Surgery Week

After the quick week that passed in the ICU, I continued my rotation in the operating theatre. I met with my advisor, who showed me where to obtain my scrub clothes including shoes, and who introduced me to the Oberaerztin (Chief) for the day. She coordinated me with a Facharzt (attending) and 1^st year Assistentarzt (resident). My initial perception was how familiar this all looked. Almost everything down to the machines involved, somehow looked the same as in the US. As this was my first day, most of it was spent in close coordination with my resident.

The day typically begins with a journal club like presentation to the anesthesia department at 7:15am. By 7:30 the presentation is finished and the anesthesiologists proceed to the operating room. There they obtain a box of controlled medications for the day. In short, a nurse signs out a box of narcotics that the physicians are supposed to return at the end of the day with all of it accounted for. It’s an interesting system, as the vials are relatively small and are the breakable glass kind. However I wonder how easy would it be to obtain a vial for oneself, while indicating on the patient sheet that they received one. There is also no concept pertaining to wasting of these medications, making this part harder to track.

After collecting their medications, the physicians head to the “abteilungraume” (induction rooms). They are small rooms that are beside or across from the operating room. There the patient is prepared (there doesn’t seem to be much in the way of pre-op rooms.). The anesthesiologist is assisted by an anesthesia nurse (not nurse anesthetist), who serves as their primary support. They prepare the rooms, medications, equipment, and serve their primary role in providing the anesthesiologists with everything they need. Inside the rooms is everything needed for general anesthesia including the respiratory and gas machines.

The patient is initially given sufentanil as an anxiolytic and pain reducing agent. Then the patient is given a bolus of propofol. As soon as they are unresponsive, a paralytic agent, almost exclusively rocuronium, is given. Following a period of pre-oxygenation, intubation is performed. Lines of various gauges are inserted. Typically the patients will receive an arterial line in their radial artery, two large bore IVs (14g), and a central jugular double or triple lumen catheter. Of course this is dictated on the type of surgery.

As I indicated in an earlier post, Heidelberg is a true tertiary care center, meaning they treat the sickest of the patients in the area. The operating rooms are divided into the Hear/Vascular wing, Visceral (Gen surg) wing, and a separate section for urological surgeries. There is a single pediatric operating room, and the OBGYN ORs are located in another building. My first week, I spent time in general surgery, while the second was spent in cardiac surgery.

Although much happened throughout my entire rotation I’ll only state a few memorable points. First, I was given ample opportunity to insert IV lines, and intubation. Unfortunately, the language barrier still provided some difficulties. There was this one case, where equipment wasn’t prepared properly. So the Oberarzt asked me to find something, of course saying it in German. I heard him, however I misunderstood him. When I returned unsuccessfully, naturally he wasn’t happy. It didn’t help that this case was extremely difficult (NICU, premature child, trisomy 21, difficult airway, etc). I felt so embarrassed! Fortunately this was one of the good supervising physicians I had. I did get to see many interesting cases, both in anesthesia and surgery.

The Surgery hallway

The Abteilungraum (Induction room)

   

My most memorable experience was seeing my first heart transplant. I was so excited when I first heard about it at the end of my shift. One of my colleagues told me that he could call me whenever they would get the green light to start the operation. It was already 8:30pm when I showed up at the hospital. Although I didn’t get a call yet, I didn’t want to miss it. I was riding through the area and decided to just check in. If there wasn’t going to be anything until later that night then I would go home. However if by chance it was taking place, then I would stay. Fortunately it turned out to be the latter. I was genuinely surprised at the relative simplicity of it all. Now don’t misinterpret me. The operation is very complicated, and takes many parts to make it work. But what I saw was a team that worked flawlessly. My biggest lesson from this: preparation. We took over 2 hours to prepare both patient and room.  Although sometimes it seems rather uninteresting, making sure that things are where they need to be makes life a whole lot simpler. Funny I actually relate this with my dad. He always told me to prepare before I go and start something. Yes it might take more time to do so initially, but it will save you more time in the long run and make everything run smoother. How true was this here. As the operation went on, everything was falling into place. I will always remember the moment they brought in the new hear into the room. Just 5 minutes after the bypass was in place with the old heart. The most amazing moment was when they cut the old hear out. There was the patient, no heart. Nothing beating except the whirring heart/lung machine. But yet, there were his vitals; blood pressure fine, oxygenation good, cerebral perfusion perfect. What an amazement in the field of medicine. They then exchanged the old heart with the new, cutting up the old one for experiments and pathology. Within 30 more minutes, a new life began for that patient. His new heart started beating. It would take another 2 hours before the operation could be finished, due to protocol, but for all intensive purposes the operation was done.

Surgeons preparing the patients old heart for removal

An enlarged diseased heart 

Anesthesia at work 

New heart in place. Much smaller than the previous one.

In the end I loved my Anesthesia rotation. If it were the same in the US, then I would definitely choose it. The ability to combine critical care, surgery, and emergency medicine into a single specialty has great appeal. Alas that is not so. I’m glad I got to see something different though there were definitely similarities to the US.