Diogo Sobreira Fernandes
During the last trimester of 2016 I did a three-month internship in Cardiothoracic Anaesthesia at Lyon, France. I was under the supervision of Prof Fellahi, who welcomed me in his department. However, this great opportunity began a year earlier when I applied for the TEP grant.
I knew about the existence of this grant when I became an active ESA trainee member. The knowledge of the existence of such a grant always excited me, and after completing my third year in residency I decided to apply. I wanted to do an internship in Cardiothoracic Anaesthesia because I believe it is one of the most challenging and complete rotations of anaesthesiology specialization. I had already decided to do this rotation abroad, first because my hospital does not have this specialty and second, because I already knew the work of Prof Fellahi in the field of hemodynamic monitoring and the use of inotropes and vasopressors. So I was incredulous when I learned that I had won the scholarship and I could do this internship at the centre I had chosen, the Hôpital Cardiologique Louis Pradel. Thereafter, I had the pleasure to start organizing my internship, which included a first meeting with Prof Fellahi at Lyon to introduce myself and deal with bureaucracies.
This was a hands-on practice internship. For this reason, I took this opportunity and committed myself to intense daily practice in this incredible centre. I was integrated into a group of seven French trainees, who showed me the whole department and gave me valuable tips. Each day I was assigned to one of the eight operating rooms: two for chest surgery, two for adult cardiac surgery, one for paediatric cardiac surgery, one for cardiac rhythm disorders, one emergency room, and one for myocardial biopsies/implantations of Portacath/pace maker/implantable cardioverter-defibrillator. The level of preoperative organization was high. Each patient underwent a preoperative anaesthesia consultation, followed by a multidisciplinary meeting where all scheduled patients were discussed, and, finally, the preoperative anaesthesia visit made by a trainee.
In thoracic surgery, I performed many thoracic epidurals and ultrasound guided paravertebral and serratus plane blocks. I was also invited to participate in a course for lung isolation techniques, which was important to improve my intubation skills with double-lumen endotracheal tubes and bronchial blockers. When necessary, a disposable fibroscope was available. I also participated in one bilateral lung transplantation.
In cardiac surgery, I performed many arterial and venous catheterizations, including Swan-Ganz catheters, central venous catheters with mixed venous oxygen saturation monitor, and a Pulse index Contour Continuous Cardiac Output system. All catheterizations of large vessels were performed under ultrasound control. Still in the context of goal-directed fluid therapy, I had the opportunity to use transoesophageal cardiac echography and endotracheal bioimpedance cardiography. This rotation was also very important in order to understand the particularities of extracorporeal circulation, most frequently with cardiopulmonary bypass, but also with extracorporeal membrane oxygenation. I also deepened my knowledge about the management of coagulation disorders, the use of antifibrinolytics, blood products, and antiplatelets and hypocoagulants. I also had contact with thromboelastography. I had the chance to participate in a wide variety of surgical procedures, namely on-pump and off-pump coronary artery bypass, minimally invasive (video and percutaneous) and conventional open cardiac valve surgery, surgical management of heart failure, congenital heart disease repair in adults and children, elective evacuation of pericardial tamponade, and two cardiac transplantations.
In addition to intensive clinical practice, a presentation prepared by trainees was held once a week. I presented the theme ‘Inotropes and Vasopressors’. Once a month there was a session given by experts in a nearby castle, Château de Montchat. I particularly enjoyed one about ‘Opioid Free Analgesia’ for its quality and relevance. In addition, many research protocols were ongoing during the period of my internship.
I was surprised to learn that in France the rotation in Cardiothoracic Anaesthesia can last six months and includes both practice in Anaesthesia and Intensive Care Medicine. In addition, once the specialization in Anaesthesia is completed, trainees become anaesthesiologists and intensivists, since the five-year specialization includes two years of Intensive Care Medicine. For this reason, the anaesthesiologists of this service routinely alternate their clinical practice between Intensive Care and Anaesthesia, thus promoting a continuum between the intraoperative and postoperative periods. I found this type of organization extremely interesting, since postoperative morbidity is influenced by the intraoperative patient management. In Portugal, in order to practice Intensive Care Medicine, it is necessary to undertake a two-year postgraduate course, since the specialization in Anaesthesiology only includes a nine-month internship in Intensive Care Medicine.
The fact that I rented a studio in the city centre allowed me to enjoy the beautiful city Lyon is. I believe that if some day my hospital starts doing cardiothoracic surgery, I can contribute in this field. Moreover, the knowledge I have learned about the handling of patients with multiple morbidities who will undergo major complex surgeries will certainly be useful in my daily clinical practice, especially when dealing with critical patients. In conclusion, this traineeship was a priceless experience and clearly exceeded my expectations.
I would like to thank the TEP Committee for making this dream a reality and all the staff of Department Anesthésie-réanimation of the Hôpital Cardiologique Louis Pradel for their warm welcome and teaching me during these three months.