Radiology Month

As soon as I came back to Germany I had my new rotation waiting for me; radiology.  As a physics major in undergrad, I really liked the concept of radiology.  Using x-rays, magnetic fields, and other physical phenomenon for medical purposes is fascinating to me.  So it was no surprise to me to be interested in the field of radiology.  Though the physics behind the field is interesting, I was weary of the mundane tasks that I might have to do.  Staring at a computer screen all day wasn’t something I would call fun.  Nonetheless, I did not have experience in the field and was willing to explore it. My schedule was broken up into four 1-week blocks as follows; a week of X-ray, CT scan, MRI, ultrasound. 

My first two weeks were in the Medizinische Klinik. The radiology reading room was definitely something that I did not expect.  A large room with a skylight, albeit with shade to avoid sun glare, lighten up fairly well. There were several computer stations with large vertical high-resolution monitors that were used by the radiologist. As in anesthesia, the bulk of the work was done by the Assistantaerzten. The X-ray department had a senior “resident” who signed off on the junior residents’ radiographs. The interesting thing was that a senior with 4 years or radiology experience could be considered a junior in the x-ray department because he did not rotate through the department enough yet.  In all the system is set up so that the residents have to have a certain number of images that they have read and transcribed.  A computer system keeps track of all the reads, though the residents must personally keep track of what modality of images they have read (X-ray, CT, MRI…etc.)  Most rotations are done in 6 month blocks.  This makes its interesting when a 3^rd year resident might be rotating into a CT scan rotation for the first time.

Computer for pulling up images, laptop for writing down results 

A senior resident flanked by two junior x-ray residents

The first day I became acquainted with my colleagues as well as reading x-rays. After the next day, I started to read them on my own, providing an oral report to a junior resident who would then write a full report. Of course my German language skills made for some difficulties in interpreting the images. What I might identify in English, I had not yet mastered in German. Writing was even more difficult, as this was not simple German to converse with, but medical speak. In spite of these difficulties I enjoyed my time there.

CT was rather different as there was only one dedicated CT scan reader.  Unfortunately this made it difficult to read images on my own, both due to lack of other computer stations, and the increase complexity of the images. As stated in a previous post, Heidelberg has very complex patients that it treats. Many were there post surgeries with anatomies not easily understandable. Even so, I did get to read images on my own and write my own mini-reports, though only in English.

There was a funny thing that happened during the rotation.  Around 11am one of my residents calls me up and says we have to go celebrate.  I was totally confused. “What are we celebrating?” I thought.  We went into the lounge area, and sure enough were champagne glasses filled with bubbly, and donuts. Two colleagues of theirs had passed their boards and this was celebratory break. Have to say, I never experienced anything like this in the USA, nor do I think this would ever be allowed.  Everyone had a glass, chatted a little, and then simply went back to work; such an odd experience.

I also had an embarrassing experience there as well.  On the last day of the two weeks in the Medizinische Klinik I brought in Russian waffle cakes that my wife had made.  The department head was walking around and saying Hi to everyone.  I had met him earlier and he seemed very friendly.  I was sitting in a corner reading CT scans when he came around and asked me a question in German.  In my surprise of being asked a question in German and seeing the department head I did not understand what he said except for one word, “mitnehmen” which means to take with.  In my panic I thought he wanted me to take my computer with me somewhere, ie to move out of the station.  To my horror, he starts motioning me to sit down and starts to laugh and ask in English.  He was asking if he could take a Russian waffle cake with him.  I embarrassingly said yes and sat back down.  Embarrassing myself in front of the department head was simply too much.

My next two weeks took place in the Chirurgische Klinik, the same building as my anesthesia rotation.  I spent the next week side by side the radiology resident reading the MRIs as they came in.  Although my resident was nice, this was the most boring of all the rotations.  I did not have the ability to read the MRI’s by myself due to limited computers, and lack of images.  It was complicated by the fact that my resident was utterly embarrassed by her English, which made things harder to understand especially for concepts that I had not previously heard in German. However I did learn a lot, and even got to have a scan of my shoulder! (A torn labrum that I was already aware of clinically though never had scans before done on it.)

The last week was the most fun. I spent time in the ultrasound department.  In the mornings we would scan the patients in the ICU and intermediate care units. Afterwards would have outpatients come in for scans.  My residents were great about pushing me to scan images on my own and report my findings to them. I was the most comfortable with this rotation as both I had plenty to occupy my time with and I got to interact with patients more. I even got to use my Russian! Though translating from Russian to German through my English mind became rather tough. I learned the most during this block and had a lot of fun too!

Everyone was very receptive in the field and were great to be around.  I did notice that people that go into this field are the same in Germany and in the US.  They tend to be more reserved, smart, and not as socially active.  I guess medical fields do cross international boarders too!

Old and New Family

After celebrating with my classmates, the following day was for my family.  As I have previously stated no one had any idea that I was coming.

My first victim was my little brother.  I had texted him several days before saying that I bought Dad a gift and it needed to be picked up in Worcester early Saturday morning.  Of course "I" was the gift!

And this is his reaction....

After a quick meeting with an advisor we drove back to Western Mass to surprise my parents.  They were closing up the bagel shop together...

We went out to lunch and then went home.  My next surprise was my brother-in-law. He had been napping with his son, my nephew, who was only born one week after I left to Germany.  In other words I had never met my first nephew.  This was my first time!

My older sister, coming home from work had a surprise in store for her.  You can see her sudden reaction to my appearance...

I went out to dinner with friends back in Worcester.  On the way back I also surprised my other brother-in-law, and my best friend/cousin and their spouses.  It was pure jubilation to see the look on people's faces when they saw me!

Finally catching my little sister was nigh on impossible!  I had to wait until the night was done and she was in bed to finally get to her...

It was my first big attempt at a massive surprise and I am surprised I pulled it off without a hitch! 

The next few days were spent with family and friends.  I said goodbye to a friend who was moving out of state before I would return to the US.  Took care of my taxes.  Packed away all the winter clothes that I had brought back with me.  And finally just enjoyed time with my nephew, as he will also being moving shortly after we arrive back in the US.  Overall it was a great time to be back home.  Just enough where I felt that I saw everyone I needed to, and didn't over extend myself. 

My little nephew and I

Wearing a University of Heidelberg onesie

Back in the States - Match Day, Surprises, and Bittersweet Goodbyes.

After my anesthesia rotation, I had two weeks were I spend doing research into emergency medicine. But after that I had something special planned. Since January, I booked a ticket home to be there for my classmates on Match Day. Match Day is the day when 4th year medical students receive the results regarding which program they matched to. At my university, all the students first obtain their match envelope and then open them at the same time. Its an amazing occasion, because thats when all the hard work of medical school finally translates into a pay-off. Only two friends from medical school knew that I was coming. I did not tell my parents, siblings, or any other friends and relatives. On a few occasions I had to directly lie to my folks as they asked me if I was coming in March, as I had previously told them that I would consider going back around this time. They were in for a total surprise. But that is for later.

I left Heidelberg around 10am, rode the ICE train to Frankfurt Airport, and flew into JFK. After a 4 hour layover helped out by the free Ipads in the Delta section of the airport, I hopped on the flight to Boston. One of those two friends I had previously mentioned picked me up. By the time I got to bed I had been up for almost 23 hours. The next morning we went to the school for the Match Day breakfast for seniors. I hadn't seen many of my classmates in over a year! Everyone was truly excited and happy. The day was going to be special, I knew it. Another great aspect was everyone's complete surprise of me being back. They were all touched by the fact that I would come back to celebrate them, but it also touched me how much people cared about me as well. Being away from everybody that I've come to know in the past 4 years makes you disillusioned to the fact that people still acknowledge your existence. Its something that I've come to learn both from moving away for school, as well as moving to a different country. If you're not in the area, then you don't see the person, and don't get reminded by them. Even if you see their statuses on Facebook, you just realize that the person exists but it makes it hard to develop a further relationship. Either way, this entire aspect of being back to say goodbye to everyone, for some maybe forever, was needed for me.

I barely even noticed how fast the time went by when I heard the loudspeaker kick in with the Chancellor's voice.  The time to open envelopes had come.  One by one they were called, all being cheered by family and friends. Almost everyone's name I recognized. A few of the extended 5th years were also called. Finally the last name was read. The student making her way forward was greeted with a tremendous applause as she was handed the basket of cash. This basket contained $1 from every student that had gone before her to collect their envelopes. It was a small gesture to help alleviate the anxiety of being the last one.  As soon as that was done, the dean started a countdown. A quick shout of "No!! Not yet!" rang out. People were still preparing themselves to open their letters. Then a few moments letter, came the countdown again. First like a deep breath, silence invoked the room.  Then a scream; a shout. Like a dam breaking, came the thunderous yells, applauses, and sounds of exuberance! The excitement was all around, palpable. Everyone was hugging, crying, and just happy! For the next hour, "where are you going?"was the only question on peoples mind. Of course I had to remind them I was extending, but it barely phased me. I was there for them.

The last envelope

After all the congratulations I had some time to do meetings with school administrators regarding 4th year planning as well as coming back to the US. We went home and grabbed some food at Five Guys; food that I had missed so much in Germany. Later on, my friend with his girlfriend picked me up and we went out to celebrate with the Class of 2014 at a local bar. The night was just wonderful! Everyone was excited, shouting, and happy. With dancing, chatting, and just plain old fun. I saw almost everyone I wanted to. Said my goodbyes and congratulations. I was so happy for them. Although I was a little sad to not be with them, my heart was still with the class.  I was never a bar scene type of person. Never liked being around drunk people. But today it felt different. No one was getting completely wasted just because. We were all celebrating our momentous achievement. So we toasted, to our futures, as physicians. But today, we were just med school students to finished that race.

A night of happiness and fun!

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.

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."