ICU Continued part 2

Grand rounds began with entering the patients room, and reporting the status of patient, recent lab results, and basic plan. One thing that I did notice was that the plan was mainly dictated by the Oberarzt. There was minimal discussion or so it seemed in terms of the plan. However, I will admit that the speed of the conversation was too fast for me to follow everything, and when I would understand one part, I would be lost on the next. This type of rounds happened with every patient on the unit, which in our case was 14 (all vented) patients.

The other aspect I noticed was the lack of any physical touching of the patient.  There was simply no physical exam to speak of. I carried around my stethoscope throughout the day and used it once or twice maximum. Occasional they would look at a drain site, or surgical site, but this was the rarity on grand rounds. Had they already examined the patient, I am not sure, but I do not think so. Much of the physical examination was done by the nurses on the unit. When I asked about this, I was told that this is mainly due to the severity of the patients in the ICU. Most are sedated, have serious complications, therefore a physical exam, would hardly help. With the amount of monitoring of these patients, maybe they are right. But I can't help that there could be a time when something could catch them off guard. For example an IV line that maybe infected, but is completely covered that could be a source of sepsis infection. Of course there are plenty of eyes on the patient, so I couldn't say that they are not looked after.  In spite of the lack of physical touching they were sensitive in attempting communication with the patient, even if they were clearly sedated.

One thing I have to say is about the nurses in the ICU. They are simply amazing. Each nurse has one room (two patients to a room), but is completely in charge of the room. I rarely see them leave the room as there always seems to be something to do. They are very conscious about infection control. Every 24hrs the lines are changed. They were coverings whenever they are touching the patient (not simply PPE, but gowns) that are specific to each patient. I know that alone would be a pain to me. Otherwise they clean up the patients, keep the room in order, and run the machines. There is no support staff to nursing as in the US. Ie no respiratory therapists, phlebotomists, IV nurse, PCA (personal care assistants) etc. Simply said, the physicians and nurses are the only ones really involved in the care of the patient. A small caveat is there are some other people involved in the care as well, but they do a task that is very specific (radiology tech, physical therapy, sonography). Because of this, I feel that each nurse/physician knows their patient very well.

After the 2+ hours of grand rounds we go about finishing the rest of our work. Often times a central line needs to be placed. They do small operation procedures inside the ICU as well. Ie placing a pt on an ECHMO machine (Hear/Lung machine). One of the philosophies here is to limit patient movement as much as possible. That means, if it can be done in the room, then do it. There is always a risk transporting the patient to the operating room, or even to a procedure room. A line can be accidentally pulled out, some equipment might break, or worst case the patient can arrest. By limiting the number and amount of time a patient is moved, we can hopefully reduce the risk of adverse outcomes.

That basically is what happened on a day-to-day basis in the surgical ICU. Teaching was very dependent on the physician involved. One of the supervising physicians was very receptive to teaching and even made it a priority with his physicians. The other was more all work-no play. Everyone was extremely nice, but some were busier than others so it seemed. I also noticed something else. Even though everyone understood English, they were all anxious about using it with me. It was as if it was embarrassing for them. I just hoped they realized speaking German in a new hospital, to brand new colleagues is just as tough. Either way, I learned a lot from only one week on this rotation.

Some links:
Heidelberg ICU medicine

ICU continued...

After finishing the early morning rounds, we set out to do our tasks. For us medical students we had to get a PiCCO (pulse contour cardiac output) measurement on some of our patients. Typically you would want this if you were wondering about the volume status of the patient. Using the numbers generated, you could add, remove, or stay with the current fluid measurement. A very simple procedure; flush cold saline solution through a central venous catheter with a special sensor attached. The sensor should detect both the temperature and fluid amount and compare it to a second sensor attached to a femoral arterial line. Using this data, the program calculates the cardiac output and index of the patient as well as further indices of heart and circulatory function. It's an interesting tool that can be useful, though my feeling is that its function should be reserved for a select few patients. Patients with questions of circulation or cardiac function should be prime candidates, ie. sepsis (due to vasodilation), severe CHF (cardiac dysfunction), etc.

Every time I enter a new hospital or join a new team, I get the feeling that I am lost, incompetent, and should not belong. I'm sure I am not alone in this. Everyone is new, everything is somewhat different, and you don't want to be a wrench to the machine that had worked without you for some time. But as I get further and further in my training, I realize that sitting around for someone to direct you is not something you should wait for. Be active. Take an initiative to do something. Doesn't mean that you have to go and just mess around with the patient without approval. Think critically of things that might need to be done. Does a line need to be changed or put in? Does a nurse need help drawing medication? Sadly, I wish I was as forthcoming as I advocate here.

Around 10am, we have früschtück (breakfast) with the team. A basket full of different bread types, jams of all kind, and meat and cheese to one's heart's delight are the order of for the morning. This is the most important thing to learn on any rotation. Keep your belly happy. The breakfast every morning is set up by the medical students (German version of scut work anyone?), but its not bad. Just a 5 min process of setting the table, grabbing things from the fridge, and putting the bread out. I can't complain because we get to enjoy in the deliciousness as well. But I must comment on one thing. I've come to realize that silence at a table is common and normal. Not the general 5 sec pause while you chew the food, but the 5 min, all-you-hear-bread-crunching silence type. As someone raised in a rowdy Russian household and talkative American life, silence is nail-on-chalkboard cringing. You don't know where to look because otherwise you would stare. So you stare at your sandwich, wondering when the awkwardness will end. This is something I could never get used to.

After breakfast we have a few minutes to gather our notes, lab results, and thoughts before we set off on "grand rounds."

ICU

My first day of rotations was in the Anesthesia department at Universitätsklinikum Heidelberg, Chirurgishe Klinik (Surgery Clinic) on the surgical Intensivstation (ICU) floor.  After quickly being introduced to the Oberarzt (Chief/Attending Physician), I joined the team on the different sets of rounds. The structure stayed the same for the entire week but I will give a breakdown here.  The sign-out from overnight is basically in the form of quick pre-rounds where overnight events are given, as well as the basic plan of tests/procedures to order before grand rounds (or regular rounds as grand rounds in the US are typically in lecture format and for the entire department.  After the "quick" sign-out (45min - 1hr), the surgeon responsible for all the patients joins the team for a quick rounds (15-30 min).  The sign-out is done by presentation of the responsible overnight physician (usually 2 for 16 beds).  However the surgery rounds is strictly Oberarzt to surgeon. 

Let me go into a little bit of the organizational structure of the ICU as it pertains here in Heidelberg.  (Note there could be a slightly different structure in other parts of Germany.  I am only applying for what I have witnessed and learned in Heidelberg).  Intensive care medicine is the field of Anesthesiology.  They are the intensivists.  You can as an anesthesiologist "specialize" in the field, but its not a specialty as it exists in the US.  Basically you have the chief of the department of Anesthesia. Then in each division, Notfall (emergency), Intensivmedizin (Intensive care), Surgical Anesthesia, etc, you have the Oberarzt. He "is" the attending that runs the show. Below him are the Facharzten (Consultant/Specialist) who can be a leader in the department or take over the job of the Oberarzt should he not be present. Beneath them are the Assitentarzten (Junior physicians = to the US version of Residents). However the Facharzten and the Assistentarzten work together and tend to split their work rather evenly. But they all report back to the Oberarzt. The other aspect is that the Facharzten are strictly Anesthesiologists, while the Assistentarzten can be both surgical or anesthesia junior physicians. It is all relatively confusing, as I am used to the titles in the United States as well as the structure. Suffice it to say, they have a hierarchy that is different, but works nonetheless.

After our early morning rounds (7-8:30a), the team writes the "things to do" on the board for each patient. Then we set off to go do them. As a medical student, my role in the department is very limited. Apart from the general awkwardness of being in a new hospital, new department, and the medicine itself, I was facing the challenge of a language that I had just begun to learn, and then one that I have never heard before, medical German.  My German language skills were no match for the speed, vocabulary, and ferocity of early rounds. I attempted to glean whatever information I could from the conversations, and would often ask someone to explain it to me, but I get the point. Early rounds are there to let the night people go, and get the day started. I got complimented on how much I learned in my first semester and they kept saying, "Oh, du sprichts sehr gut Deutsch." (You speak very good German). However telling people about me and my day is easy enough. Trying to explain the complications of a central venous line placement in German is totally different. 

What was super fortunate for me was the presence of another medical student on the team. Though she was only in her 4th (out of 6) year, she was very knowledgable and had been with the department for one week already. The best part was that she is half American and spoke English without a hint of an accent. Having her there was invaluable, especially the first day as she showed me the basics of the department, helped clear up my questions, and was a great partner to work with. You could obviously tell that she had to be half-American; she was too happy to be fully German.  

As this was my first week, I did not have the responsibility of carrying any single patient by myself. This was both a relief but also a little disappointing. I think the former was greater than the latter. I had come to Germany to learn some of the medial system here. After 6 months of no rotations, I was dying to learn medicine again. Its actually quite amazing how fast details came back to me in spite of my lull. But the challenge of navigating a new system and language are also too great. In the end I was glad that I participated in the care, but was not held responsible to it. A person must know when to draw their own limits.  I am here to learn and not to do the job of the physician. Sometimes as medical students we get lost in our desire to impress, and forget that our role is always to learn. Sometimes those two collide, other times you must choose sides. My opinion, is that we should always err on the side of learning first.  

Most of the patients in the SICU were extremely ill. Many had been there for weeks and were still on pressure supporting medications. Many had liver transplants, Whipple procedures, or simple large surgical procedures done. As a place to heal, this was hell. Half of our patients had serious infections (MRSA, VRE, and a new one MGRM), with sepsis being a history in almost all at some point. Now my initial impression was more of a questionable one. Why were there so many sick patients here? I learned that it was because of Heidelberg University. As a university hospital, Heidelberg takes the sickest, challenging, and overall more complicated patient types across the board. This is what makes them one of the best in Germany. 

-To be continued...

Finally Medicine in Germany

So after 5 months of German language classes, and patiently waiting for replies from physicians and coordinators alike, I started my Anesthesiology rotation. While the program itself is not very organized for students, there are definitely things for students to do. First let me clear up what I mean by organization. I was rather surprised that after I recieved my "acceptance" for an Anesthesia rotation, there were no further details. Requests for further information were very hard to come by. It wasn't until I met up with my preceptor here that I found out details. There are none. No set program to follow, no set time, no set schedule. Whatever you want to do you can do. I decide on letting myself get to know the full expanse of Anesthesia as it is practiced in Germany, rather than just a single facet. My only stipulation was that I had to meet up with my preceptor in the beginning of the week in order for him to introduce me to the appropriate teams.

First day was interesting to say the least. I had no idea what to expect, and I truly hoped that my time spent learning German wasn't in vain. My first week is in the surgical ICU at the Chirurgische Klink. The first challenge was getting up early in the morning. Since moving to Germany I had grown accustomed to my late rises (8/9am) vs what I had previously done, 6am everyday. But again I had to be there for 7am. I am fortunate that my apartment is only a 5 min bike ride away. I am lucky that the winter here in Germany is so mild this year. I can't imagine pedaling in the snow. Its hard enough in the freezing cold, with rain almost everyday. My wife has been a true darling about it all. She woke up extra early to use the laundry machines (by midday there are lines), and then made Russian Blini for me! She is always so kind, and I am lucky to have an awesome person like her in my life. About 2 min into my ride I realized that I had forgotten something; my white coat! I called my wife and asked her to grab it and meet my outside. It was an amazing picture to see her running outside with my white coat because she didn't want me to be late! I am truly blessed. So after all that I pedaled furiously to the clinic, locked up my bike, and headed indoors.