A Change of Course: The Case for a Neurorecovery Clinic
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A DAY IN THE LIFE OF A NEUROCRITICAL CARE TRAINEE
A Change of Course: The Case for a Neurorecovery Clinic Matthew N. Jaffa*, Jamie E. Podell and Melissa Motta © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Introduction Everyday during neurocritical care rounds, we find ourselves obsessing over dips in sodium, liquid stool, and whether a urinary catheter is truly indicated. We scrutinize minutiae with the goal of keeping those teetering on the edge, alive. The long-term implications of the patient’s brain injury are often left for whispered conversations or private contemplation, when we question whether our patient will ever be the person he once was. During family meetings, we describe in broad strokes the natural history of the patient’s disease and potential outcomes. Often these conversations end with a discussion about goals of care (GoC) and questions posed to families—“If your loved one was able to make decisions; how would he want us to move forward? What amount of disability would be acceptable to her? In light of this, often uncertain, prognosis and potential for recovery, would they choose a medically-aggressive restorative path or ask to focus solely on comfort?” Implicit but overlooked in this discussion is the idea that disability has a predictable effect on quality of life (QoL). As intensivists, we may place our patients within the literature to give the dire prediction of a modified Rankin score of 5, but we rarely see how patients and families experience such an outcome after they leave the intensive care unit (ICU). Acknowledging the complexity of the actual versus predicted psychosocial impact of neurologic disability on patients’ and caregivers’ QoL is paramount to guiding families to make the most informed decisions for their loved one’s care. Recovery clinics for ICU survivors have consistently demonstrated
*Correspondence: [email protected] Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD 21201, USA
benefits in these realms for both patients and ICU teams [1].
A Not‑so‑Unusual Case During the summer of 2019, a young father in his 30 s was found unconscious in his home. Outside hospital imaging revealed an aneurysmal subarachnoid hemorrhage with blood casted in the right lateral, 3rd, and 4th ventricles. On arrival to our unit, he was comatose with unequal pupils and decerebrate posturing. An extraventricular drain was emergently placed, and he was taken to the interventional radiology (IR) suite for coiling of his anterior communicating artery aneurysm. Already, his angiogram demonstrated severe bilateral anterior cerebral artery vasospasm. Over the next 2 weeks, he required high-dose vasopressors and frequent trips to the IR suite for management of severe vasospasm. He developed a host of complications including stress cardiomyopathy, hypoxic respiratory failure, paralytic ileus, recurrent refractory fevers, and healt
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