Uncertainty in principle entails the presence of doubt. This can lead to the inability
of delayed decision making. To an observer, this will lead to skepticism and unwillingness
to work with the process. Ultimately if the process continues, it will lead to mistrust
and a dysfunctional working environment. William Osler was one of the first to recognize
how uncertainty plays a role in our medical practice. His statement “One special advantage
of the skeptical attitude of mind is that a man is never vexed to find that after
all, he has been in the wrong”[1] helps with the concept he proposed in the practice of medicine. But despite the
uncertainty that surrounds medicine, the history of the disease creates challenges
around the individuality of each patient. This challenge is present in the practice
of neurocritical care.
Acute neurological crises were considered to be part of the black box of complex brain
derangements. Over time, with extensive advancement of neurological sciences with
tools like neuroimaging, neuromonitoring, surgical procedures, and protocols, the
black box is more open now. The practice still has uncertainties, especially with
new and complex diseases like coronavirus disease 2019 and the introduction of complex
therapies including extensive use of different monoclonal antibodies.
Patients with the acute neurological crisis have a multisystem presentation.[2] The uncertainty of when an acute pulmonary injury happens with an acute brain crisis
is always there.[3] Which one is the primary and which one is the key aspect at the time of examination?
The neurological examination of these patients can be unreliable due to multiple factors
including sedation requirement for ventilator stability to surgical stability to avoid
hemorrhagic conversion.
The recognition of the presence of this uncertainty is important in neurocritical
care. The goal should be to work on facts and change the management based on the response
of the therapeutics that are used under the umbrella of the best clinical practice.
