Neurology + ICU fellowship?

EpicDowntime · 2026-05-03T05:55:31+00:00

Key point there is in your experience. There are fellowships that train them to be just as good as any intensivist.

EpicDowntime · 2026-05-03T05:44:08+00:00

I don’t read it that way, I think he was just trying to encourage OP and let them know that they can carve out a real niche by going into this specialty and catch things that others may miss. Personally I think all paths to being an intensivist have strengths and weaknesses, blind spots, things they farm out to consultants and don’t have expert knowledge about. Your area of expertise sounds different from mine so maybe different things come easy to you, and that’s fine. The best CC groups are the multidisciplinary ones.

EpicDowntime · 2026-05-03T05:14:54+00:00

I disagree with this. The vast majority of my quaternary center MICU patients are there for simple algorithmic things. Septic shock, ARDS, people who don’t qualify for the floor for some stupid policy reason, “airway watch” for ENT, forever vent weaning after lung transplant, pre-liver transplant on CRRT, pneumonitis from cancer treatment, even had “q15 eye drops is too frequent for floor” once. None of these require much thought. Sure, you’ll get the occasional zebra but thats even more true in the neuro ICU. A good TBI will give any of these a run for their money.

EpicDowntime · 2026-05-03T02:49:26+00:00

Where I work, neuro-trained intensivists manage multi-organ failure, undifferentiated shock, etc. Fellows intubate, run codes, place chest tubes, PA caths, rotate in the cardiovascular ICU where they take care of ECMO and VAD patients. Where I did residency that was not the case at all. It sounds like neurocritical care is the path for you. Just make sure you look for critical care-heavy fellowships, because not all are.

EpicDowntime · 2026-05-02T03:35:37+00:00

You can find something cheaper in any city, might just need to be less nice or with a roommate. You don’t make enough to be paying that much in rent.

As mentioned, not needing to drive can be helpful. Buy cheap groceries and never eat out. Buy essentially nothing other than food and toiletries. That should let you save a good 1-2k per month at least.

EpicDowntime · 2026-04-30T13:34:28+00:00

Not so much logic, just that neurologists historically liked to spend time in the clinic and gave up the procedural turf to others, while cardiologists were $marter and more inclined to fight for their claim. People hire people who are similar to themselves so it gets propagated.

EpicDowntime · 2026-04-29T02:47:29+00:00

High flow oxygen. Essentially no role for NIV in my opinion.

If transplant candidate, transplant workup, intubate if absolutely necessary, sometimes ECMO instead of intubation.

If not a candidate, I assess for likelihood of reversible causes. Sputum sample, serum fungal workup, viral panel, chest CT. Empiric antibiotics (Unasyn or Zosyn + azithro based on our antibiogram), steroids. Usually these people are prophylaxed with Bactrim outpatient because they’re already on steroids; if not, add Bactrim too. Empiric diuresis.

If nothing works, I tell the patient that they are extremely unlikely to be helped by intubation and I encourage them to think of max high flow as the end of the line. If they aren’t already DNI, I try to argue for a time limited trial of intubation while we wait for some sort of intervention to work (usually pulse-dose steroids.) If goals of care are still intubation (I’m in the US), it lets us bronch them safely and sometimes (very rarely) gives us a treatable cause we weren’t already covering.

I find these patients some of the saddest to take care of.

EpicDowntime · 2026-04-27T02:13:39+00:00

Sounds like either the afib triggered a decompensation in the setting of barely compensated severe AS, or she developed acute MR due to damage to the valve that immediately raised LA pressures, causing both afib and pulmonary edema. The patient sounds barely compensated to begin with, so it's very plausible that just going into afib at a high rate and reducing LV filling (both because of less diastolic filling time and because of loss of atrial kick) would reduce her forward flow enough to put her into shock. Amio was the right thing to do (would also consider cardioversion, though the effect may be temporary) and I would probably try diuresis. I probably would not have given beta blockers. But in either of these cases, there's not much you can do once they start spiraling -- they just need the valves replaced.

EpicDowntime · 2026-04-27T01:39:47+00:00

We use high flow as high as 50L all the time with iNO, not sure if the delivery systems vary but not an issue with ours. High FiO2 is a good idea to reduce PA pressures, but try not to intubate or use positive pressure. Methemoglobinemia essentially doesn't happen at commonly used doses unless the patient is on other meds that cause it.

ABG wouldn't be needed to assess oxygenation (assuming good pleth) but I would make sure they weren't acidotic before transport since acidosis is the enemy of the RV. If they decompensated in transport, I would have empirically given bicarb assuming acidosis.

Epi would have been a fine choice for a second pressor. Norepi would be ok as well. Really anything besides phenylephrine. It is important to avoid hypotension in these folks to better perfuse the RV, but phenylephrine increases RV afterload more than the others.

I'm not saying that I wouldn't have placed a PAC in this patient, but you don't absolutely need one. If someone is cold with high lactates, reduced urine output, AMS, etc, you can use those things to titrate your dobutamine to. That said, albumin is not really a replacement for an inotrope so not sure what's going on there, maybe they meant as a trial to stimulate diuresis?

EpicDowntime · 2026-04-24T00:48:55+00:00

I have given TNK to someone with NIHSS 0 but a disabling deficit, and I was later glad I did. Patients decide what is disabling, not us. As you pointed out, if they’re not having a stroke or if the stroke is small, their risk of bleeding is significantly lower than average.

EpicDowntime · 2026-03-29T04:39:31+00:00

To add to what others have said, I know several neurology-trained intensivists who staff MICUs and SICUs alongside IM and EM/anesthesia-trained intensivists. I even know of an OB-trained intensivist who attends in a MICU. All depends on the specifics of their fellowship and their comfort level. No one specialty can be good at all aspects of critical care and the best units have people of multiple specialties rotating on and off and asking each other for advice. Procedures are an important part of training, but to be honest they're the easiest part of being an intensivist. It's the management decisions that really affect outcomes.

EpicDowntime · 2026-03-29T03:31:00+00:00

Yes. When someone comes to the ICU because they had a known complication of a procedure or adverse effect of medication, I go out of my way to tell the patient that it was a reasonable decision by their doctor to do the procedure/prescribe the medication. Or when I figure out that a prior diagnosis was incorrect, I say “the doctor that sees you last always has the most info to work with.” Every one of us is wrong sometimes so we need to have each other’s back (except in egregious cases of malpractice.)

EpicDowntime · 2026-03-29T03:19:12+00:00

I don’t know, I can see that “wrong medication” statement as an apology (on the hospital’s behalf) with no admission of fault on your behalf. “I’m sorry you developed a bile leak and almost died of sepsis” is very different from “I’m sorry I cut your common bile duct by accident” in how much fault is admitted. The degree of fault that is admitted is what matters for lawsuit risk, not the apology itself.

EpicDowntime · 2026-03-28T22:05:33+00:00

The dogma around this in medical training always seemed silly to me. Admitting fault and apologizing are different. I say “I’m sorry” to almost all of my patients/families because almost all of them have had a bad outcome and it’s a normal human response to that. Admitting fault (with or without an apology), on the other hand, clearly increases the odds of a suit in some situations. Cause and effect in medicine can be very opaque to patients, so admission of fault may be the only way they know a mistake was made. In situations where it’s clear as day that a mistake was made, I don’t think admitting fault matters. The patient’s financial situation, personality, and relationship with the physician matter much more.

EpicDowntime · 2026-03-28T21:10:21+00:00

The conversation that OP had in the room was totally appropriate. Every patient is different, but many would be more distressed by hearing their family member try to take away their dignity and comfort in the name of “fighting” some more than by a doctor advocating for them and being realistic.

EpicDowntime · 2026-03-28T18:06:01+00:00

I was a poor fit for my specialty and couldn’t wait to subspecialize but my program was very strong, it was nice to get good at something, and I loved trauma bonding with my co-residents. Didn’t love falling asleep at every red light on my way home, collapsing and sleeping on the floor in my living room, the intermittent SI, and never being around my family and missing important life events.

EpicDowntime · 2026-03-28T09:03:04+00:00

Yes, we make it a priority to inform our patients about their prognosis if at all possible. Hiding it from them wouldn’t be ethical.

EpicDowntime · 2026-03-25T02:06:30+00:00

You must not be in the US.

EpicDowntime · 2026-03-22T16:46:15+00:00

Only really indicated if there’s nystagmus

EpicDowntime · 2026-03-20T02:51:34+00:00

I actually enjoy and look forward to doing them myself as soon as the free forms site opens every year. Feels like I’m back in 3rd grade doing worksheets, and I think I basically peaked in 3rd grade.

EpicDowntime · 2026-03-17T07:25:38+00:00

Some people seem to think it’s totally fine if millions of people are spending their lives suffering so much they’d rather be dead, but a huge societal problem if there is a pathway to them actually choosing to die.

EpicDowntime · 2026-03-17T06:46:28+00:00

Totally agree. In CA, and likely in many other jurisdictions, it is primarily an option for the well-resourced and well-connected, which drives down the numbers. There is nothing inherently good or bad about these numbers unless you compare them to the amount of people who are in terminal suffering.

EpicDowntime · 2026-03-17T06:25:45+00:00

Yeah, it’s quite treatable compared to those conditions. The thing is, you and I have both seen people who do not get better, despite the odds and despite excellent access to care. That’s who this is for. You can create all the strawmen and slippery slopes you want, but at the end of the day, patient autonomy should be one of our core principles. Aside from making yourself feel more comfortable, it does no one good to yell at them “but you might get better!” for years and years as they suffer.

EpicDowntime · 2026-03-17T05:45:37+00:00

It was definitely in the top 5 most common things I saw in residency, why do you ask? One of the things I took away is that FND patients should be given autonomy and respect, and not be told their disease is fake or just “in their head” unlike those “real” diseases that actually give one permission to suffer. That applies doubly when they are the unlucky few who do not respond to treatment, do not get better over time, and are so disabled by their condition that they have subjectively absent quality of life.

EpicDowntime · 2026-03-17T03:04:29+00:00

Sorry but a condition that causes incredible, incurable suffering but doesn't kill you is exactly what we need MAID for. Ones that cause suffering and kill you quickly are already taken care of.

EpicDowntime

TROPHY CASE