Janos Geli | Sweden
My Name is Janos Geli. I am a 5th year anesthetic trainee at the Stockholm South General Hospital. Throughout my training I have encountered several people who did part of their anaesthetic training abroad and heard particularly positive comments about the UK anesthetic training experience. A new colleague in our hospital who had been an ESA trainee fellow a few years before gave me a hint that this program might be something for me and be an amazing opportunity for professional and personal development. I was extremely glad to be one the few fortunate European fellows selected by the Trainee Exchange Committee.
Shortly afterwards I got in contact with my future mentor Dr Timothy Strang at the UK host hospital. Dr Strang works as a senior cardiothoracic anaesthetist at the University of South Manchester Wythenshawe Hospital (USMWH), which has one of the largest academic cardiothoracic centers in the United Kingdom. To get an impression about each other and the host hospital, ESA generously sponsors a first visit to the host hospital. I met Dr Strang and we discussed my professional interests and how they could be matched with a productive rotation at the hospital. My immediate feeling was that I was up for an exciting and rewarding experience at UHSM. The next step in the preparation process was acquiring full license to practice with the General Medical Council, which is the professional regulatory body for doctors in the United Kingdom.
The Department of Cardiothoracic Anesthesia and ICU at the University of South Manchester, Wythenshaw Hospital.
The Cardiothoracic Critical Care Unit (CTCCU) at Wythenshawe hospital is a 26 bed busy tertiary critical care unit. It receives around 1000 patients / year following complex cardiac procedures, 500 patients after major thoracic operations and 50 heart / lung transplantations annually. The CTCCU also receives about 30 respiratory ECMO patients / year as well as VA ECMO and patients requiring mechanical support like Ventricular Assist Device or Intra-Aortic Balloon Pump) for heart failure. The hospital actively participates in training medical students, registrars and fellows. and has an increasingly vibrant academic life.
Work in the ICU
In total I spent 3 months at UHCSM . My time in the hospital was divided between theatres (approximately 40%) and the ICU (approximately 60%).
In the ICU, days start at 8 o’clock with a half hour morning handover from the night team. They tell us, which patients are stable enough to be discharged to the wards in the morning.
The day-team usually consists of two consultant anaesthetists and two to three trainees. On average each trainee will see 5 to 7 patients (on weekends more). The consultation consists in examining patients, reviewing vital signs, labs, X rays, fluid balance, touching base with nurses and writing a daily review note.
Uncomplicated postoperative cases take only 10 minutes whereas complex cases such as transplants, ECMO, or unstable patients may take considerably longer. Following this, the ICU team convenes to start the ward round. Rounding on all 20-26 patients takes about 2 hours.
We go around the bedside of each patient and the trainee assigned presents the case and formulates a plan (under supervision of the consultant). . This means that we spend almost all time in close physical proximity to our patients and the whole rounding team can see the patient, the monitors enabling us to get a quick impression about the most obvious problems. Presenting in front of the whole team has several advantages, it is a great opportunity to compare and discuss different potential approaches to the same problem by consultants with sometimes divergent styles.
After rounds we split up daily work (line changes, tracheostomies, transports to CT, bronchoscopies). In the meantime new cardiothoracic postoperative patients arrive in the unit and are admitted by whoever has time. At 5 PM short day staff leave, 1 consultant and 2 trainees (on long day duty) stay on carrying the beepers. In the evening we complete procedures, review pending diagnostic tests, touch base with the transplant team and talk to patients’ relatives. At around 6 pm another wave of postoperative patients arrives at the ICU (afternoon cases from the theatres). At 8 o’clock the night team arrives (2 trainees) and we do the handover. By 8.30- 9-ish the day is finished and we head home to get a good rest. Long days tend to be put together in three to four day blocks followed by two to three days off work.
Night calls on the unit are covered by two trainees (one senior and one junior/ mid-grade) and a consultant anaesthetist at home. After evening handover divide up the patients. Each fellow will usually see 10 to 14 patients. Since many of the patients are very sick, on high dose inotropes, mechanical support devices etc. emergency events occur frequently. As there are only 2 trainees in house it is a fantastic opportunity to exercise medical decision making (of course with adequate backup from the consultant). Several times we had to call in the consultant physician in the middle of the night to evaluate a patient’s heart with transthoracic echocardiography. Nights can be extremely busy; on my first night call we had an emergency re-opening of the chest in the ICU on a postoperative cardiac patient who became unwell.
Once a week we have journal club where trainees critically evaluate some current ICU relevant article. The Unit is high paced; therefore there is not always much space for formal teaching during the day. Nevertheless, consultant physicians are always happy to answer questions and even give mini teaching sessions on some relevant topics if requested by the trainee. I had very informative sessions on respiratory weaning strategies, mechanical cardiac support etc. Another aspect I found extremely valuable was learning communication strategies in the context of addressing difficult end of life, withdrawal of care discussions with patients’ families. I am particularly grateful to Dr Sara Sterling and Alan Ashworth who took the time and effort to teach me some of the key aspects and attitudes on such conversations.
It was a great opportunity to learn about vasoactive drugs and to get some basic understanding of the various mechanical circulatory support devices (VAD, ECMO, IABP).
At almost any time we have 5 to 10 patients in the ICU who have recently undergone heart or lung transplantation. They will be seen first by the multidisciplinary transplant team (5-10 persons): transplant surgeons, a cardiologist or respiratory physician and transplant fellows. After morning handover one of the anaesthetic trainees will be assigned to go with the transplant team to see the patients and document discussions, requests by the transplant team.
Work in the Cardiothoracic Theatres
Days in the theatre offered me an immense learning experience. Half of my theatre service was spent in cardiothoracic theatres and the rest in thoracic theatres.
Days in the theatre start at 8 AM. The patients on the list have usually been seen the previous evening.The whole surgical team convenes in the anaesthetic room to briefly touch upon the day’s cases. Expected surgical and anaesthetic challenges, required equipment, time plan are discussed and a plan is agreed upon. Patients arrive in the anaesthetic room.
Peripheral venous and arterial lines are inserted followed by anesthesia induction, intubation, central line insertion and insertion of a TOE probe.
On a regular cardiac day we had 2 to 3 cardiac cases most of them on bypass. When the patient goes on bypass there is time for the novice to get acquainted with some basics of Transoesophageal Echocardiography. As trainees work with different consultants on a daily basis knowledge transfer is outstanding, concerning both clinical anaesthetic skills as well as knowledge base improvement. At the conclusion of the case the patient is to the nearby cardiothoracic ICU, handed over to the ICU nurse and one of the doctors in the unit. The day finishes between 5 and 6 pm, after which, we would go and do the preop assessment for next day’s cases.
Every year a considerable number of heart and lung transplantations are carried out at UHSM. The timing of such an event is of course highly unpredictable. During my time at UHSM, on numerous occasions I had the privilege to participate in the anaesthetic management of transplant patients. I had the feeling this cases are as complex as anaesthesia ever can get.
Thoracic days were just phenomenal. High risk patients are common on the operating lists. On my thoracic days I worked mainly with my mentor Dr Tim Strang who not only has an excellent sense of humor but is also a phenomenal teacher. We tried a range of different double lumen tubes, bronchial blockers. He taught me how to site thoracic epidural with the “hanging drop” technique and how to do paravertebral blocks. Thoracic days were second to none-you will be tired in the end but leave the hospital with the feeling that you have learnt a tremendous lot. I am also indebted to Dr Lajos Szentgyorgyi who taught me a great deal of practical skills in thoracic anaesthesia as well as basic aspects of Transoesophageal Echocardiography.
My 3 month fellowship in Manchester was a superb educational and personal experience. I would like to thank all staff (doctors, nurses, administrators) at the host institution making my stay a very pleasant and rewarding experience. I am particularly indebted to my mentor Dr Timothy Strang and our chairman Dr Julian Barker, the educational lead Dr Anita Szabo-Barnes, consultant anesthetist Lajos Szentgyorgyi as well as all other consultant anesthetists in the CTCCU.
The ESA trainee exchange scholarship is an absolutely fantastic opportunity to get novel perspectives and learn new techniques. Also it is a great chance to meeting interesting people and expand ones professional network. The scholarship is truly an outstanding tool for facilitating European interaction within anaesthesia in our increasingly globalised world.
I am immensely grateful to ESA for allowing me the privilege of participating in the Trainee Exchange Programme.
Does this experience inspire you? In 2016, the ESA will sponsor 10 ESA Trainee Members to spend 3 months in a European centre of excellence.
Application deadline: 15 September 2015.