P.B. Raksin MD
29 August 2022
Who resides under the big tent of the Joint Section on Neurotrauma & Critical Care?
This is hardly a trick question. After all, there are spine surgeons in the Spine Section, tumor surgeons in the Tumor Section and vascular surgeons in the Vascular Section. I would assert, however, that the answer here is a little more nuanced.
Some of us have made our homes in Level I, urban safety net hospitals, where the majority of what comes through the door fits the definition of urgent or emergent and where a referral practice is non-existent. But even among such creatures, there are those who would self-identify as primarily a brain or spine surgeon. Some deploy their critical care skills alongside their surgical practice, while others function exclusively in the ICU and have long since forgotten how to scrub. What of the vascular surgeons who develop the expertise to care for their very sick patients in the ICU? And let us not forget the complex spine surgeons who might pair a particular interest in spinal cord injury with a love of heavy metal. They, too, consider themselves “trauma people” (though some might choose to entrust their patients to the “critical care people” at the ICU door).
In short, self-identity within the JSNTCC is a complex thing – perhaps more so than in the other Sections. This complexity, in turn, breeds both challenge and opportunity. The challenge lies in how best to harness the full range of interests and expertise that populates the section and direct it toward advancing common goals. Opportunity presents itself in the possibility to embrace that diversity as the building block for a paradigm shift.
Defining ourselves has acquired new resonance in light of recent changes within the ABNS credentialing process and with respect to evolving patterns of practice. Some may not be aware that there is a movement afoot to carve out specific certification pathways in the areas of neurotrauma and neurocritical care. While this is a positive development in the sense of recognizing subspecialty expertise – above and beyond that granted by general ABNS certification – it ultimately may have the unintended effect of forcing a distinction between a “neurotrauma” and a “critical care” practice. Those with less traditional trauma backgrounds (namely, our friends with dual citizenship in other sections) may find it challenging to seek certification if their credentials do not fit neatly in one box.
At the same time, the recent reconfiguration of the ABNS oral board exam has placed renewed emphasis on the initial evaluation and management of time-sensitive neurosurgical problems that are not necessarily grounded in trauma, but still require rapid processing of data and application of clinical judgment to triage acuity and determine the need for prompt intervention – skills transferable to any clinician functioning as a first responder. These entities run the gamut from cranial and spinal trauma, to shunt failure, stroke, aneurysmal subarachnoid hemorrhage, pituitary apoplexy, cauda equina syndrome, metastatic cord compression and central nervous system infection – not to mention the critical care concerns that may befall such patients. In the recitation of this list, one starts to envision a role for each and every provider who might occupy the JSNTCC tent and the rationale for a new model of practice that is grounded in the urgent and emergent – across the spectrum of neurosurgery.
The American Association for the Surgery of Trauma (AAST) defines “acute care surgery” as incorporating elements of three disciplines: trauma, critical care and emergency surgery. Acute care surgery adapts the systems-driven, evidence-based approach of trauma care to the management of patients with other not necessarily traumatic, yet time-sensitive surgical conditions. While general surgeons have embraced the practice of acute care surgery, it remains a designation largely foreign to neurosurgeons.
It is time to put a recognizable face on a concept that is a natural outgrowth of the acute care surgery movement, but has not been defined previously as such within organized neurosurgery. The acute care neurosurgeon should demonstrate proficiency in both the emergent operative and critical care management of patients with surgical neurologic illness. The JSNTCC provides the natural home for individuals who might master this diverse skill set.