María Georgina Cubas Quiroga
My name is María Georgina Cubas Quiroga. I’m originally from Caracas, Venezuela, where I completed my medical studies. I have always been known as a person who seeks to expand her horizons and explore possibilities. That is why, in 2008, I moved to Barcelona, Spain, where I did my Postgraduate training in anaesthesia at the Hospital Clinic de Barcelona.
From the beginning of my training I was interested in Hepatobiliary Surgery and Liver Transplant (LT). Hospital Clinic is a Spanish centre that has a well-developed LT program, performing an average of 70 transplants a year. As part of my educational program, I worked on the LT team during my final year of training, where I had an opportunity to increase my knowledge and skills in this area. During this time my interest continued to grow, and I started planning to find a way to get more experience in this field. It was during the summer of 2013, that I decided to apply for the Trainee Exchange Program (TEP), 2013.
When I reviewed the list of hospitals where the European Society of Anaesthesia (ESA) offered training in Liver Transplant, I was surprised not to find King’s College Hospital (KCH), London, on the list. However, there were other excellent hospitals, so I decided to select St James’s University Hospital in Leeds, UK, as my first choice, mainly because I have knowledge of the English language. The die was cast, and there was nothing to do but wait for the decision of the evaluation committee. After a month of waiting, with a mixture of optimism and resignation, I received the anticipated e-mail: I had been selected! This brought me great satisfaction, as all my efforts had paid off.
Image: With Liver ITU Consultants. From Left to right: Dr. Chris Willars, Dr.María Georgina Cubas, Dr. William Bernal and Prof. Julia Wendon.
The truth is that I was to become even more fortunate. Shortly after, I received an email from the TEP office asking me if I would have a problem in doing my training at KCH, instead of St James´s Hospital, as my mentor, Dr. Zoka Milan, had moved to London to join the liver transplant team at King´s. Even though St James´s is a great hospital, it is well known that KCH is one of the most important centres for LT in Europe, and it has on its staff some of the top specialists in this area. Plus: it was in London! Obviously, my answer was that I would love to accept their offer. I want to emphasise all the effort that Dr. Milan had gone to in order to have King’s included in the list of European Centres of Excellence, thereby making it possible for me to do my TEP in this important hospital.
In June 2013 I went to England for my first visit. London greeted me with a bright sunny day and the weather remained like that for the 7 days I was there. A good sign? I met again with Dr. Milan, whom I had previously met in Barcelona during Euroanaesthesia. She showed me around the hospital, the Liver Intensive Care Unit (LITU) and the liver transplant theatre. I was also introduced to the LITU Consultants. Everything was set for me to begin in September 2013.
But I was not to begin in September 2013. In order to work with full clinical responsibility, I decided to postpone it until April 2014, when I would have my European Rights and could therefore apply for a full UK medical license (General Medical Council Registration).
Image: Dr. Zoka MIlan and Me. Liver ITU.
So, in mid-April 2014, after what seemed like a long wait, I arrvied at KCH. With my mentor, we had decided that my training would be based primarily in the LITU, combined with anaesthesia for liver transplants, and hepatobiliary surgery, when I had the opportunity of going into theatre.
During the 3 months that I was at KCH, for bureaucratic reasons, I wasn’t able to work with full clinical responsibility, but I did acquire much new knowledge. The day at LITU starts at 8:00 am, with a short handover from the nightshift. Immediately after the urgent things have been done—lines, echoes, and blood samples—the round begins. There are 16 patients in the unit. We examined the patients and developed a daily plan which was subsequently discussed and reviewed in conjunction with all team members. In the mid-afternoon we made another small round to discuss details before attending a 5:00 o’clock meeting. Not only the LITU team attended this meeting, but also the entire hepatology department; the goal was to reassess the plans and get opinions from the experts. In addition to the clinical responsibilities, other meetings were scheduled, such as Morbidity and Mortality, and X ray sessions. Fridays were my favourite days as two very useful activities were performed: The Journal Club, where a paper on a relevant ICU topic was discussed, and the Multi-disciplinary Transplant Pre-assessment and Listing Meeting.
The LITU was a very busy unit with a wide range of patients, all with hepatobiliary diseases. For me, it was an honour and a privilege to learn from the experts whose papers I had previously read. Under the guidance of Professor Wendon, Dr. Auzinger, Dr Bernal and Dr. Willars, I learned more about the clinical management of this kind of patient, including advanced management of acute liver failure, total plasma exchange, different types of renal replacement therapy, and ECMO for patients with cardiorespiratory failure.
Image From Left to right: Mrs . Mona Dave ( Perfusionist) , Dr. Zoka Milan and Me
Regarding the anaesthetic management of liver transplantation, as KCH is a high volume centre that serves patients of high complexity, I witnessed different types of procedure to which I had not previously been exposed, such as Paediatrics, Splits, and Auxiliary liver transplant. One of the novelties that impressed me greatly (both for its concept and possibilities) was the use of Organox, which is an autonomous liver preservation system, currently in use only in clinical trials, but with promising results.
I also had the opportunity to collaborate in research activities in anaesthesia in the LT field, under the guidance of Dr. Milan and the rest of the liver anaesthetics and perfusionist team , from whom I learned so much.
I believe this experience has been invaluable for me, not only from the professional point of view, but also personally. I had the opportunity to live in one of the most interesting cities in the world, I improved my language skills and I met wonderful people, not only professionally, but also as human beings. I would definitely recommend that all trainees should consider applying for this wonderful opportunity.
I want to thank the TEP Committee for giving me this opportunity and Dr. Milan for all her help, guidance and support, all of which were crucial for me. My thanks also go to Prof. Wendon and the whole LITU and LT team, for the teaching and the assistance they provided. Finally I would like to thank Anny Lam, the Secretary of TEP for all her patience and support.