The Neurocritical Care Fellowship curriculum is flexible, and any of the critical care neurology areas may be emphasized, depending on your individual interests and needs.
Our fellowship at Mayo Clinic's campus in Rochester, Minnesota, is particularly strong in teaching fellows the main neurological manifestations of acute neurological disease. Teaching includes recognition of acute neuromuscular respiratory failure, diagnosis of different stages of coma and its consequences, and post-neurosurgical complications.
Fellows are involved in multidisciplinary care, coordinating surgical and neurointerventional procedures, and discussions with family members about prognosis. Fellows are closely involved with brain death and donation after cardiac death protocols.
Six months of the first year is spent in the specialized Neuroscience Intensive Care Unit (NICU) and three months in non-neuroscience ICUs. The second year is divided between the Neuroscience ICU, non-neuroscience ICUs, ICU neurology consults and electives.
The Neurocritical Care fellow is expected to perform all central lines, intubations and bronchoscopies with supervision by anesthesia staff. Opportunities exist to perform other procedures, including thoracentesis, chest tube placement and paracentesis.
Fellows start a major research project within the first two months and are closely mentored throughout. Research entails primarily clinical research, with efforts greatly facilitated by Mayo Clinic's extensive medical record system, the Division of Biomedical Statistics and Informatics, and a specialized media support department. Fellows publish multiple manuscripts and present them at meetings.
Neuroscience ICU (NICU)
Approximately nine to 10 months of the fellowship are spent in the Neuroscience Intensive Care Unit (NICU), a 20-bed unit that is shared between neurology and neurosurgery.
The NICU team is the primary provider for all patients except for uncomplicated postoperative neurosurgical patients, epilepsy grid monitored patients and patients with traumatic brain injury. The NICU team is consulted on traumatic brain injury patients with refractory intracranial hypertension or medical complexity.
Uniquely, all acute stroke management is directed by the NICU team, including determining eligibility for thrombolysis and endovascular therapy. The patient is transferred to the stroke team after 24 hours of ICU stay depending on his or her medical readiness.
NICU team and rounds
Mayo Clinic's campus in Rochester has four neurointensivists who share call. The rounding team is made up of the consultant, NICU fellow, a day and night resident (12-hour shifts), neurology pharmacist, charge nurse, and nurse manager. An anesthesia team co-manages mechanical ventilation.
Days in the NICU for the fellow are generally from 7 a.m. to 6 p.m. depending on the case load, with shifts on Monday, Tuesday, Friday and Saturday. The NICU fellow does a night shift on Wednesday to relieve the night resident.
In the second year of fellowship, the fellow takes night pager calls from the neurology emergency medicine resident as well as the NICU resident. This transition prepares the fellow for upcoming years after training.
Step-down care, otherwise known as the Progressive Care Unit (PCU), is physically located in the NICU. These patients remain under the care of NICU team, whether they are ICU or PCU status. Neither general neurology nor stroke neurology staff rounds on any patients while they are physically in the NICU.
ICU neurology consults
Approximately two months of your training is allotted to neurology consultations within the other ICUs at Mayo Clinic Hospital, Saint Marys Campus and Methodist Campus. This includes medical, surgical, trauma, cardiac and cardiothoracic surgery ICUs.
Patients in these ICUs requiring a neurological consultation are seen by you and one of the four neurointensivists.
Fellows rotate through the medical, surgical, transplant and medical ICUs for a minimum of six months. In the first year of fellowship, the fellow functions as the primary fellow in the surgical ICUs and is accompanied by a second critical care fellow while in the medical ICU, due to internal medicine regulations.
The fellow functions as the primary fellow in all ICUs in the second year of fellowship.
All four of the neurointensivists are highly published and cited. The experience of your mentors is broad and includes chapter writing, research articles and participation in clinical trials. There are two to three months allocated for research, and more can be requested in electives. The NICU fellow is strongly encouraged to participate in research projects.
Approximately three months of elective time is available in your training. Common options include neurosurgery, neuroanesthesia, transcranial Doppler ultrasound (TCD), electroencephalography (EEG), infectious disease ICU consulting or additional research.
The TCD rotation is available at Mayo Clinic's campus in Jacksonville, Florida. Travel and housing expenses for such rotations are covered by Mayo.
Clinical conferences, seminars, small discussion groups, journal clubs, didactic courses and one-on-one instruction are all integral parts of the Neurocritical Care Fellowship.
Formal didactic courses are available. Understanding statistical principles as applied to biomedical investigation is an important component of the fellowship. Mayo Clinic offers a number of courses in epidemiology, biostatistics, and design and conduct of clinical trials.
A dedicated neurocritical care course is given by expert neurointensivists every summer to prepare trainees for rotations in the Neuroscience ICU. Major topics covered include acute ischemic stroke, subarachnoid hemorrhage, status epilepticus, bacterial meningitis, acute neuromuscular respiratory failure, traumatic brain injury and brain death.
A major goal of Mayo Clinic's critical care specialists is to continue a long tradition of clinical research in critical care neurology. Clinical epidemiological research is emphasized in division research activities, including clinical treatment trials and medical records research. These types of research are a natural extension of Mayo's extensive experience with patient care, a unique records system and a unique local population base.
Development of independent research projects is encouraged and is supported with training in database management and biostatistics.
When you complete your research, you are expected to present it at a scientific meeting or prepare it for publication in a scientific journal. Past fellows have been very successful, with some completing up to 15 manuscripts a year.
Throughout your fellowship, you participate in and periodically present at weekly conferences:
- Neurology Grand Rounds. Research presentations are given by Mayo Clinic faculty, visiting faculty or neurology residents. Clinical pathological and vascular conferences are held several times a year.
- Cerebrovascular Case Conference. Cerebrovascular cases are presented and discussed. This is held jointly with the Department of Neurologic Surgery every other Monday.
Tuesdays and every other Wednesday
- Core Curriculum. This is a comprehensive critical care curriculum that covers all aspects of critical care and includes board review sessions every year.
- Clinical Case Conferences. Every Wednesday, critical care conferences are held at Mayo Clinic Hospital, Saint Marys Campus, and alternate among the adult inpatient neurology, child and adolescent neurology, neurosurgery, and neuro-ophthalmology divisions.
- Clinical Pathological Conference. On Wednesdays, opposite the Core Curriculum, there is an interdisciplinary conference with critical care medicine where challenging cases are presented and discussed in an interactive fashion.
- Critical Care Grand Rounds. A broad range of topics relating to critical care are discussed on a weekly basis.
- Subspecialty conferences. These conferences focus on the pathophysiology, diagnosis and management of neurological disorders. Subspecialty conferences are presented on a rotating basis by all subspecialty divisions of the Department of Neurology.
Fellows also participate in an evidence-based neurocritical care journal club that takes place monthly.
Additionally, visiting professors have small group discussions with neurology residents and fellows. Topics covered include child and adult neurology vignettes and neuro-ethics.
During your first year of fellowship, you are allowed 10 presentation trip days. Approximately three days are allowed for each trip. Mayo reimburses costs incurred up to $1,750 for each trip.
During your second year of fellowship, you are allowed 10 presentation trip days and five attendance trip days with the same reimbursement guidelines. An attendance trip does not require that you present research.
Vacation is limited to 15 days each year.
To ensure that you acquire adequate knowledge and develop your technical skills, your performance is monitored carefully during the course of the Neurocritical Care Fellowship. You are evaluated formally by your supervising faculty member after each clinical rotation and then meet with the program director to review these evaluations.
In addition, you regularly evaluate the faculty to ensure that your educational needs are being met.