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...