Notfallmedizin

Notarzt ride (February 2014)
Today I had to opportunity to ride along with the Notarzt(in), the emergency medicine doctors. To those that don't know the EM system here in Germany is different than that of the US. There is no real emergency room as we have in the states. The EM doctors ride in their own car, and respond to accidents and calls.

Prepared in all my "Sicherheit Kleidung" (Safety clothes)

Our Ride!

Of course we ride only German made autos!

Our first call was around 8:40a to a electrical accident at a manufacturing plant. The worker was on a ladder with a tool in one hand and moving wires in his other. Although we don't know the full details, as he was moving the wires an electrical shock of ~400V ran from one hand to the other. At this point he fell backward off the ladder (<10ft) onto the concrete ground. No one was a full witness to the event. The first response ambulance, fire department, and police was already on the scene when we arrived. We were a team of a Notaerztin (Female EM physician), a Rettungsdienst (EMT/Paramedic) and I. The scene was inside a manufacturing plant in an industrial park. The notarztin and myself went to see the patient, while the rettungsdienst followed behind with the equipment. With the sounds and smells of an active manufacturing plant roaring in the background, we quickly found the patient with a half-dozen people surrounding him. He was lying on his left side, and the first i quickly noticed was his black hands, particularly on his fingers. My immediate reaction was that this was a severe burn on his hands. However on closer inspection it was actually oil/grease. He did have what appeared to be a full thickness burn <1cm diameter one of his fingers, with another area on his other hand of similar size. He was awake, speech unimpaired, and had no signs of a heart arrhythmia on initial 3 lead EKG. Quickly asking the patient, he does remember exactly what happened as he was moving wires with his one hand and  then felt a shock and woke up on the ground. Quickly working, a primary survey with head/neck immobilization was done. An IV was inserted and a small amount of midazolam was given. The patient didn't complain of any pain except his feet, but only with movement. As we were examining him, a friend of his walked up and they started speaking in French. With my 4 years of French from high-school, I could only understand that they were speaking French. After hooking him up to a larger EKG monitor, we got ready to transport him to the stretcher. Being at the head, I initiated the transfer. We used a contraption that I could only describe as a bean bag used in the operating theater. Basically it is a flexible bean bag that is in the form of a mattress. Once vacuumed of air, the mattress folds into whatever shape you make it, securing the patient. I have never seen these used in the field, but it seems like a great idea, as it allows it to act as a hard board, without being the straight hard board that typically is used.

After transfer to the ambulance, a secondary survey was done. I attempted to place an IV line into the forearm, but unfortunately was not successful. Rather than attempt once more, I asked for help from the Notaerztin. By this point, the adrenaline was rushing through my system. My hands were shaking. My heart and blood were pumping. I could basically feel my blood pressure working, and my kidneys filtering. Due to his continued agitation and complaints of pain, we gave him ketamine. That was an interesting idea, as he started to blabber even more. He started to talk about how he is German, his family is half german, and his has been working here for a long time. To me it sounded like a man high on drugs, which was exactly what it was.

After roaring through the streets of Heidelberg, we arrived at Heidelberg Chirurgische Klink in the Schockraum (Trauma room). There a team was waiting to receive the patient, and continue with his care. The Notaerztin presented the patient, and care was transferred to the receiving team. The surgical department continued with the examination of the body. Radiology did a fast ultrasound exam. Anesthesia inserted IV lines and handled the airway. Once sign-out was completed we proceded back to the vehicle to finish gathering our things and get ready for the next call.

We had a few more calls later that day; a question of seizures from a nursing home patient; an older gentleman with a history of COPD with progressive difficulty of breathing.

We even got a chance to see the "Notaufnahme" which is the emergency room at the Medizinische Klinik (Medical Hospital). It was a small room, with enough beds for 12 patients or so. It is usually handled by junior physicians with occasional oversight from an attending. According to my colleagues, when they built the hospital they forgot to account for the emergency room. This just displays how little importance is placed on a receiving emergency room. However the next surgery building, which should be built by 2018, will have a state of the art emergency room. Though it is hard to tell what that entails because the definition of emergency room ranges from hospital to hospital and region to region.

All in all my first experience was fantastic. Of course this is only an observation based upon a single experience, my take on having a physician on the scene of these cases was positive. I hope to learn more as time progresses.

Energy blast!!!

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.

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