The NCCU education website is a good place to start – www.cambridgecriticalcare.net . There is a very useful page under Education, Quants titled ‘Neurocritical Care for the Naïve’ produced by one of the previous FY2s (Dr Tamara Tajsic). Here, you can find useful reviews on the common pathologies seen in NCCU patients.

NCCU is ICU specifically catering for neurosurgery, neurology and trauma patients. It has 17 level 3 beds (intensive care) located downstairs (ward A2) and 6 level 2 beds (high dependency) located upstairs (part of ward A3). There are 5 side rooms for isolation on the main unit and the rest is an open unit. The unit can increase its capacity by 3 further level 3 beds in the annex if required. You will probably have a quick tour as part of the induction.

Care on NCCU is Consultant led. There are always 2 Consultants on during the week and the patients are split between them (Beds 1-12, and beds 13-17 plus HDU) for the ward round. The unit is covered by 1 Consultant out of hours. The Consultants change daily. A timetable of the NCCU Fellows and Consultants can be obtained from Liv Williamson (liv.williamson@addenbrookes.nhs.uk), NCCU Administrator.

There are usually 4 NCCU fellows covering the unit in addition to the FY2s during the day. There will be a ‘long day 1’ fellow covering beds 1-12 and ‘long day 2’ fellow covering beds 13-17 and HDU until 2000. They will also carry the bleeps and response to trauma calls.

NIC- Nurse in charge. Very important person. Will co-ordinate all bed moves and nursing distribution. Be nice to them and the waters will part when you need an extra pair of hands. This goes also for all the NCCU nurses. They have a lot of specialist knowledge and tend to filter out a lot of the little problems you may face on the wards so when they come to you with an issue it is invariably important.

Pharmacists. David Robb and team. Highly knowledgeable and approachable. Often appear on the unit most days but easy to reach via bleep/switch.

Dietitians. Emma Service and Anuska. They will set up all enteral feeding plans. If special edit is needed they are often a step ahead of you but contact if unsure. If you need PN then you need to refer to the parentral team often this will be co-ordinated for you.

Physiotherapy and SALT work closely with each other, particularly when swallowing issues are making weaning difficult. Caroline is one of the leads and the physios are the best to speak to regarding trachae management especially in acute situations which you may encounter on the neurosurgery wards.

You will be part of the neurosciences rolling rota (12 SHOs: 8 for Neurosurgery, “ for Neurology, 2 for NCCU). 8am-6pm on the unit On calls, night and weekends covering neurosurgery and neurology ward patients and admissions.

Annual leave and lieu days are already included in the rota.

This is a great placement to learn. Make the most of it!

NCCU morning handover starts at 8am in the B spur library on week days and in the NCCU coffee room on weekends. Lasts until 9 or 9.30. Morning plans will be formulated there and once back on the units, patients will be split between SpRs/CFs/FY2s - depending on the number of Drs present, you will be allocated 3-6 patients. you're expected to review your patients and do he jobs from the morning handover before the consultant ward round starts around 11. There are 2 consultants present every day and they will split the patients. Ward round can last for hours. After the consultants have seen your patients you can do the jobs. There is a short evening ward round ( consultants + fellows on call) around 7-8, before evening handover at 8pm in the NCCU coffee room.

There is a lot of teaching in the department, formal and informal. The teaching calendar can be found on the NCCU education website. There regular vascular access and ECHO (FICE) teaching sessions.

There is ALWAYS support from the SpRs and Consultants and scope to learn and do procedures (CVC insertion, Arterial lines, LPs, chest drains etc). When one of the fellows is on their Twilight shift they end up being getting all the outstanding procedures and are generally worth following.

7.45am – B-spur meeting room neurosurgical SPR/consultant on-call handover. Optional but often of some educational value if attended regularly and gives you an insight into neurosurgical mind-set and justification for their decisions.

8am (prompt) – NCCU handover until approx. 9am in B-sour meeting room (NCCU coffee room weekends/bank holidays). This is led by the clinical fellows on overnight and the consultants on that day. Scans are driven by the neurosurgical SPR who will stay until the neurosurgical patients are discussed then an NCCU clinical fellow/FY2 will operate the imaging. The FY2 on the unit also is responsible for documenting the morning MDT notes on EPIC which serves as a guide to the plan for the patient. Most people arrive in scrubs already for this meeting.

9am – Board round. Consultant or senior clinical fellow on the unit will assign patients for all fellows and FY2s to assess prior to the consultant ward round. You will probably be assigned 3-5 patients a day depending on the number of fellows. Initially do not take on too many patients or very complex ones until you find your feet.

9-11am – Assess your patients, notes, bloods, scans, clinical examination, discuss concerns with nurses etc. FY2 normally needs to phone through CXR requests and ensure they are booked early so the CXR is done prior to ward round. Also consider booking CT heads as portable to prevent a transfer from the unit- it is more difficult to do this late in the day so plan early. If you finish your assessments early try to prepare the transfer summaries for those likely to be stepped down to the ward. Most of these patients will be on HDU.

11ish until early afternoon – Consultant led ward round. An ongoing procession around the unit from both ends by two consultants. Join for as much as you are able although it is difficult to be there for all as you will need to sort jobs and may be needed elsewhere. Present your patients to the consultant on and come up with a plan. Once settled in you will be expected to come up with a decent plan yourself and even as an FY2 your opinion will be valued. See the ward round not as series of OSCE stations or hot cases but as an often one-on-one expert led teaching session. Put it and you will get out etc. Post ward round- do jobs. The culture is such that if one of your patients’ needs a line, drain, bronchoscopy then you will play a central role. You will not be able to put in a central line on day one, but you should be able to do this with indirect supervision by the end of the placement.

4.30pm- There is a teaching session at 4.30 several times a week. Keep up to date with the schedule on the NCCU Education website (http://cambridgecriticalcare.net/) and look out for emails. Many people have gone to some effort to contribute to teaching sessions so be respectful and plan your day to get to this session at all costs bar a clinical emergency.

6pm- Handover the current situation of your patients to the long day fellow and aim to get off on time. Note that although the structure of the day should follow this schedule that it can vary depending on the number of fellows, the consultant in charge and how busy the unit is. Clearly if several patients need to go to scan and you are not airway trained you will end up picking up jobs from other patients whilst the anaesthetic trained fellows transfer the patients to scan. You should go with them as far as possible for experience and learning. Many senior fellows will lead you lead the transfer as an educational experience.

Trauma/polytrauma, traumatic brain injury, SAH, ICH/IVH, epileptic status, brain tumours, Spinal pathology, meningitis/encephalitis etc.

Neurosurgery and trauma patients are the most common, but also neurology and stroke patients too. Occasionally there is some movement to and fro with the John Farman Unit which is the general intensive care. Common conditions seen on the unit and some up to date reviews about their basic pathophysiology and management can be found on the NCCU Education website under the Quant ‘Neurocritical Care for the Naïve’: http://cambridgecriticalcare.net/quant-neurocritical-naive/

Admission can be from:

ED

The ward

Theatre

Hospital ITU Transfer

There is a follow up clinic on a Wednesday afternoon with Prof Menon which you should try to attend.

You will not work on NCCU out of hours as an FY2- all on-calls are for neurosurgery.

On call duties for Neurosciences consist of the following; On call day 0800 until 2000 = usually once a week during which you carry the on call bleep (152 357) from 0800 until 2000. You should usually not have any bleeps from 0800 until 1800. After 1800 you will cover all of the neurosciences ward patients and any new admissions. The SHO does not accept new admissions.

On call weekend long day 0800 until 2000 = The long day SHO will do a ward round with the neurosurgical registrar of all neurosurgical patients first thing without the bleep. At 1200 you receive the handover from the short day SHO and carry the bleep from 1200-2000.

On call weekend short days 0800 until 1200 = The short day SHO carries the bleep (152 357) and completes ward jobs and clerks any new admission until 1200 whilst the long day SHO is on the ward round. Handover is at 1200 to the long day SHO.

NCCU WEEKENDS 0800 until 1600 = Working day is the same as the normal NCCU day however the SHO is more likely to be allocated HDU on the weekend.

NIGHTS 2000-0800 = The SHO holds the bleep (152 357) overnight covering the wards and any new admissions. The on call registrar for neurosurgery will be in hospital as well. The majority of the work load will be neurosurgery however you are also responsible for neurology patients. The neurology registrar is contactable via switchboard. Nights is a good time to assist in theatre if interested.

See entry for Neurosurgery as same applies when on call.

When on the unit, some extra numbers are located above the doctors station in the main unit. In an emergency use switchboard to go to mobile if needed. It is often useful to visit the neuroradiology team in person to discuss scan requests and reports. This can be educational also as they are often willing to explain exactly what is going on!

This a 50% banded job. You are on the neurosurgery SHO on-call rota (see neurosurgery page for detailed information). You will get a 1 day neurosurgery specific induction at the start of the placement. The rota has many half days in it. If you leave them as this you will end up doing full days! Discuss early with the neurosurgical SPR co-ordinating the rota to convert into normal days and get some extra days off. You need to make sure the other FY2 on NCCU in on those days in order to do so as at least 1 FY2/SHO must be on NCCU every day including weekends. When you are on-call for neurosurgery you must call carry the neurosurgery bleep. It goes off a lot, especially if you colleagues are covering multiple wards. If you are bleeped by a ward politely redirect them to junior covering that ward during the day. If that junior is uncontactable and the issue can wait then ask the ward to wait for the junior to return to the ward. If it is an emergency you must attend. The only other neurosurgical work you should do before 6pm is pop to ED to clerk a patient if the neurosurgical SPR on call asks you to do so. Do not do jobs for any other neurosurgeon between 8am-6pm as they have their own juniors and your responsibility is to NCCU patients.

Study leave can be arranged as per FY2 allowances. Annual leave is fixed and there is a policy that there has to be at least one SHO on NCCU during normal hours. Annual leave requests can be discussed with Dr Lavinio, NCCU Director, if you need to change your allocated leave.

The NCCU website is the hub of educational focus and can be found at: http://cambridgecriticalcare.net/. There is an expectation that you will contribute to it during your time on the unit. Such contribution is not contractual despite rumours/pressure it may be, however it does get your name on a website and other people can see your efforts so that the journal club or nugget of information you have does not disappear into the ether. For those who are website friendly I’m sure there would be opportunities to contribute to website maintenance.

All procedures including CVC, arterial line, chest drain, lumbar puncture, bronchoscopy, tracheostomy, emergency airway skills, cardioversion, resuscitation, ICP bolt/EVD insertion (if friendly neurosurgeon) are all fair gain for FY2s to perform under supervised conditions. Ask and ye shall be granted. Don’t ask and ye shall be a jobs monkey for four months and get little practical procedure out of this job, which probably has the most potential practical skills out of any F2 placement.

You may be daunted initially by the array of monitoring, pumps, ventilators etc by the bedside and even if you understand what each thing is doing you may not be au fait with its workings. The nurses are a fount of practical knowledge and understand all the devices in detail. It is important to either ask them to alter something or inform them you have done it. It is important to get some induction to the ventilators in order to operate them if you need to.

As the FY2 you will often be responsible for reporting cases to the coroner and issuing death certificates. This needs to be done in a timely way (i.e. the same or early next working day). During the week you may be the continuity on the unit as consultants change daily and the clinical fellow rota is complex so you need to keep tabs on this. REPORTING TO THE CORONER CANNOT BE DELAYED AND YOU MUST TAKE RESPONSIBILITY FOR IT OR ENSURE A FELLOW IS REPORTING IT. Always discuss with the neurosurgeons/home clinical team what they want on the MCCD before discussing with the coroner’s officer. If the coroner asks you to write a doctors report then draft and get the neurosurgical consultant who that patient was under to check it before signing it. It is important as the information in this report is the primary evidence the coroner will use and may determine if you and others get called to an inquest/if there is an inquest at all. It is common to write a report for trauma cases in particular.

There are often medical students. Try to involve them and explain what’s going on. If you are assessing a patient let them see everything and learn!

General approach to ICU patients

Essentially a mnemonic encompassing the ICU tab on EPIC, a quick read and emphasis on the basics, also useful if you like mnemonics:

Give your patient a fast hug (at least) once a day External Link

Critically ill patients need “FAST HUGS BID” (an updated mnemonic) External Link

Cardiovascular

The use of inotropes/vasopressor and cardiac output monitoring is rather unfamiliar when first starting.

This is a brief summary of the main agents, mostly in table form: http://lifeinthefastlane.com/ccc/inotropes-vasopressors-and-other-vasoactive-agents/

This is more comprehensive with particular detail of the pharmacology: Bangash. Use of inotropes and vasopressor agents in critically ill patients. Br J Pharmacol 2012;165(7):2015–2033 External Link

These are both brief summaries but hopefully mean that the cardiac output monitors look more than just expensive machines when first viewed:

Pearse. Equipment review: An appraisal of the LiDCO™plus method of measuring cardiac output. Crit Care 2004; 8(3):190–195 External Link

http://lifeinthefastlane.com/ccc/picco/

Ventilators

Bristle. Anesthesia and critical care ventilator modes: past, present, and future. AANA J 2014;82(5):387-400 External Link

Sedation

The first first link is quite short and has emphasis on NCCU, the second is probably more comprehensive (quite long) addressing general principles of sedation and analgesia in ICU.

Birinder. Sedation in neurological intensive care unit. Ann Indian Acad Neurol 2013;16(2): 194–202 External Link

Intensive Care Society Review of Best Practice for Analgesia and Sedation in the Critical Care External Link

Finally- enjoy the job. In our opinion it is probably the best clinical rotation in the hospital from a trainee point of view and you can get a lot out of it.

Dr Tamara Tajsic, Dr Andrew Kane, Dr Sarah Leir, Dr Negin Amiri, Dr Sam Cook Dr Man-Cheung Lee Foundation Year Two Doctors