- How To Apply
- Benefits / Salary
- Moving to Baltimore
- GME Policies
- Postdoctoral Association
- UCNS Accredited
- Duration of Program: 2 Years
- Positions Available: 4
- Application enrollment date(s) or deadline: October 1st – April 30th
- Applicant Qualifications:
- Emergency Medicine
- Internal Medicine
History: Neurocritical care as a subspecialty has grown rapidly over the last 25 years with the advent of newer monitoring and diagnostic and therapeutic modalities in a variety of brain and spinal cord injury paradigms. Fellowship training in Neurosciences Critical Care at the Johns Hopkins University School of Medicine has been in place for more than 20 years. Education and research are an integral part of providing a continuing service to acutely ill neuroscience patients at the Johns Hopkins Medical Institutions (JHMI). The Neurosciences Critical Care Unit (NCCU) was initially established to manage particular subsets of neurological and neurosurgical patients. It functions following a “closed ICU” model where the ICU team directs all medical management. In over 25 years of operation, the population of patients in the NCCU has diversified to include any critically ill patient with multi-system disease and neurological dysfunction. Due to the increasing demand for NCCU services, we have recently expanded to a new state-of-the art 22-bed unit. The unit is completely staffed and equipped as a critical care area, having a 1:2 nurse-to-patient ratio, resident and fellow coverage and staffed by an attending faculty member. The patient population in the NCCU comprises patients that are medically or neurologically unstable from the specialty areas of neurology, neurosurgery, orthopaedic spine and neuroradiology. The Bayview Medical Center, linked to Johns Hopkins Hospital (JHH) has another 14-bed NCCU for critically ill neurological and neurosurgical patients that are managed by the NCCU faculty/resident team.
Trainee Outcome: Graduates from our fellowship training have been highly successful in becoming leaders in the field at other institutions. The program has an outstanding track record in this respect. Graduates from our training program are heavily sought-after by several major teaching institutions and hospitals around the country. A majority of our graduates have gone on to become directors and to organize their own programs in neurocritical care in such institutions. Our program has served as a template for many of these newer emerging programs. Many of our graduates hold key leadership positions in national scientific societies such as the American Heart Association, Society of Neurosurgical Anesthesiology and Critical Care, the American Academy of Neurology and the Society of Neurocritical Care. They are frequently invited as guest speakers at national and international scientific meetings, as well as to serve as ad-hoc reviewers and serve on editorial boards of major scientific journals. Over the past 5 years, all trainees except 1 have successfully completed the two-year fellowship program. The trainee who did not complete the program, decided to leave the program for personal reasons after a year of fellowship training. Below is a list of trainees and their current positions since the institution of the Neurosciences Critical Care fellowship training at the Johns Hopkins Medical Institutions.
Goals and Objectives for Training: The training period is 2 years, which entails 50% time-effort as clinical rotations in the NCCU (22 beds) at Johns Hopkins Hospital. Fifty percent time-effort is dedicated toward academic activities with emphasis on clinical and/or laboratory-based research under direct supervision and mentorship of a designated faculty member in the division. A major program goal is to train critical care clinician scientists. The research interests of the staff physicians are varied and there is adequate time provided for development in these areas. It is expected that fellows will take part in 12 months of research. Each fellow has the combined resources of major contributing departments at his/her disposal. Once an area of interest is identified, a formal mentorship is established. JHMI provides an environment whereby a multidiscipline team functions in a manner to affect a common goal. This consists of physicians, nurses and ancillary personnel including nutritionists and physical, occupational, and respiratory therapists. The physician team consists of full-time practitioners trained in Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine. They provide the leadership to the NCCU inpatient care management and nursing staff in areas of education and research.
Duration: The duration of the fellowship is 2 years with 50% of total time devoted to clinical training and 50% to research endeavors. The fellowship training program is designed to be completed in two years. The first year as a Junior Fellow is spent developing patient care skills and teaching the ICU house-staff and nurses as it pertains to the bedside care of patients. The second year as a Senior Fellow confers the added responsibilities of team management and formal teaching on the concepts of neurophysiology, the treatment of various neuropathologic processes and general critical care issues.
Rotations: Clinical rotations in the NCCU at JHH as well as NCCU at Bayview Medical Center are in 1-2 week blocks. Other clinical rotations include a 2-week block in the Surgical ICU, Medical or Cardiac ICU as “observers” (participation in rounds, and all academic activities, but not directly responsible for patient care) and a 2-week block in the operating rooms for exposure to intra-operative monitoring and elective intubations/airway management.
Facilities: The NCCU in Johns Hopkins Hospital comprises of a 22-bed unit and a 14 bed NCCU at Bayview Medical Center. Both units are state-of-art facilities for the care of critically ill patients and equipped with bedside monitors for invasive hemodynamic monitoring, ventilator capabilities and computerized data recording systems. The specially trained neurocritical care team of physicians and nurses, respiratory therapists, pharmacists and social workers provides the multidisciplinary cohesive approach to the care of patients. There is a highly developed neuroradiology department with sophisticated neuroimaging (CT, MRI) equipment and interventional neuroradiologists available at all times for emergency diagnostic and therapeutic procedures. The stroke team closely interacts with the NCCU team that has developed critical pathways for patients with ischemic and hemorrhagic strokes.
Clinical and Research Components
Clinical Component: The training period is 2 years, which entails 50% time-effort as clinical rotations in the NCCU (22 beds) at Johns Hopkins Hospital and NCCU at Bayview Medical Center (14beds). Fifty percent time-effort is dedicated toward academic activities with emphasis on clinical and/or laboratory-based research under direct supervision and mentorship of a designated faculty member in the Division. Clinical rotations in the NCCU at JHH as well as NCCU at Bayview Medical Center are in 1-2 week blocks. Other clinical rotations include 2-week blocks in the Surgical ICU, Medical or Cardiac ICU and time in the operating rooms performing intra-operative monitoring, elective intubations and airway management. Finally, fellows rotate to the R. Adams Cowley Shock Trauma Center for experience in managing patients with multiple traumatic injuries including traumatic brain injury.
Research Component: Fifty percent of time is allocated toward research endeavors that may comprise of clinical or laboratory-based research. Clinical research participation is mandatory for all fellows in training via participation in the numerous ongoing (institutionally-based or multi-center) clinical trials on a variety of themes such as brain resuscitation, stroke and ischemic neuroprotection. Laboratory based research in the areas of epilepsy, cardiac arrest and stroke entails active participation under close supervision of the mentor and senior laboratory investigator.
Hours and Supervision: The program is designed to have close and direct supervision from attending staff during clinical rotations. During clinical rotations (1-2 week blocks) fellows spend 10-12 hours per day providing direct patient care. Typically, the NCCU team consists of an attending, 2 fellows, 3-4 resident house staff and a nurse practitioner’s team. With this team approach, sleep deprivation and excessive hours rarely is an issue, but if it arises on occasion, the team approach allows for appropriate backup from attendings and co-fellows. A mentorship program has been developed recently whereby each fellow is assigned to a faculty member in the division who functions as a mentor for all non-clinical research activities (laboratory-based and clinical) including writing and reviewing articles in peer-reviewed journals, formulating hypothesis-driven research protocols, grant writing etc.
Participant’s Supervisory and Patient Care Responsibilities
Rounds: Rounds are structured toward active participation with distinct roles for each member of the team (attending, fellow, resident, nurses, pharmacist, social worker). Detailed critical care rounds occur with a “systems-approach” to each patient and special emphasis is applied to bedside teaching as it pertains directly to patient care. Multiple goal-directed rounds occur through the course of the day (Combined neurosurgical rounds, critical care rounds, radiology rounds, evening rounds) and the fellows lead these rounds. The first year as a Junior Fellow is spent developing patient care skills and teaching the ICU house-staff and nurses regarding the bedside care of patients.
All procedures are closely supervised and countersigned by attending staff during clinical rotations. Procedural competence is an integral part of training. Procedures include arterial line and central line placement, Swan-Ganz catheter placement and interpretation, thoracentesis, airway management including endotracheal intubation and bronchoscopy. Fellows are permitted to perform procedures independently only during emergencies and following approval from the NCCU Director and Co-Director.
Didactic teaching: Didactic teaching sessions occur daily for fellows and resident house staff. Topics include diseases that are seen commonly with special emphasis on fundamental principles, pathophysiology and critical aspects of patient management. In addition, over the first 1-2 month period at the start of fellowship training, there is an intensive didactic lecture series on topics that include cardiopulmonary aspects of critical care as it pertains to critically ill neurological and neurosurgical patients. An intensive one-week course in neurosonology (Transcranial Doppler) comprising of lectures and “hands-on” practice is mandatory for all fellows in the first six months of fellowship training. Intensive one-week courses for Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) are also mandatory for all fellows toward obtaining certification.
Conferences: Conferences include a weekly divisional research conference (institutional CME-approved) where a broad spectrum of topics in basic science and clinical research are presented. Particular emphasis is paid to basic science research that has translational significance into clinical paradigms. Attendance at this conference is mandatory for all faculty and fellows in the Division. Updates on patient enrollment in ongoing clinical trials and alterations in existing protocols are also provided. Invited speakers comprise of faculty from the NCCU division, from other faculty at the JHU and other institutions as well as pharmaceutical-based experts in the research field. Fellows and faculty are encouraged to attend weekly departmental grand rounds in the Departments of Neurology, Neurological Surgery and Anesthesiology/Critical Care Medicine. A journal club encompassing recent published research articles are presented by fellows and critically discussed once a month at these conferences.
Personal Enrichment Programs: Fellows are encouraged to attend courses given by the School of Public Health and the School of Medicine and other CME courses at the national meetings of the Academy of Neurology, American Neurological Association and the Society of Neuroimaging. Courses on medical ethics, biostatistics, and epidemiology are particularly encouraged.
Teaching Opportunities for Fellows: Participation in bedside teaching as well as with didactic lectures is an integral part of fellowship training. Fellows are given specific topics and expected to give 1-2 lectures per week formally to resident house staff during their NCCU rotations. Other informal bedside teaching sessions to resident house staff are an integral part of the fellowship training. Participation as speakers at courses organized by the Divisional faculty at national meetings (American Academy of Neurology, Society of Critical Care Medicine) is encouraged.
Fellow participation in Divisional/Departmental and Institutional Committees: Fellows have a strong voice in the overall implementation and execution of ideas as it pertains to day-to-day activities of the Division and are active participants in special task forces set up in the Division. They have an important representation at the Fellowship Forum of the Academy of Neurology where they can be share their experiences with potential candidates for the fellowship program.
Quality Assurance: Fellows are charged with tracking of Morbidity and Mortality in the units and take turns presenting such cases formally at a divisional conference held every other month. Fellows are also designated to other task force committees for specific practice parameters as performance improvement tools such as incidence of unplanned or self-extubations in the NCCU, patient-family satisfaction surveys etc. Such focused work groups consist of selected nursing staff and are frequently headed by the designated fellow.
Progression in Responsibilities: Critical evaluation by the faculty at the end of first year as a Junior Fellow determines the fellow’s promotion to the second year as a senior fellow in the training program. Second year of training focuses on developing leadership and administrative skills in managing a busy critical care unit in addition to teaching and supervising junior fellows and house staff. Specially gifted fellows are enrolled in the institutional Advanced Specialized Training Program (ASTP) in their second year of training. Fellows are given remedial coaching in areas of weakness and, on occasion in the past, the fellowship program has utilized the Faculty and Staff Assistance Program (FASP) in cases that have special needs and face difficulties during their training period.
The faculty in the Division of Neurosciences Critical Care comprises of fully trained Neurologists or Anesthesiologists (or both). H. Adrian Püttgen, MD, is the Director of Fellowship Training and is directly responsible and provides mentorship during each of the fellow’s training. Presently the faculty in the Neurosciences Critical Care Division includes:
Marek A. Mirski, M.D., Ph.D. - Vice-Chair, Department of ACCM; Director, Division of Neuroanenesthesia; Professor of ACCM; Staff Attending, ACCM and NCCU
Romergryko Geocadin, M.D. - Director, Division of Neurosciences Critical Care Medicine; Director, Johns Hopkins Hospital NCCU, Associate Professor of Neurology; Staff Attending, Neurology and NCCU
Neeraj Naval, M.D. - Director, Johns Hopkins Bayview Medical Center NCCU, Assistant Professor of Neurology, Staff Attending, Neurology and NCCU
J. Ricardo Carhuapoma, M.D. - Assistant Professor, Neurology; Staff Attending, Neurology and NCCU
Wendy C. Ziai, M.D. - Assistant Professor, ACCM, Staff Attending, NCCU; Director, Neurosonology Program
Robert D. Stevens, M.D. - Associate Professor of ACCM, Staff Attending, ACCM and NCCU
Geoffrey S.F. Ling, M.D., Ph.D. - Director, Neurocritical Care, Uniformed Armed Forces, Walter Reed Medical Center; Adjunct Associate Professor, Neurology
Paul Nyquist, M.D., MPH - Assistant Professor, Neurology; Staff Attending, Neurology and NCCU
Bradford Winters, M.D., Ph.D. - Assistant Professor, ACCM; Staff Attending, ACCM and NCCU
Athir Morad, M.D. - Assistant Professor; ACCM; Staff Attending, ACCM and NCCU
Lucia Rivera Lara, M.D.
Adam Schiavi, MS, Ph.D., M.D. - Assistant Professor; ACCM; Staff Attending, ACCM and NCCU
H. Adrian Püttgen, M.D. - Assistant Professor, Neurology; Staff Attending, Neurology and NCCU
Christa San Luis
Department of Anesthesiology and Critical Care Medicine
The Johns Hopkins Medical Institutions
600 N. Wolfe Street, Meyer 8-140
Baltimore, MD 21287
Hans Puttgen, M.D.