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.

Computer is returned

After 5 months and dozens of emails I have finally got my computer back. The story basically begins with me arriving in Germany. About a week in, my wife and I traveled to the Rhine Valley. Naturally i left my computer at home, or rather the place we were staying in. Needless to say, I returned to find my computer utterly dead. Nothing. Not even a blip. Contacting Apple support and my university I had the options to: 1) Travel or send the Apple Store 2) Go to an authorized apple repair store 3) Send back to my university. I really wanted to avoid the last option. So after I got into Heidelberg I went to Theile, a local authorized apple retailer and repair shop. After quick inspection they told me that there seemed to be some sort of water damage and that AppleCare warranty would not cover this repair. That left me with no choice but to send it to the United States. After some difficulty (not being able to send a lithium ion battery via USPS) I finally got it out. Took a while for the University to even begin with the repairs even though I had asked they expedite it as this had most of my data on it. Either way, they determined also that the repair needed to be taken out via the insurance plan I had on it. After the insurance replaced the logic board and other components they sent it back to my University. However, when they replaced it they only substituted 2Gb of memory in the laptop instead of giving me back the original 8Gb that I had installed prior to the shipment to the US. This of course delayed things more as the laptop needed to be reshipped to the repair facility, memory replaced, and then sent back to the University. It wasn't until Christmas time when all was said and done. Even then it took forever to figure out how to ship this laptop back to me. Only via assistance of my brother who drove an hour into Worcester to pick it up, did the laptop even get shipped. Now the story didn't end there. As after almost 3 weeks in transit the Zollamt (Customs office) got a hold of it. They tried to make me pay a 19% tax on my own laptop that was being returned to me. Fortunately for me, I had some documentation. If I would have any advice to anyone, talk to the Zollamt directly so as when you recieve something back you won't have to pay custom duties on it. Frustrating, annoying, and just an overall terrible experience. But hey I got it back. At least the post didn't lose it!

Weihnacht (Christmas) in Heidelberg

Growing up I believed in Santa Clause or at least the Russian version called "Dyed Moroz" (Uncle/Grandpa Frost). I always thought that Santa Clause was strictly an American creation. Growing up we sang carols, went to church, and saw the bright lights. When we were still deciding to go to Germany, my wife remarked on how famous European Christmas markets are and especially the German ones. The descriptions she gave me excited me. I was very much looking forward to it. Unlike in the US though Christmas is truly a time of year and not a two day holiday. Yes I understand that in the US there is a Christmas season, but it pales in comparison to how these Europeans celebrate Christmas. Cities light up with decorations, advertisements everywhere, special Christmas candies in stores all serve as a introduction to the Christmas season. And finally almost every city erects their own Christmas market. Which is basically a large amount of booths serving all sort of food, drinks, and crafts. It runs rather long, from Nov just up until Christmas Eve. But it is a wonderful experience. Seeing lots of people gathered near the Gluewhein stand, kids riding the carousal, and of course the smell of bratwurst in the air. A very memorable experience at that. We we fortunate to attend Heidelberg's Christmas market several times, as well as the famous Nuremburg Christkindmarkt (Christ child market), and the ones in Rothenburg ob die Taube and Stuttgart.

Nuremburg Christkindsmarkt

The Original Feuerzangen-Bowle (Flamed Gluewein with Rum)

Of course Lebkuchen (Gingerbread)

The different handmade crafts and ornaments for sale.

The Kinder Christkindsmarkt

Rothenburg ob die Taube

Heidelberg Weihnachtsmarkt

The famous Gluewein stand

Autumn Falls

Much has happened both since I last wrote in my blog even prior to that. Instead of just filling in on my details I decided to make a small tip sheet of what I feel is very important here.

Not in any particular order

So every apartment/household in Germany has to pay this Rundfunkbeitrag, which is essentially a monthly tax that is charged for Deutsche Radio, TV, and News. It is rather frustrating as the cost is 17,98 Euro/month. What I did was send a letter stating why I thought  I should not be responsible for paying this fee: I am a student, no real income, on scholarship, don't use a TV or Radio or German News.

So for any student that is living in the Studentenwohnheim: After the initial meeting with the Studentenwerk, which is in charge of the service, you receive your keys. Each apartment is slightly different but for the most part it was a bed, table, and some chairs and storage space. Nothing special. You can receive your keys after you move into your apartment but you still need to register with the Hausmeister (which is basically the Landlord/Maintenance man of the buildings). They will give you a sheet where you can write down anything that is wrong with the apartment so as you will not be responsible for it later. In every apartment building there is a type of RA or student ambassador and one for international students. I found mine via a bulletin board at the entrance to the building. Trash is separated into plastics, biodegradable and un-recyclable materials, paper. The mattresses here are semi-comfortable. After being babied in my Queen size pillow top, the hard foam mattress took some time getting used to. I definitely would recommend a mattress top to help ease those joints. For those who live in apartments, you probably will need to buy utensils and the like. One of the easiest ways is via Ikea about a 1 hr away via train. They also have a TKMaxx (TJMaxx) here. Both are decent places where one can buy what you need for cheap. You can also look at the student Facebook groups which often have students selling their own things.

Stores: There are a few choices in Heidelberg and fortunately they are not too far apart from each other. The high end supermarkets are Kaufland, Rewe, Bio-markt (organic store). They are the largest and offer the most in terms of choices. The biggest Rewe is in Handschusheim, while Kaufland is near the Heidelberg Hauptbahnhof. Bio-markt is also in the same plaza as Rewe in Handschusheim. The discount stores are Aldi, Lidl, Pennymarkt, and Nahkauf. These also have reasonable prices, though Aldi and Lidl carry their own brands of foods not found in other stores. Personally we shop at Penny and Lidl the most, with supplemental shopping at Rewe and Aldi as needed. Whats interesting is that sometimes Aldi and Lidl have things for home, however they are only available for a limited time and tend to be of cheaper quality. But for living abroad for only one year it most likely will last. Each has their advantages and disadvantages, but the best bet will be to shop at whichever is closest.

Get a bike! Heidelberg is a bike city. Make no doubt about it, you will wish to have one. Taking the bus is easy enough, but they don't always run and don't run when you might need them to. Also it helps to transport groceries. I bought my used bike at Ruprecht Rides. They have a good variety and stock some every week. They are also the cheapest bike seller around. Its a trek to get there but usually worth the trip. And they do speak English!

Uni and Our Trips

So its been a while since I have written in my blog. Too long for that and so much has happened that it would be hard to even put down all the details. To summarize, since my last post, I have finished my month-long intensive language course, traveled to London, Hiked up Mt. Pilatus in Lucern, Switzerland, explored the Schwarzwald, and visited old friends in Pirmasens, and new friends in Bruchmuehlbach-Miseau, on top of living and exploring Heidelberg.
  About a month ago I started my new German class ~20 academic hours. However 1 academic hour equals 45min of real time. So though it seems like I have 4 hours of class a day, in reality it only translates to 3hrs 15min. Just one of the small things that German Universities like to complicated. Sometimes its amusing while other times frustrating with the entire system. For example things are not as easily coordinated as we would like in the USA. But I believe that most of this is due to the small administrative staff that is kept. This way it allows the Uni to keep costs low for local citizens and international students. It reminds me of an article I  read recently that talks about the reasons why American Universities and Colleges keep raising tuition every year faster than the rate of inflation. Admin costs take precendence over academic endeavors in the US. Although I believe that this can be a good thing, overbloated admin budgets are rife with waste and fraud. Unfortunately the goverment keeps adding subsidies to students and the colleges respond in kind. Ie. if the cost of attendance is $20k/year and the student gets $14k in financial aid then the following year since the government will increase financial aid to $16k/year the school responds in kind and raises tuition to $22k/year making up for their lost profit from direct student contribution. However in reality the school has just made an extra $2k. Though the student appears not to have paid anything more (and this is their justification) in reality he is paying more due to government loans. Just another way that the system is terrible in the US. This is where capital market systems DO NOT WORK! I could go on as this is a topic I am quite passionate about though I appear this passion is futile to make a change. Giving people scholarships and the like is just feeding the problem. This is something I always found annoying. If I earned a scholarship (merit based), I earned it! Don't then go and say well you don't have a need anymore and take away any other money. How is it fair that the person who didn't try as hard or who didn't spend countless nights studying to get good grades recieves the same aid as the one who did, but come from the same social backgrounds. It becomes Communism 101.

But I digress! Well here are some photos from our trips.

London

Switzerland

Schwarzwald: Triberg und Freiburg