforation, a patient is very slow to wake up. When he does, he cannot move his arms, but the distribution of his weakness does not occur in a common stroke pattern. An alcoholic with cirrhosis comes in with a stroke; after several days of confusion, we struggle to figure out whether it's encephalopathy from his liver, symptoms of his stroke, or the beginning of alcohol withdrawal.

None of these situations are altogether too difficult, but seeing so many in a week helps me realize that I want to get better at neurology. I am working to better understand how to read head CTs, when to order EEG, and how to use a precise neurologic exam to tease apart similar diagnoses. Luckily, we have a dedicated and brilliant neurology consultant who takes his time to dig deep into these problems and teach us when he can. This, I suppose, is one example of how learning never stops.