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Faculty Spotlight: Brad Kolls, MD, PhD, MMCi

Wednesday, February 6, 2019

Brad Kolls, MD, PhD, MMCi, first became interested in neurology as an undergraduate, when he wondered how the nervous systems of salamanders and lizards could allow them to regrow lost limbs. Now as a clinician-scientist within the Duke Neurology Department, he’s involved with numerous projects, including contributing to clinical research in our Neuro ICU and at the DCRI, leading the adoption of telehealth services within our Department, optimizing inpatient Maestro Care functionality, and mentoring residents, undergraduates, and Neurocritical care fellows in the basic science lab. In this week’s “Spotlight” interview, Kolls talks to us about these roles, how he hopes brain monitoring can help patients with brain injury, and the revolution he’s seen in stroke care since he was a resident.

What are your current responsibilities within the Department?

My days are quite variable actually as a result of the many things I do and involved with. My roles at Duke include being a  faculty member in the Duke Center for Health Informatics, and I participate in the oversight and organization of ongoing clinical research in the Duke Neurocritical care ICU.

I was also the founding Medical Director of the Duke Telestroke Network, the Virtual Neurocritical Care Consult service (VNCC), and Critical Care EEG Monitoring. While serving as the Critical Care and Neurology EPIC inpatient Champion I have undergone significant training on the EPIC platform and am a certified physician builder. I have participated in the development and optimization of our electronic health records here at Duke from initial installation to ongoing improvements to date.

I’m also a faculty member in groups such as the Duke Global Neurosurgery and Neuroscience division, building care capacity and sustainable training programs in Neuroscience in Uganda, as well as a faculty/research mentor for residents, graduate students, undergraduates, Neurocritical Care Fellows and MMCi students.

Finally as Vice Chair of Informatics and Teleneurology in the Department of Neurology, I provide leadership and guidance in the adoption and implementation of telehealth services within the department as well as represent the Department within the telehealth efforts of Duke Health system.

What does a typical day for you look like?
My typical day involves working on and managing the various telemedicine services we have or are developing, organizing the development or review of Maestro Care content for inpatient care services, operational and medical monitoring aspects of an active clinical trial at the Duke Clinical Research Institute and operationalizing and developing novel data collection approaches to improve the system of care for stroke and other acute neurologic conditions, clinical care ranging from reading of EEG, managing acute stroke consults to rounding in the ICU, to designing and reviewing basic science research data around the brain’s response to injury, the effect of novel therapies on that response and the development of brain monitoring technology for clinical care.

While I am not able to work on all of these things every day, as the demand of one project or another shift I end up with a wonderful variety of work that makes every day a new and interesting challenge.

How and when did you first get interested in neurology?
I have always been interested in science and understanding how things work. I got interested in neuroscience as an undergrad. I was sitting in a lecture as a college student learning about how some salamanders and lizards can regrow limbs and tails and wondered, “why can’t we do that?” This got me interested in central nervous system physiology.

As an undergraduate I was fortunate enough to work in a lab that studied synaptic physiology and mechanisms of learning and memory. This got me hooked on research and moved me away from neurosurgery as a potential career to neuroscience and neurology. I then looked for MD/PhD combined training programs to further my understanding of how the central nervous system can respond to injury. I worked on the goldfish visual system as a graduate student, trying to understand how it is able to regenerate the visual projections from the eye into the brain and restore vision within 12 weeks of optic nerve crush injury.

This work has shaped my thinking about brain function and has been a driving force behind how I look at brain injury, recovery, and brain physiology. My thinking about EEG from our brain-injured patients is definitely changed by what I came to understand from my lab investigations, and this drives me to develop new technologies to provide better, more informed care to our patients.

What do you enjoy most about working in stroke and neurocritical care?
What makes the ICU special are the people working there. The nurses are great and it is a great group of ICU providers to work with. To my thinking, if you are going to be on call and respond to emergency calls around the clock, you want your expertise to be important to patient care. Our specialty is still relatively new and we are just now starting to get data to support many of our practices in the neuro ICU. We are brain focused which results in very different priorities and concerns when compared to other ICUs. Over the last several years there is growing appreciation that ICU survival may not be as critical as neurologic outcomes associated with survival.

More and more it is becoming clear that the brain is being injured by ICU level illness even when brain injury is not the primary cause for the ICU admission. This has broadened our role in co-managing patients across ICU specialties and has required our group to learn about the many critical care practices going on at Duke. This is a constant challenge that our provider groups take very seriously and we all work together to stay informed and up-to-date on what we should be doing to optimize our patients’ neurologic outcome.

This makes every week on service a new learning experience with new challenges and new ideas for how to provide the best care possible. While demanding and often emotionally draining, the work is rewarding and exciting and with each recovery and good outcome we learn that what we do is making a difference and that we need to continue to strive to improve care and treatments for acute brain injury patients.

Much of your research focuses on improving brain monitoring for patients with traumatic brain injury, stroke, and other serious conditions. What potential does brain monitoring have to improve care for these patients?
Acute brain injury, most commonly in the form of stroke and trauma, affects over 1 million people in the US every year and over 25 million individuals worldwide. Despite the pervasiveness of this devastating medical condition, there are few monitoring techniques available to treating physicians that provide information on current brain function. In cases of stroke, current clinical practice is limited to monitoring heart rhythm and blood pressure and performing a clinical neurologic exam.

Current practice guidelines based on targeted thresholds for vitals prohibit personalization of care or the determination of the effectiveness of clinical interventions during the acute injury phase of care. Worse, therapies and interventions on neurologic injury and disease are typically measured at 90 days post event, which is quite remote from the clinical interventions, with many uncontrolled events occurring between endpoint assessment and interventions.

For these reasons, the creation of an approach to continuously monitor whole brain function has the potential to significantly impact clinical care of patients with acute brain injuries in the same way that EKG and cardiac enzymes, biomarkers of underlying heart injury and disease, have transformed acute myocardial infarction care and management. The creation and implementation of clinically relevant brain monitoring would revolutionize brain injury care by providing a direct measure of brain function to guide early management, and would allow for comparison of current brain function against baseline function and normative recovery curves, providing a foundation for more accurate prognosis and trajectory of clinical recovery.

Not only would this dramatically change clinical care practices, but would revolutionize clinical trials in brain injury as the endpoint for therapy could be measured as an improvement in brain function and recovery trajectory in response to therapy instead of disposition at discharge or function at 90 days which can be adversely impacted by numerous other factors unrelated to the effect of the early therapeutic intervention.

What’s the biggest challenge in the way of implementing brain monitoring at the systematic level?
The biggest challenge to implementing brain monitoring once it is created is creating the data to prove it makes a difference and getting the monitoring technology applied to the patients. I have been working to develop EEG as the foundation for brain monitoring. It is non-invasive and broadly available. However, it requires certified technologists to apply the leads and specially trained experts to review the data generated. These factors limit the scale to which EEG can be applied as a brain monitor. New technologies and approach to applying the electrodes, reviewing the signals and using EEG data at the bedside are needed. I have been working on clinical trials to evaluate the functionality and signal quality of various EEG lead application and recording systems for the past several years as well as working with Duke Engineers to devise new approaches to using EEG signals in hopes that we can make these technologies and systems scalable and more widely available to all ICU patients.   

What is the biggest change in your practice since you completed your fellowship here at Duke?
Without a doubt, stroke care has been the biggest change for me. We have gone from no treatments, to lytic therapy only in the first three hours, to treating 100% of eligible lytic patients out to 4.5 hours, to now treating the largest and most disabling of strokes with endovascular intervention up to 24 hours after the onset of symptoms.

There are ongoing trials looking at novel surgical approaches to treating hemorrhagic stroke patients that, if positive, will once again change the landscape of stroke care and outcomes. It is unfortunate that we have not seen much advance in the area of neuroprotection and direct treatment for acute brain injury. Much of the focus for this has been on post stroke medical therapies, all of which have failed. We continue to explore new approaches to treatment and hopefully soon may have a medical therapy for treating acute brain injury.

What is the biggest change you see coming over the next decade?
While I wish I could say I expect a cure for brain injury to pop up, I really think the biggest changes are going to come from the shift in health care to a digital age. Regardless of your political leanings, the affordable care act really began to change (by force) the focus of care from quantity to quality of care delivered. This change in value has led to the widespread adoption of electronic medical records nationally, if not globally. The digitization of medical information will now allow for more rapid cycles of exploration and learning from the care we deliver, review of practices and identification of areas where things need to be improved and the global access to cumulative medical knowledge.

While we have not seen the improved up front efficiencies that digitization has afforded many other industries, like the financial market, we will soon see the massive gains in efficiency on the research and educational side as we are able to share data and identify best practices more quickly and easily than ever before. The adoption of telemedicine has furthered the spread of digital medicine and allowed us to begin to address the many disparities in care that exist in the nation and globally.

While the change has been hard and painful for the current generation, it was necessary and ultimately I feel we, in the medical field, will be the better for it. We will eventually know we are indeed providing the best care, as our systems will be able to provide us the decision support and comparative statistics to allow us to better understand our patients’ needs and the best therapies for them. All of these early years spent optimizing and adapting this digital approach to care will eventually provide the foundation needed to smooth out the documentation and front end system interactions that are burning out clinicians at a high rate today. We will finally see the efficiency gains that were promised. Not until the nation fully adopts quality based payments and abandons fee for service models will we see relief from the documentation burden on providers. Not until we can stop documenting hundreds of repetitive lines of text to justify payment and move to an era when we document to communicate treatments and medical decisions will we fully benefit from the digitalization of medicine. I am hopeful this can really start to take hold within the next decade.

What other passions or hobbies do you have outside of the Department?
While I have enjoyed playing golf and basketball in the past, upon moving to North Carolina many years ago my family became my primary focus outside of work. With 5 children I have had the pleasure of coaching baseball and basketball teams, cheering at soccer games, innumerable school events, and watching the kids become amazingly good at Tae Kwon Do (all 5 are now black belts, the 4 older are all 3rd degrees).

The family vacations and time at home have provided me a much needed and much appreciated break from the busy and crazy days I have at work. Now that the kids are older, helping them find their way through work and college has been a new challenge. As they are slowly but steadily developing independent lives, my wife and I are looking forward to traveling more and spending more time together.

Kolls poses with his children as they show off their black belts.