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1.Brief summary of Leave : |
Modern management of Pediatric Intensive Care Unit (PICU) has a short history and there was a little experience in this regard in Iran. Children's Medical Center, the pediatric center of excellence in Iran, has renewed its PICU and the way care was given to patients. After I established the first emegency pediatric ICU and managedit for 2 years, I felt a great need to learn more about practical scientific management of Pediatric ICU in developed countries. I did not want to be an Observer, so choosed to study in Ludwig Maximilian University of Munich, Germany. This University has been considered as one of Germany's as well as one of Europe's most prestigious universities; with 34 Nobel laureates associated with the university, it ranks 13th worldwide by number of Nobel laureates.
The Pediatric Hospital, named Dr. von Haunersches Kinderspital, was founded by a non-profit sponsoring organization 160 years ago. This pediatric hospital has 119 beds, the pediatric surgery hospital has 61 beds. Both hospitals also offer multiple subspecialty services and provide outpatient care with 3 levels of Neonatal, Infant and Pediatric intensive care units and are capable of treating even the most severe medical and surgical conditions. The Division of different ICU departments was also very intresting: They had an intermediate ICU department between NICU and PICU which, As tolld earlier, was named infant ICU and managed patients aged between 3 months to 1year.
First I preferred to take part in the training pogram at Infant ICU. The first important thing I found was a combined team work between Doctors and Nursing staff. All the personels attend the morning round and shared their knowledge and experiences about the patients. Every department had “A guideline based management” , which was renewed each year and all the patients were managed according to the guidelines. Only if there was a conflict or something which were not found in the guideline, the department’s Chief or a Senior physician would have guided the residents.
At Infant ICU, I got familiar with special problems of this age group and especially NIV. It seems that the most important development in the field of Pediatric mechanical ventilation over the past 15 years has been the emergence of noninvasive ventilation (NIV) as an increasing part of the critical care management. NIV is the delivery of mechanical ventilation to patients with respiratory failure without the requirement of an artificial airway. Traditionally NIV was often used for long-term nocturnal or continuous support of patients with forms of chronic respiratory failure but its use is increasingly popular in varied clinical situations in the intensive care unit setting, too.
It has decreased complications associated with invasive mechanical ventilation such as upper airway trauma, ventilator-associated pneumonia and should, however, be considered in some cases an alternative to invasive mechanical ventilation rather than its replacement . Keys to the success of NIV and to improve clinical outcomes of patients are careful patient selection and a well-designed clinical protocol. Also a variety of good NIV masks and Nasal Devices play a great role in patient acception and satisfaction.
Then I worked in the interdisciplinary PICU designed for children older than 1year of age and took part in care of children with pediatric medical and surgical intensive care needs. The spectrum also includes severe burns and compliactions after solid organ transplantation, as well as all acute life threatening emergencies including Accidents and Intoxications. There I got familiar with German’s unique emergency medical service ( EMS ) or the “Rettungsdienst “. It is a service of public pre- and in hospital emergency healthcare primarily financed by the German health insurance companies. EMS is a component of one of the key tasks (public safety) which every municipal government is required by law to perform. As a result, there are strict regulations regarding qualifications, job performance, response time, and the types of equipment required. The Medical Director is responsible for the creation and issue of regulations, protocols, and standards of care on behalf of the community.
Of utmost importance for me was learning and working at the Home Mechanical Ventilation unit. As an increasing number of children who would have previously died can now survive. They can be managed with home mechanical ventilation. There is a shift in patient diagnoses mandating long-term ventilation; respiratory diseases such as chronic lung disease have been replaced by neuromuscular disease, spinal injuries, and central hypoventilation syndromes. Advances in medical care and ventilator technology specifically available in the home has broadened the composition of ventilatory modalities for long-term use.Furthermore, there has been a deeper understanding of the family centered benefits for transitioning out of intensive and acute care departments. Also the overall costs and side effects are less while the benefits are more when we are able to manage such patients in home. In this unit first I learned how interact with patient’s family and then the way to use Ventilator at home and how to respond to questions and problems of the family, the patient and the responsible Nurse who helped the family at home.
The Cardiac ICU was in another hospital, The Klinikum Großhadern. It is the largest hospital complex in Munich, owing to its affiliated institutions and 1,418 beds. The organ transplantation department of the clinic is one of the leading organ transplantation clinics in Germany. All clinically established forms of organ transplantation are implemented, e.g. Heart, Heart & Lung (simultaneously), Lungs (one or two), Pancreas, Kidney and Pancreas & Kidney simultaneously. I spent near two months in Cardiac ICU to learn modern management of complicated congenital heart diseases, post cardiac transplantation problems, complicated heart failure and use of Left ventricular assist drive (LVAD). The left ventricular assist device is a mechanical pump that is implanted inside a person's chest to help a weakened heart ventricle pump blood throughout the body. Unlike a total artificial heart, the LVAD doesn't replace the heart. It just helps it do its job. This can mean the difference between life and death for a person whose heart needs a rest after open-heart surgery, or for some patients waiting for a heart transplant (called "bridge to transplant"). LVADs may also be used as destination therapy, which is an alternative to transplant. Destination therapy is used for long-term support in some terminally ill patients whose condition makes them ineligible for heart transplantation.
As Children’s Medical Center was planning to open their new Bone Marrow Transplantation ward, I was requested by our Pediatric Department to attend in the Stemcell transplantation devision. Really it was a modern department which used its’ own and confidential Protocols and had lots of patients from outside the Germany. All complicated and referal patients were managed in a teamwork. There I got some experience in their modern and new Transplant programs and also special problems of those patients such as GVHD, mixed chimerism, and the manner they followed them up in ambulatory clinic after discharge such as Donner Lymphocyte Infusion, BMA, and etc.
Finally as part of training program, I have attended the Neonatal ICU in Munich’s Women hospital and gained more experience in early management and resuscitation in emergency delivery room and emergency cesarean section department and also special NIV and Mechanical Ventilation, fluid and electrolyte, Infection control and their modern computer based Parenteral nutrition programs.
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3.Acheivements(Publications,research,et.al.) : |
As I have told previously, Pediatric intensive care is a new division in our university. No one had a good experience in this regard. I had established the first Emergency PICU in our university and managed it for the first 2 years. I felt the utmost need to educate in a scientific department of a well known university. Also it was crucial for me to work, and not only OBSERVE, in different divisions of PICU ward.
I think in the new scientific situations, it is also important for a university faculty member to be able to speak in at least 2 foreign languages, and now I am proud not only to be the first pediatrician in our university which has completed a training fellowship coarse in a world recognized university, but also proud of learning German as a second language. |
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4.Assessment of Value of Sabbatical leave(benefits,faculty development,future professional activities,...) : |
It seems that it is my duty to promote the ability and knowledge I have acquired. Fortunately our department was approved to train pediatricians in the field of Intensive Care. In near future it certainly will be a subspecialty and I will do my best in this regard. Making a better prognosis for sick children is the duty of our hospital in the country, as it is the Pediatric center of excellence and intensive care plays the most important and critical part in this mission. I wish to be able to take part in this regard. Connection with world’s famous universities also plays an important part in transfer of knowledge and I hope to facilitate this connection with Ludwig Maximilian University of Munich. |