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Episode 91: PERSPECTIVES - Dr Jamil Dibu

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Description

Dr Jamil Dibu joins Dr Lauren Koffman to discuss building a neurocritical care unit in Abu Dhabi and developing a framework for determining death by neurologic criteria in the United Arab Emirates.

Contributors

  • Aanand D Naik, MD

    Baylor College of Medicine
    Houston, TX

  • Lauren Koffman DO, MS

    Assistant Professor, Clinical Neurology, Lewis Katz School of Medicine at Temple University

  1. 00:00:19
    Hi, everyone. I'm Dr. Lauren Kaufman
  2. 00:00:21
    and I'd like to welcome you to the NCS
  3. 00:00:23
    podcast. Today, you turned into
  4. 00:00:25
    another episode in our perspective
  5. 00:00:27
    series where we explore the diverse
  6. 00:00:29
    perspectives and neurocritical care.
  7. 00:00:31
    Today, I'd like to welcome Dr. Jamil
  8. 00:00:33
    DiBou to the podcast to discuss
  9. 00:00:35
    neurocritical care practice and the UAE
  10. 00:00:38
    and how he's been involved in the
  11. 00:00:39
    creation of a brain death protocol for
  12. 00:00:40
    the region. So Jimmy and I go back to
  13. 00:00:43
    our days in Cleveland Clinic, but for
  14. 00:00:45
    those that don't know you, would you
  15. 00:00:46
    mind giving a brief little summary of
  16. 00:00:48
    your background where you train and what
  17. 00:00:50
    your current position is?
  18. 00:00:52
    Yeah, thank you. Thank you NCS and
  19. 00:00:55
    Lauren for the invite. It's a pleasure.
  20. 00:00:59
    Yeah, Lauren, we I did so I'm born the
  21. 00:01:03
    US raised in Lebanon. I did medical
  22. 00:01:05
    school in the American University of
  23. 00:01:06
    Beirut. I went to the US in 2010, did
  24. 00:01:10
    neurology and a lot of Arkansas and then
  25. 00:01:12
    two years of neurocritical care
  26. 00:01:14
    fellowship at Cleveland Clinic. And
  27. 00:01:16
    this is where we met. You were chief
  28. 00:01:17
    resident, I was fellow. And yeah,
  29. 00:01:20
    actually there is where I got recruited
  30. 00:01:23
    to come to Abu Dhabi where the Cleveland
  31. 00:01:26
    Clinic opened up their hospital. So
  32. 00:01:28
    that's in a nutshell,
  33. 00:01:31
    my training and how I got to Abu Dhabi.
  34. 00:01:35
    And so did you have any like idea that
  35. 00:01:37
    you'd be practicing abroad when you went
  36. 00:01:39
    into medicine or did you just take this
  37. 00:01:41
    opportunity when it came off? Yeah, no,
  38. 00:01:46
    so frankly, I was in fact, after
  39. 00:01:50
    neuro-critical care. So I did my two
  40. 00:01:51
    years in dental clinic. I was actually
  41. 00:01:54
    going after a stroke fellowship and then
  42. 00:01:57
    stay in the US. I had no plans to leave
  43. 00:02:01
    the US.
  44. 00:02:04
    And then while I was a fellow,
  45. 00:02:06
    they cleaved in 2015, dental clinic in
  46. 00:02:09
    Abu Dhabi opened their doors And
  47. 00:02:12
    suddenly ICU their of many, first their
  48. 00:02:12
    all had they
  49. 00:02:17
    neurokeletal care patients and then they
  50. 00:02:19
    quickly realized they need a
  51. 00:02:20
    neuro-intensivist as they grow, they
  52. 00:02:23
    need to set up a dedicated neuro
  53. 00:02:26
    ICU. So then they flew to Cleveland,
  54. 00:02:29
    they talked to my mentor, Dr. Mano,
  55. 00:02:31
    which you know very well and known in
  56. 00:02:34
    the society, he was my mentor. I was
  57. 00:02:36
    fortunate to have him there with me and
  58. 00:02:38
    he told them just talk to Jimmy since I
  59. 00:02:40
    was graduating, I have ties to the
  60. 00:02:43
    region. Yeah, they just plainly asked
  61. 00:02:46
    me, would you, when you done
  62. 00:02:47
    fellowship, can you come set up dinner
  63. 00:02:49
    ICU? I thought it's crazy because
  64. 00:02:52
    you're a fellow and your first obsession
  65. 00:02:55
    after fellowship is clinical and, you
  66. 00:02:58
    know, growth exposure and mentorship.
  67. 00:03:02
    So that's what I told Dr. Chapman,
  68. 00:03:05
    who's currently still here, they had a
  69. 00:03:07
    quality institute and respiratory
  70. 00:03:08
    institute from Cleveland. I told them,
  71. 00:03:11
    you know, I'm a fellow, right? He's
  72. 00:03:13
    like, yeah, I'm like, okay, fine.
  73. 00:03:15
    I'll jump on it and I knew I was scared
  74. 00:03:20
    because it's a big role to come set up a
  75. 00:03:22
    program out of fellowship. For two
  76. 00:03:24
    reasons, one, I was scared because the
  77. 00:03:26
    clinical exposure was not guaranteed.
  78. 00:03:29
    We only have few beds of the entire
  79. 00:03:31
    hospital as you open. We didn't know if
  80. 00:03:33
    the growth is gonna be guaranteed, the
  81. 00:03:35
    clinical load is gonna be there. So it
  82. 00:03:37
    was a bet that I put in and I knew the
  83. 00:03:39
    exposure at the beginning for clinical
  84. 00:03:41
    work was tough But then the second,
  85. 00:03:45
    what made me comfortable, that's what
  86. 00:03:47
    made me uncomfortable. What made me
  87. 00:03:48
    comfortable is I knew we had a good
  88. 00:03:50
    system in Cleveland. So I just needed
  89. 00:03:52
    to replicate it. So that's really how,
  90. 00:03:56
    no, I didn't know I'm gonna end up in
  91. 00:03:57
    Abu Dhabi, but it's an opportunity to
  92. 00:04:00
    be asked, I was actually 30 years old
  93. 00:04:02
    and my second year fellowship or first
  94. 00:04:04
    year fellowship to come set up a unit.
  95. 00:04:06
    I don't think that comes around a lot.
  96. 00:04:08
    And it's a Cleveland clinic, DNA, true
  97. 00:04:10
    DNA on the ground here Wow, I can't
  98. 00:04:13
    imagine that I'm going to scare you,
  99. 00:04:15
    I'm going to scare you. And what year
  100. 00:04:17
    was that when you went to start it? And
  101. 00:04:19
    who was on your team at that point? And
  102. 00:04:21
    how has it grown since then? Yeah,
  103. 00:04:26
    2015, I was flown in here to interview.
  104. 00:04:31
    There were only six beds out of now.
  105. 00:04:34
    What we have total ICU beds in the
  106. 00:04:36
    entire hospital 72. Six were
  107. 00:04:39
    operational and they were mixed units.
  108. 00:04:41
    So I came to interview to set up a unit
  109. 00:04:44
    So I tried to envision they told me it's
  110. 00:04:46
    going to become 24 dedicated in the
  111. 00:04:48
    right two beds out of 72. So
  112. 00:04:53
    it was a big bet. And so 2015, I
  113. 00:04:56
    interviewed, I went for it, 2016, I
  114. 00:04:58
    came. After my fellowship, I graduated
  115. 00:05:00
    in July, took a month off, best month
  116. 00:05:03
    of my life, where you wake up, there's
  117. 00:05:05
    no emails to attend to, you're not
  118. 00:05:06
    responding. You don't have to report to
  119. 00:05:08
    anybody
  120. 00:05:11
    have flown in here. That's August 2016.
  121. 00:05:15
    There was me, it was end of one. And I
  122. 00:05:18
    was responsible, I'm the only
  123. 00:05:19
    neurointensivist and I was responsible
  124. 00:05:21
    to, as we grow the number of beds, at
  125. 00:05:24
    that point, just to establish policies,
  126. 00:05:27
    procedures, epic order sets, acquire
  127. 00:05:30
    medications, everything from scratch.
  128. 00:05:33
    And then as the patient load increase,
  129. 00:05:36
    start recruiting accordingly. And
  130. 00:05:38
    that's really what happened. So fast
  131. 00:05:40
    forward, 2016, I think there were
  132. 00:05:42
    eight total beds. Now the hospital runs
  133. 00:05:44
    at 72 ICU beds, out of which 24 are in
  134. 00:05:48
    one unit are dedicated neuro-ICU. I
  135. 00:05:51
    recruited two fellowship trained
  136. 00:05:53
    neuro-intensivists from the US, one
  137. 00:05:55
    trained with Dr. Panos in Detroit,
  138. 00:05:59
    Hossam at Cambridge, and one trained
  139. 00:06:01
    with Gretchen, a work with Gretchen
  140. 00:06:02
    Brophy
  141. 00:06:05
    in VCU. And then a nurse practitioner
  142. 00:06:07
    from Cleveland, from Hartford and from
  143. 00:06:10
    University of Maryland. That's
  144. 00:06:11
    something we'll talk about shortly about
  145. 00:06:13
    nurse practitioners. The team has grown,
  146. 00:06:16
    and I had two people, palm critical
  147. 00:06:17
    care from the US, that decided to take
  148. 00:06:21
    up their ICU. They decided they liked
  149. 00:06:23
    it at their middle age, and then we
  150. 00:06:25
    trained them, actually. We went
  151. 00:06:27
    through how to take care of these
  152. 00:06:29
    patients. They sat even recently for
  153. 00:06:30
    the ABIM board. So for me, I consider
  154. 00:06:32
    them now also neuro-intensive. So it's
  155. 00:06:35
    a big team, and we've grown pretty much
  156. 00:06:40
    to a large team with very busy units And
  157. 00:06:44
    you, so it sounds like all of your
  158. 00:06:46
    positions have been trained in the US.
  159. 00:06:48
    We're all the APPs as well, the US
  160. 00:06:51
    trained. Yeah, yeah, yeah. So, and
  161. 00:06:54
    then this part of the experience that
  162. 00:06:56
    I'm sure we're going to touch upon. So
  163. 00:06:59
    I have a couple of colleagues from
  164. 00:07:00
    Europe, and the reality is on this side
  165. 00:07:05
    of the world, there's more staff from
  166. 00:07:08
    Europe overall in the hospital, even in
  167. 00:07:10
    the country than from North America.
  168. 00:07:14
    And it's a popular destination for UK,
  169. 00:07:18
    Italian, German trained physicians to
  170. 00:07:20
    come here for various reasons. And I
  171. 00:07:24
    have two or three of my team members
  172. 00:07:27
    under no issue, they're from Europe.
  173. 00:07:29
    And it's not the same. And we'll talk
  174. 00:07:33
    about this overall and in terms of one
  175. 00:07:36
    of the big differences practicing here.
  176. 00:07:39
    Generally,
  177. 00:07:42
    there's not much of extreme
  178. 00:07:45
    specialization and multidisciplinary
  179. 00:07:49
    manpower in Europe as much as in the US.
  180. 00:07:51
    And I'll touch upon this shortly. And
  181. 00:07:54
    there's difference in practices. But I
  182. 00:07:57
    do have colleagues from Europe with us.
  183. 00:08:01
    And it's an interesting perspective.
  184. 00:08:02
    Honestly, it teaches you a lot that
  185. 00:08:05
    what exists outside the US, actually,
  186. 00:08:06
    there's plenty. And you can adapt your
  187. 00:08:09
    practice to that. It's not always the
  188. 00:08:11
    US way, neither a cleave on connect way
  189. 00:08:12
    and it works both ways.
  190. 00:08:16
    And in terms of APPs and P's, there's
  191. 00:08:18
    no such thing in Europe, there's no APP
  192. 00:08:21
    and P. Even when we came to this
  193. 00:08:23
    country,
  194. 00:08:25
    we had to, the country does not have,
  195. 00:08:29
    I think in the region, overall, GCC,
  196. 00:08:32
    Middle East, North Africa, there's no
  197. 00:08:34
    such thing as nurse practitioner or PA.
  198. 00:08:36
    So what we did as Cleveland Clinic,
  199. 00:08:39
    because we're used to it, our executive
  200. 00:08:42
    leadership drafted a business white
  201. 00:08:44
    paper to the country's regulatory health
  202. 00:08:47
    care force. They describe what NPPA is
  203. 00:08:51
    and the role of their and how they can
  204. 00:08:53
    support. And they embedded that in the
  205. 00:08:56
    healthcare regulatory laws and
  206. 00:08:58
    regulations that it's allowed. And
  207. 00:09:00
    we're still today probably the only
  208. 00:09:02
    hospital that hires NPPA is because the
  209. 00:09:05
    rest of the country, even the region
  210. 00:09:07
    does not really understand what the
  211. 00:09:09
    value that NPPA is bring to healthcare
  212. 00:09:13
    So in other ICUs outside of the
  213. 00:09:16
    Cleveland Clinic and the area is it just
  214. 00:09:17
    the physicians managing all of these
  215. 00:09:19
    patients or maybe trainees as well?
  216. 00:09:22
    Correct. So trainees less so
  217. 00:09:27
    training
  218. 00:09:29
    and fellowship and residency, there are,
  219. 00:09:33
    it's under development. And definitely
  220. 00:09:36
    this is one of the big key areas for the
  221. 00:09:38
    country's leadership that are asking and
  222. 00:09:40
    mandating, especially us, that
  223. 00:09:42
    ultimately we want to develop talent
  224. 00:09:44
    from the region. For the most part,
  225. 00:09:46
    for the longest, they rely on importing
  226. 00:09:50
    talent, but things are changing and
  227. 00:09:52
    they want to train, that's one of the
  228. 00:09:54
    many missions that we have.
  229. 00:09:57
    Here, there's some sort of different
  230. 00:09:59
    dynamics. This country in particular,
  231. 00:10:02
    the UAE, has some specific tuning for
  232. 00:10:06
    physicians. So if you're trained in
  233. 00:10:08
    Lebanon, say, or Egypt, Did your
  234. 00:10:11
    residency and fellowship? you get hired
  235. 00:10:14
    in the UAE, it's not gonna be the same
  236. 00:10:18
    full role or full senior, not seniority,
  237. 00:10:21
    full, let's say,
  238. 00:10:25
    it's not, you don't have the same
  239. 00:10:26
    privileges as someone trained in North
  240. 00:10:29
    America, board certified intensivist.
  241. 00:10:31
    So
  242. 00:10:34
    they, I think they call them associate
  243. 00:10:37
    level and then there's consultant level.
  244. 00:10:39
    That's what we're called if you're board
  245. 00:10:42
    certified, you're consultant if you're
  246. 00:10:43
    from Egypt or Lebanon or Jordan, you're
  247. 00:10:46
    associate. So there's some kind of
  248. 00:10:48
    supervision or sign off on these
  249. 00:10:50
    patients from
  250. 00:10:53
    the
  251. 00:10:55
    consultant to the associate. So that's
  252. 00:10:55
    a bit of a different dynamic. Super
  253. 00:10:55
    fellows, you can call them. So that's
  254. 00:10:58
    a bit in nuance, but you can think of
  255. 00:11:01
    these guys as the fellows and APPs in
  256. 00:11:03
    North America. And then there's the
  257. 00:11:04
    board certified UK, some other
  258. 00:11:07
    countries, Germany, the US, that are
  259. 00:11:11
    considered consultants or staff as in
  260. 00:11:13
    attending staff in the US, yeah. And
  261. 00:11:15
    what would you say is the case to mix
  262. 00:11:17
    like, is it what you're expecting or is
  263. 00:11:19
    it significantly different from the US?
  264. 00:11:22
    So I was extremely lucky because I was
  265. 00:11:27
    fortunate recently to host the NCS
  266. 00:11:30
    leadership. As you know, they can
  267. 00:11:32
    visit the unit and we talked about this
  268. 00:11:35
    interestingly, not by chance that
  269. 00:11:40
    we have exactly almost the same mix of
  270. 00:11:42
    patients as we had in main campus in
  271. 00:11:44
    Cleveland. We're very heavy in
  272. 00:11:46
    cerebrovascular diseases, very heavy
  273. 00:11:49
    for two reasons. One is
  274. 00:11:53
    our center in the
  275. 00:11:56
    Cleveland Clinic Abu Dhabi and which is
  276. 00:11:57
    the Abu Dhabi is the capital of the UAE
  277. 00:11:59
    is the only center and frankly,
  278. 00:12:02
    potentially of the entire nation that is
  279. 00:12:04
    capable of giving the full spectrum care
  280. 00:12:07
    from the moment you're admitted with any
  281. 00:12:09
    stroke type. you get the charge. So,
  282. 00:12:11
    Wordy, essentially, they only analyze
  283. 00:12:13
    you in the country, dedicated, and its
  284. 00:12:16
    form of definition, and we're the only
  285. 00:12:19
    probably in Abu Dhabi region for sure,
  286. 00:12:21
    from back to me capable center. So, by
  287. 00:12:25
    default, the Department of Health
  288. 00:12:27
    mandates that all patients come to us.
  289. 00:12:30
    And that's number one. Number two,
  290. 00:12:33
    interestingly,
  291. 00:12:35
    in terms of patients' demographics, you
  292. 00:12:40
    probably were exposed recently to the
  293. 00:12:42
    demographics here. And the UAE, almost
  294. 00:12:45
    80 are expats. And out of the 80, a
  295. 00:12:49
    majority comes from Indian subcontinent
  296. 00:12:51
    and Philippines. And they're on the
  297. 00:12:53
    younger age side. And for whatever
  298. 00:12:55
    reason, someday, we always keep saying
  299. 00:12:58
    someday, we're going to publish data.
  300. 00:13:01
    Our patients' admissions start with
  301. 00:13:04
    40-year-old Indian patient with no past
  302. 00:13:07
    the past Metaphy Street, Pigeons
  303. 00:13:08
    presents with a large stroke. or high
  304. 00:13:11
    grade subarachnoid. It's completely
  305. 00:13:13
    different from your traditional in the
  306. 00:13:15
    US. 70 year old with the abattic
  307. 00:13:17
    hypertension presents with the bleed
  308. 00:13:18
    different demographics, different
  309. 00:13:20
    pathologies. And because of these
  310. 00:13:23
    patients are the bulk of the nation in
  311. 00:13:25
    terms of demographics, it turns out
  312. 00:13:28
    that we and the mandate that we have
  313. 00:13:30
    were the only center that can treat
  314. 00:13:32
    these patients. It turns out that we
  315. 00:13:33
    have high volume. So we're talking
  316. 00:13:35
    about over 100 ICHs per year, over 100
  317. 00:13:39
    subarachnoid hemorrhages per year, over
  318. 00:13:42
    200 plus, I'm sure is kimic strokes,
  319. 00:13:44
    which are TPA plus or my thrombectomy or
  320. 00:13:47
    malignant. Very heavy and
  321. 00:13:50
    cerebrovascular. Of course, we have a
  322. 00:13:52
    very advanced, fully capable
  323. 00:13:54
    neurosurgical team. So
  324. 00:13:57
    we have lots of postops,
  325. 00:13:59
    transphenoidals, meningiomas, XYZ,
  326. 00:14:02
    subduros, all that stuff And I think it
  327. 00:14:06
    matters, honestly, in the US. Every
  328. 00:14:08
    now and then you get neuromuscular, you
  329. 00:14:09
    get status. We do see autoimmune
  330. 00:14:12
    encephalitis. So
  331. 00:14:14
    that's really the kind of the breath,
  332. 00:14:17
    but mainly heavily cerebral vascular.
  333. 00:14:19
    And so you mentioned that the concept of
  334. 00:14:22
    something super specialized like
  335. 00:14:24
    neurocritical care doesn't really exist
  336. 00:14:25
    in the region. So when you started this
  337. 00:14:27
    program, was it embraced? Or was there
  338. 00:14:29
    like a culture shock or pushback? What
  339. 00:14:31
    was the response? Yeah
  340. 00:14:36
    Actually, so in our hospital, I got a
  341. 00:14:40
    lot of support. So you, obviously I
  342. 00:14:44
    know it's cliche, but it took an entire
  343. 00:14:48
    health system to support us to get this
  344. 00:14:51
    done because they had, they know what
  345. 00:14:54
    we had in Cleveland. We had a work
  346. 00:14:55
    class in RICU. They wanted the same
  347. 00:14:58
    here. And our leadership that is
  348. 00:15:00
    physician-led, like in Cleveland Clinic,
  349. 00:15:02
    understands the value of neurocritical
  350. 00:15:04
    care and by default also.
  351. 00:15:10
    You know, the bulk of the admissions
  352. 00:15:12
    and the ICU, I mean, the big bulk,
  353. 00:15:14
    big bulk is dominated by neuro ICU
  354. 00:15:17
    admissions. So we're a bit fortunate,
  355. 00:15:19
    I guess, compared to other hospitals,
  356. 00:15:21
    you know, especially in main campus,
  357. 00:15:22
    for example, there's the cardiac ICU
  358. 00:15:24
    volume is much more bigger. Even
  359. 00:15:27
    medical ICU here were 24 beds neuro ICU
  360. 00:15:31
    similar to the cardiac, similar to the
  361. 00:15:33
    medical So there, and the leadership
  362. 00:15:36
    that came also from Cleveland
  363. 00:15:37
    understands the value of neuro ICU and
  364. 00:15:39
    know that this exists. So I was lucky,
  365. 00:15:41
    I didn't have to explain to our hospital
  366. 00:15:43
    leadership what neuro ICU is, but
  367. 00:15:46
    coming outside the Cleveland Clinic,
  368. 00:15:48
    it's a new concept and you've seen it
  369. 00:15:51
    recently in the conference. So there's
  370. 00:15:53
    a lot of subliminal we can talk about
  371. 00:15:55
    this shortly, out of all the
  372. 00:15:57
    conferences and lectures we've given
  373. 00:15:59
    over the years, subliminally we're
  374. 00:16:01
    educating the nation, we're educating
  375. 00:16:04
    neighboring nations about the value of
  376. 00:16:07
    having a neuro ICU a dedicated, because
  377. 00:16:10
    here in this part of the region, and
  378. 00:16:13
    I'm sure in the US, it still exists in
  379. 00:16:15
    some areas, it's the intensivist,
  380. 00:16:17
    manages neck down, the surgeon will,
  381. 00:16:17
    and the neurologist will walk and tell
  382. 00:16:17
    you about neck up, but then the
  383. 00:16:18
    interplay gets lost in translation, and
  384. 00:16:18
    therefore the outcomes are not the same.
  385. 00:16:19
    So the classic reason why neuro
  386. 00:16:30
    ICU is important, but they don't know
  387. 00:16:34
    yet that it A exists and B it's
  388. 00:16:36
    important. And that's subliminally what
  389. 00:16:39
    we're trying to spread the message
  390. 00:16:42
    alongside many other things. Looking
  391. 00:16:45
    back, if you could give, you know,
  392. 00:16:47
    2015, 2016 Jimmy advice as you were
  393. 00:16:51
    embarking on this, what do you think
  394. 00:16:53
    you wish you knew at that time?
  395. 00:17:02
    The biggest thing that comes to mind,
  396. 00:17:04
    which I don't know that I would help
  397. 00:17:07
    myself back then, is I would wish I had
  398. 00:17:11
    mentorship, which I tried. I actively
  399. 00:17:16
    reached out to everybody in the US all
  400. 00:17:18
    the time from either mentorship
  401. 00:17:21
    developing programs to clinical, right?
  402. 00:17:24
    I was out of fellowship, I still didn't
  403. 00:17:26
    know at all, so I had to call up people,
  404. 00:17:28
    Hey, is this right next step? in terms
  405. 00:17:31
    of management, clinical management,
  406. 00:17:32
    but the biggest thing is leadership,
  407. 00:17:36
    mentorship. I got it here proactively,
  408. 00:17:41
    but as you can imagine, at the age of
  409. 00:17:44
    30, and some RRT members, I think on
  410. 00:17:47
    average, they're older than me by, I
  411. 00:17:50
    don't know, 10 years or so, minimum
  412. 00:17:53
    managing a team. setting up program at
  413. 00:17:56
    the age of 30,
  414. 00:17:59
    takes a lot of leadership skills and
  415. 00:18:01
    experience. I had this stamina, I had
  416. 00:18:05
    the proactivity, but then obviously
  417. 00:18:08
    communication and leadership
  418. 00:18:13
    ways of handling it, there was a lot of
  419. 00:18:15
    learning on my end. I know looking back,
  420. 00:18:18
    I would like to change it, but no one's
  421. 00:18:20
    born a leader smoothly in terms of
  422. 00:18:21
    communication. And although you would
  423. 00:18:24
    think you're doing the right thing,
  424. 00:18:25
    being proactive, but you have to
  425. 00:18:27
    understand who you're dealing with. So
  426. 00:18:30
    if I go back,
  427. 00:18:33
    I would wish to probably clamp down on
  428. 00:18:37
    more leadership support and mentorship.
  429. 00:18:41
    I was, again, fortunate to just
  430. 00:18:42
    replicate the systems we had in
  431. 00:18:44
    Cleveland. You know them, all the
  432. 00:18:46
    protocols, order sets. Honestly, I
  433. 00:18:47
    just, for the most part, replicated
  434. 00:18:49
    the same. with some adjustment to the
  435. 00:18:52
    country's needs or variability in
  436. 00:18:54
    practice that we don't have in the US.
  437. 00:18:57
    So that helped me a lot from the
  438. 00:18:59
    clinical perspective, but then
  439. 00:19:00
    leadership was a big thing. I didn't
  440. 00:19:02
    have the time, I was graduating, I
  441. 00:19:04
    didn't realize what leadership of a big
  442. 00:19:06
    team, of a big hospital.
  443. 00:19:09
    Yeah, that's the one thing I would
  444. 00:19:11
    probably work on, but we were alone,
  445. 00:19:13
    everybody, so we were a small pond.
  446. 00:19:16
    And so there was a handful of physicians
  447. 00:19:19
    in the entire hospital And everybody had
  448. 00:19:21
    a task. So it's not like we had a
  449. 00:19:23
    leadership that's over there and
  450. 00:19:25
    everybody's chill and we can mentor each
  451. 00:19:27
    other. No, no, it was
  452. 00:19:30
    everybody had a task and we're racing
  453. 00:19:32
    against time and we needed to expand X
  454. 00:19:34
    amount of beds every X amount a month.
  455. 00:19:37
    So you had just to do it and learn on
  456. 00:19:40
    the goal. So that was the biggest thing,
  457. 00:19:42
    yeah. Well, I mean, you've mentioned
  458. 00:19:44
    a few times the conference and for those
  459. 00:19:46
    that haven't listed to some of our other
  460. 00:19:48
    podcasts, I was able to attend the
  461. 00:19:50
    Emirates critical care conference about
  462. 00:19:52
    a month ago, we're able to catch up.
  463. 00:19:54
    And I was so impressed to hear your talk
  464. 00:19:56
    about brain death and the evolution of
  465. 00:19:58
    the concept in the region because I
  466. 00:20:00
    truly had no idea that it just wasn't a
  467. 00:20:03
    thing there for until several years ago,
  468. 00:20:06
    not even several, a handful of years
  469. 00:20:08
    ago. So would you mind telling our
  470. 00:20:10
    listeners a little bit about how the
  471. 00:20:12
    concept of brain death started in your
  472. 00:20:13
    role in that process? Yeah, so before
  473. 00:20:17
    I go, I'm gonna go on a little tangent
  474. 00:20:18
    related to that and then I'll talk about
  475. 00:20:21
    the brain death evolution and talk about
  476. 00:20:23
    the role of neuroticusoid and that
  477. 00:20:25
    conference per se because it touches
  478. 00:20:28
    upon what we discussed. So the tangent
  479. 00:20:30
    is first, so, and to all the listeners
  480. 00:20:34
    that plan to come here or elsewhere to
  481. 00:20:38
    practice outside US. and have never
  482. 00:20:41
    left North America.
  483. 00:20:44
    There are differences in practice and be
  484. 00:20:47
    it, so for example, in Europe,
  485. 00:20:50
    there's no such thing as respiratory
  486. 00:20:51
    therapist. And when we first came and
  487. 00:20:55
    we had respiratory therapists because
  488. 00:20:57
    it's a Cleveland Clinic model. So the
  489. 00:20:59
    European colleagues were baffled. So
  490. 00:21:01
    why is someone touching my ventilator?
  491. 00:21:05
    They manage the ventilator. So we had
  492. 00:21:06
    to explain to them that there's actually
  493. 00:21:07
    people trained to do that. They don't
  494. 00:21:10
    have pharmacotherapists. They don't
  495. 00:21:11
    have dietitian. They don't have their
  496. 00:21:12
    own dialysis So the biggest lesson here
  497. 00:21:17
    was starting with this minor thing with
  498. 00:21:20
    our colleagues. Know who your
  499. 00:21:22
    colleagues are and not everything. And
  500. 00:21:24
    we used to tell them, oh, the
  501. 00:21:25
    Cleveland Clinic way. I mean, true,
  502. 00:21:27
    we try to replicate the best we can.
  503. 00:21:30
    But if your workforce mostly is from
  504. 00:21:32
    Europe or Asia, you need to understand
  505. 00:21:36
    where they're coming from, what they're
  506. 00:21:37
    used to and what they know know. So
  507. 00:21:39
    that so coming to so we first game and
  508. 00:21:42
    start practicing and first patient,
  509. 00:21:44
    second patient. And then you get a
  510. 00:21:45
    patient that is suspected dead by
  511. 00:21:49
    neurologic criteria. All right. And
  512. 00:21:51
    then I look around, it's like, oh,
  513. 00:21:52
    there's no such thing as brain death.
  514. 00:21:55
    And I pull up the law. There's only you
  515. 00:21:57
    die from a heart arrest or cardiac
  516. 00:21:59
    arrest. So what do you do? Well,
  517. 00:22:03
    there's no comfort care. And so you
  518. 00:22:07
    just keep the patient or the suspected
  519. 00:22:10
    dead patients in front of you and then
  520. 00:22:13
    the third aspect was the family. They,
  521. 00:22:16
    there's a culture of not believing that
  522. 00:22:19
    anything cannot be done anymore. And
  523. 00:22:21
    they believe that God will help and
  524. 00:22:25
    you're not God for the most part again.
  525. 00:22:28
    But that was the predominant culture
  526. 00:22:30
    where I came from North America. Oh,
  527. 00:22:32
    living with advanced directive, that
  528. 00:22:35
    binauralgic criteria, we're gonna pull
  529. 00:22:36
    the tube completely different. So that
  530. 00:22:38
    was a real culture shock So that was
  531. 00:22:41
    2016. Then July, it was work in the
  532. 00:22:45
    works, apparently. And then July,
  533. 00:22:47
    they come to us and say, the law now is
  534. 00:22:51
    passed. There was a law actually in
  535. 00:22:53
    1993 to acknowledge brain death, but
  536. 00:22:55
    then it was paused. And in 2016, as
  537. 00:22:59
    the country has a vision to develop on
  538. 00:23:01
    all aspects in the country,
  539. 00:23:02
    particularly healthcare, they realize
  540. 00:23:04
    brain death has to be acknowledged and
  541. 00:23:05
    organ donation. And transplantation is
  542. 00:23:09
    a key healthcare element of practice And
  543. 00:23:11
    we have to offer that to the country.
  544. 00:23:12
    So, but we need to start with brain
  545. 00:23:14
    death declaration. So the law was
  546. 00:23:16
    passed to enact 1993 and brain death was
  547. 00:23:19
    sanctioned. So they come to us first,
  548. 00:23:23
    the national committee and say, well,
  549. 00:23:26
    guys, we need to set up protocols. And
  550. 00:23:30
    since we're the only linearizer in the
  551. 00:23:32
    country and I was the only fellowship
  552. 00:23:34
    trained person in the country, you
  553. 00:23:37
    wanna help us. So let's get on it. And
  554. 00:23:40
    I had colleagues from neurology. One of
  555. 00:23:42
    them is the chair currently, who's also
  556. 00:23:44
    under-intensive as, but is doing more
  557. 00:23:46
    in her IR. So I saw this help. We
  558. 00:23:49
    looked at the law. A lot of, there was
  559. 00:23:52
    a lot of things not congruence with the
  560. 00:23:55
    AN. guidelines, but we had to use it.
  561. 00:23:57
    So for example, temperature threshold
  562. 00:23:59
    of 34 to do an exam. I don't know what
  563. 00:24:02
    was written in 1993, but there was
  564. 00:24:03
    there. So we had to work around this
  565. 00:24:06
    stuff. They were mandating EEG for
  566. 00:24:08
    everyone So there was a lot of variation.
  567. 00:24:10
    Some are significant, but we had to
  568. 00:24:13
    craft the policy for the hospital,
  569. 00:24:15
    share with the National Committee to
  570. 00:24:16
    share with other hospitals. And then
  571. 00:24:18
    off we go, we started doing declaration
  572. 00:24:21
    in the hospital, teaching everyone that
  573. 00:24:23
    this exists. And the biggest culture
  574. 00:24:25
    shock was for the families. And now
  575. 00:24:28
    you're coming in, telling the family,
  576. 00:24:30
    oh, we declared the patient dead.
  577. 00:24:33
    And then they look at you, obviously
  578. 00:24:35
    the first, which many people, of
  579. 00:24:37
    course, everywhere in the world, with
  580. 00:24:38
    the new but there's a heart beating.
  581. 00:24:40
    They tell you no, he's still alive.
  582. 00:24:42
    And this thing is only in America is not
  583. 00:24:45
    here, you're introducing something
  584. 00:24:47
    different. So then you have to print
  585. 00:24:48
    the law, tell them this is a new change.
  586. 00:24:51
    So obviously a new change for a 50 year
  587. 00:24:53
    old country, you're changing entire
  588. 00:24:54
    culture. So fast forward, we went on,
  589. 00:24:59
    we developed policies, protocols. I
  590. 00:25:02
    was lucky to recruit all these good guys
  591. 00:25:04
    with me. We went on supporting the
  592. 00:25:06
    national programs, did a lot of
  593. 00:25:09
    workshops nationally, every year,
  594. 00:25:11
    twice, three times on different
  595. 00:25:12
    conferences, educating the brain death,
  596. 00:25:15
    A, exists, how you do it, and what
  597. 00:25:18
    are the challenges? And we're still
  598. 00:25:21
    doing it to date. And recently with the
  599. 00:25:23
    support of the leadership, which we're
  600. 00:25:24
    gonna talk about. In 2022, two great
  601. 00:25:27
    things happened. One is they allowed us
  602. 00:25:30
    finally to change the actual law. So I
  603. 00:25:33
    drove a committee with four or five
  604. 00:25:35
    great physicians across the nation to
  605. 00:25:38
    end. implement the changes needed to,
  606. 00:25:40
    honestly, to bring it as closer as we
  607. 00:25:42
    can get to the AN guidelines. So we
  608. 00:25:44
    made it simpler, no need for EEG, no
  609. 00:25:48
    need for waiting, you know, it was
  610. 00:25:51
    waiting at least six hours between tests,
  611. 00:25:54
    the
  612. 00:25:56
    number of physicians, we had a lot of
  613. 00:25:57
    changes to make it simple and closer to
  614. 00:25:59
    the AN. And at the same time, I was
  615. 00:26:03
    fortunate enough with the help of our
  616. 00:26:05
    dear colleague Yasser Rilhasan from
  617. 00:26:07
    Kuwait, who sits on the board of
  618. 00:26:08
    directors of NCS, who responsible for
  619. 00:26:11
    establishing the MENA chapter for NCS.
  620. 00:26:14
    Part of the ECC and that conference that
  621. 00:26:16
    happens in Dubai, we started
  622. 00:26:18
    introducing brain death as a con as a
  623. 00:26:21
    lecture, then as a workshop. Then Dr.
  624. 00:26:25
    Jean Sung came, he supervised one and
  625. 00:26:27
    helped us quarter back one. Up until in
  626. 00:26:30
    2022, the idea came up. Why don't we
  627. 00:26:34
    have the neurokeletal care society
  628. 00:26:35
    formally collaborate with the. Ministry
  629. 00:26:39
    of Health here and conduct certification
  630. 00:26:41
    of brain death because we lack that.
  631. 00:26:43
    And remember, we talked about earlier
  632. 00:26:45
    that there is no other literally besides
  633. 00:26:48
    the three of us here, board certified
  634. 00:26:50
    neurointensivists. Everybody else is an
  635. 00:26:52
    intensivist that does neuro ICU cases or
  636. 00:26:56
    declares death. Neurologists usually
  637. 00:26:59
    are not involved, believe it or not,
  638. 00:27:01
    usually it's anesthesia. So there was
  639. 00:27:03
    some discomfort that are they
  640. 00:27:06
    comfortable doing it? And we remove the
  641. 00:27:09
    answer to testing, and some are not
  642. 00:27:11
    comfortable. They think answer testing
  643. 00:27:13
    is the key. So we thought, you know,
  644. 00:27:15
    and then there's the brain death toolkit,
  645. 00:27:17
    that's a perfect marriage of formally
  646. 00:27:20
    supporting the country by training them
  647. 00:27:23
    through the brain death workshop. And
  648. 00:27:24
    that's what we did. First time this
  649. 00:27:26
    year, took, you know, many rounds of
  650. 00:27:28
    discussions to a line of what the
  651. 00:27:30
    ministry needs at the level of the
  652. 00:27:32
    country, talk to them exactly the
  653. 00:27:34
    history I'm sharing with you so and
  654. 00:27:37
    quickly they understood what they're
  655. 00:27:38
    country needs, adapted the workshops
  656. 00:27:40
    accordingly, and recently we
  657. 00:27:42
    successfully did
  658. 00:27:44
    three days back to back, covering
  659. 00:27:46
    essentially the entire nation. With the
  660. 00:27:50
    support of ministry, we had over 300
  661. 00:27:53
    physicians undergo lectures by Dr.
  662. 00:27:57
    David Greer, arguably one of the
  663. 00:27:59
    leaders and Dr. Panos, very less, the
  664. 00:28:01
    leaders of the World Marine Death
  665. 00:28:02
    Project, series of lectures, and
  666. 00:28:06
    hands-on working simulation, attended
  667. 00:28:08
    by over 10 faculty, and these are world
  668. 00:28:11
    leaders, such as Dr. Deerenger, Dr.
  669. 00:28:13
    Mann, Dr. Torbei, you know, to name
  670. 00:28:16
    a few. So they really got a unique
  671. 00:28:20
    opportunity, which you and I, when we
  672. 00:28:22
    were fellows and residents, applying to
  673. 00:28:24
    fellowship, we were targeting to train
  674. 00:28:26
    with these guys, and we got them all
  675. 00:28:28
    together in this country and then
  676. 00:28:29
    trained them once and for all. So I'm
  677. 00:28:32
    extremely happy now looking back was
  678. 00:28:34
    just us trying to set up the program and
  679. 00:28:37
    educating that A, brain death exists,
  680. 00:28:39
    B, that's how you do it. C, we
  681. 00:28:41
    changed the law. To now, we got world
  682. 00:28:44
    leaders sharing that message with the
  683. 00:28:48
    obviously granularity that they were
  684. 00:28:50
    able to deliver. Yeah, I'm so
  685. 00:28:53
    impressed with the initiatives that have
  686. 00:28:54
    been put in place to train physicians.
  687. 00:28:56
    I wonder, has the cultural shock from
  688. 00:28:58
    the family side changed it all in the
  689. 00:29:00
    past few years? Or do you think that's
  690. 00:29:02
    gonna take a lot longer?
  691. 00:29:05
    It's certainly changed. There's more
  692. 00:29:07
    acceptance Less hesitance, less
  693. 00:29:09
    doubting. And it will definitely take
  694. 00:29:14
    more time, but we've made, so there
  695. 00:29:17
    was also congruent nationwide message
  696. 00:29:21
    from the ministry, from the government,
  697. 00:29:24
    lots of education to the nation to
  698. 00:29:28
    understand that this exists right now.
  699. 00:29:31
    And so there is less hesitance, less
  700. 00:29:34
    doubt we feel more comfortable
  701. 00:29:36
    conducting them, less challenged. but
  702. 00:29:38
    there's still a lot ways to go. And in
  703. 00:29:41
    the other aspect in terms of the support
  704. 00:29:44
    from the neuro-ISU and coming back to
  705. 00:29:47
    the point about spreading the message
  706. 00:29:49
    about the importance of neurocritical
  707. 00:29:51
    care. So a lot of these attendees also
  708. 00:29:53
    opened their eyes that, oh, wow,
  709. 00:29:55
    there's not only brain death, but
  710. 00:29:57
    remember, these are the all-stars of
  711. 00:30:00
    neurocritical care. There's a society,
  712. 00:30:01
    there's neurocritical care world leaders,
  713. 00:30:03
    they read about them, they know about
  714. 00:30:04
    them. Oh, okay, they have a dedicated
  715. 00:30:07
    units where they come from and we were
  716. 00:30:09
    successful showing them also our units
  717. 00:30:11
    here. So all of this, and we have
  718. 00:30:13
    people not only from the UAE, we had
  719. 00:30:15
    people from Bahrain, from Egypt,
  720. 00:30:18
    Jordan, neighboring countries. So they
  721. 00:30:20
    all went back and already actually we're
  722. 00:30:22
    getting some invites to go to other
  723. 00:30:26
    neighboring nations to talk about brain
  724. 00:30:28
    death, but also talk about
  725. 00:30:30
    neurocritical care and embed in their
  726. 00:30:31
    conference the neurocritical care
  727. 00:30:32
    concept. So
  728. 00:30:35
    it started in brain death, I know over
  729. 00:30:38
    the years can I expand to bigger than
  730. 00:30:39
    that, which is the neurocritical
  731. 00:30:41
    concept in the region. Wow. I mean,
  732. 00:30:45
    you've already accomplished so much,
  733. 00:30:46
    but is there any other project or goal
  734. 00:30:49
    in the near future you hope to achieve?
  735. 00:30:56
    Oh, look, so professionally or at
  736. 00:31:01
    the unit level at neuroICU, I think the
  737. 00:31:04
    biggest work is joining So on a
  738. 00:31:08
    Cleveland Clinic Abu Dhabi, we're
  739. 00:31:10
    fortunate that all our programs
  740. 00:31:12
    flourished, be it neuroICU, neuroIR,
  741. 00:31:15
    neurosurgery, neuroinesthesia,
  742. 00:31:17
    resources, thankfully, we have it all.
  743. 00:31:20
    And we're able to deliver really the
  744. 00:31:23
    highest standards that is in the US and
  745. 00:31:25
    everywhere and the biggest centers to
  746. 00:31:26
    the patients. So there I'm fulfilled.
  747. 00:31:28
    And we're fulfilled as Cleveland Clinic
  748. 00:31:32
    and we achieved that goal. Now,
  749. 00:31:34
    frankly, it's beyond our double doors.
  750. 00:31:37
    And this is where I'm fortunate that the
  751. 00:31:40
    neurocritical care society and the MENA
  752. 00:31:43
    chapter is able to accomplish to ECC and
  753. 00:31:45
    others because we need to tell the rest
  754. 00:31:49
    of the Emirates here and the neighboring
  755. 00:31:53
    regions, there is a huge value of
  756. 00:31:55
    neurocritical care dedicated units. You
  757. 00:31:58
    don't have to hire a neuro intensivist
  758. 00:32:00
    dedicated from the US or Europe because
  759. 00:32:04
    we've also trained a lot of our doctors
  760. 00:32:06
    from Egypt, from India. Here, that
  761. 00:32:09
    work with me, we train them. And they
  762. 00:32:11
    are they're big physicians. And we
  763. 00:32:14
    don't have a fellowship, but I think I
  764. 00:32:15
    have two or three superstars that if I
  765. 00:32:18
    had a fellowship, I would have awarded
  766. 00:32:19
    them a fellowship already. So and I
  767. 00:32:22
    want we want to see that because we want
  768. 00:32:24
    the patients across the nation and
  769. 00:32:27
    neighboring countries get the true
  770. 00:32:29
    missing link between pulmonary critical
  771. 00:32:32
    care and neurology neurosurgery So I
  772. 00:32:34
    think I'll be fulfilled. The next year
  773. 00:32:37
    is to come to see these programs at
  774. 00:32:39
    least in conferences, but also in
  775. 00:32:41
    concept and reality evolve in the region.
  776. 00:32:43
    That's probably what I wish to see. Wow.
  777. 00:32:46
    Thank you so much. We really appreciate
  778. 00:32:48
    you taking the time to talk to us today.
  779. 00:32:51
    Well, thank you for having me and I
  780. 00:32:54
    hope this measures spread wide about the
  781. 00:32:56
    interesting part of this region and we
  782. 00:32:58
    hope to see many
  783. 00:33:01
    come visit us and any questions or
  784. 00:33:03
    queries I'm sure there's a way for them
  785. 00:33:05
    to find out my contacts happy to address
  786. 00:33:07
    them. Thanks, Jimmy