“How can you have a practice focused on neurotrauma? Are you on-call 24/7?” It is possible; and no – I’m not on call 24/7. Just as other neurosurgeons subspecialize in tumors, I subspecialize in neurotrauma. I am fellowship trained in neurotrauma and I tailor my surgical duties, my outpatient clinic, and my research efforts to the treatment of traumatically injured patients. As the Director of the Neurotrauma Center at a Level I Trauma Hospital, I serve as the neurosurgery liaison and coordinate and direct the care of our neurotrauma patients. In short, I run a neurotrauma service line that is not only clinically and financially viable but also personally fulfilling.
Neurotrauma is the treatment of the traumatically injured neuro patient (traumatic brain injury and spinal cord injury). It is distinct, though often intertwined with being a neurointensivist, a provider who manages the critical care treatment of all neuro patients in the intensive care unit. In my hospital, I do not work as a neurointensivist, I work as a neurotraumatologist. I manage and treat all new traumatic brain injured (TBI) patients that enter our hospital during daytime hours (6a-6p). In addition, I share evening call with my colleagues, taking call about once every 5-7 days. Each morning I assume the care of new TBI patients that were admitted overnight. Neurotrauma patients in our Neurosciences ICU are admitted under my service (or under trauma service if significant polytrauma). Critical care issues, including ICP management, are managed by the neurotrauma team with collaborative management with our neurointensivists. Non-critical neurotrauma patients are also transferred to and managed by the neurotrauma service. We manage all follow-up and perform all additional surgeries (including cranioplasties and shunts). All TBI patients, including complicated mild TBI patients, follow-up in our dedicated neurotrauma clinics.
In addition to the surgical treatment of neurotrauma patients, as a neurotraumatologist, I create hospital guidelines for neurotrauma patient care and coordinate the care of these patients across the care continuum. This includes overseeing neurotrauma specific performance improvement initiatives: monthly neurotrauma quality assurance meetings, identification of areas with opportunities for improvement, and facilitating multidisciplinary care meetings for discussion and management of complex neurotrauma patients. In addition, I coordinate a robust clinical research infrastructure that allows us to participate in and initiate large-scale neurotrauma clinical trials.
As the volume of neurotrauma patients is large, and their management complex, the neurotrauma service line includes not only a neurotraumatologist, but also other crucial support to ensure the efficient management of patients.
Our neurotrauma service line includes a dedicated advanced practice provider (APP) to assist in the care of TBI patients. Responsibilities of the APP include daily rounds, assisting with orders and checking daily labs, scans, and consults needed for management of primary patients. In addition, the APP is knowledgeable and available to participate in bedside patient education and family discussions for all severities of TBI patients. Our APP can independently see patients in clinic, including interpreting imaging, formulating and implementing plans of care. The ability for the APP to document and bill on patients independently increases our ability to provide care to a maximum number of patients while prioritizing surgical patients to my concurrent clinic.
The care of our neurotrauma patients is immensely improved by the work of our Neurotrauma Nurse Navigator. Our nurse navigator is a dedicated individual that assists in care coordination for TBI patients. Neurotrauma patients often have need for follow-up appointments with varying services, are often discharged to a facility, and hence can easily be lost to follow-up. Our neurotrauma nurse navigator reviews the inpatient list daily, coordinates discharge needs, and collaborates with other care coordinators and/or social workers to assure neurotrauma patients with complex needs are receiving resources. She also provides bedside education for mild TBI patients, assists with outcomes questionnaires in clinic, and oversees the neurotrauma hotline, a resource for patients, caregivers, and providers.
The coordinated efforts of the members of our neurotrauma service line allow us to provide the best care for patients. As a dedicated neurotraumatologist, I am able to focus on the emergent and complex neurotrauma surgical care while building a neurotrauma program that excels in patient care and research. Since implementing our neurotrauma service line, we have built a robust multimodality monitoring program and seamlessly provide patient care that adheres to clinical best practice for TBI. In four years, we have improved our ACS TQIP risk-adjusted mortality for severe TBI patients from 1.25 to 0.66. Our clinical trial engagement has increased from 2 to 8 actively enrolling neurotrauma clinical trials, including a mix of government-funded, industry-supported, and investigator-initiated trials.
There are varying practice models for those interested in neurotrauma and/or neurocritical care. As a research-focused neurotraumatologist, I conduct translational research, focus on improving neurotrauma patient outcomes, all while having a rewarding clinical practice – and without taking call 24/7.
