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
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