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EH 1_2015 31INTENSIVE CARE cry, ‘So we are significantly below this level with our core working hours being a maximum of 48 hours a week.’ ‘These hours are obviously exceeded at times, however, gen- erally not by doctors who are still undergoing training. It applies more to senior doctors and medical direc- tors who must abide by certain special regulations, such as being on call. ‘A few years ago, an EU-decision entitled the Working Time Directive, outlined that on-call duty must be classed as working time, and we now have to work around this. Because of that directive continu- ous working is no longer possible. If a trainee surgeon goes home after work and the next day cannot carry out an interesting intervention, that’s just a loss. Receiving consist- ent care from one doctor is no longer guaranteed and the level of continuous change has increased.’ Assessing the actual work- ing hours It’s difficult to assess the actual hours worked, Prof. Vogt pointed out. Additional obligations around scientific work take place in doc- tors’ spare time, as are writing articles, attending conferences and continuing professional education. ‘It’s never been any different and cannot be managed in any other way,’ he said. ‘In our hospital, post-surgi- cal patients are seen twice a day, because doctors must go home after night shifts, and this redundant system ensures that the flow of information across the hospital can be maintained. Collectively agreed standard working hours are indis- putable, but we have the dilemma of having to train junior doctors within a manageable period,’ he said, add- ing that the legal requirement lead to interruptions, making that harder to achieve. Promoting alternatives Germany’s specialist medical soci- eties aim to improve the curric- ula with the present framework. ‘Ultimately, all we can do is optimise the preconditions in hospitals. As specialist societies we are neither associated with the Federal Ministry of Science, Research and Economy nor with the Federal Ministry of Health. The specialist societies also have a very different significance in the USA and Great Britain, which ensure the implementation of fur- ther training on site. We have no control over training procedures because this is within the remit of the General Medical Association, which, incidentally, is now planning new regulations on further educa- tion, although not in the sense of a complete restructuring. ‘It’s conceivable that the frame- work for trainee surgeons will improve, so that respective amounts are factored into the DRG system. In contrast to German’s a ratio of around 1:5 – one consultant to five senior house officers, other coun- tries have five consultants to one senior house officer. ‘To achieve that we’d have to implement completely different staff ratios and improve training. As President of the DGCH I feel strongly that the prevailing eco- nomic view of medicine is wrong. The attempt to meet both economic and training obligations simultane- ously is doomed to fail.’ Continued from page 4 Trainee surgeons suffer permanent stress The 35th ISICEM An isolation unit flying on 60-metre wings Held every year in March, for the past 35 years, the International Symposium on Intensive Care and Emergency Medicine has been organised by the Departments of Intensive Care and Emergency Medicine at Erasme University Hospital, Université Libre de Bruxelles, in association with the Belgian Society of Intensive Care and Emergency Medicine (SIZ). For three and a half decades, the event’s main organiser has been Jean-Louis Vincent MD PhD, Professor of Intensive Care at the Université Libre de Bruxelles and Head of the Department of Intensive Care at Erasme University Hospital. Here he reflects on the simple begin- nings of the ISICEM, it’s huge attendance and authority today, and current key issues in intensive care. Brussels, Belgium:17-20 March 2015 Cautionary measures for Ebola evacuations This year we are celebrating our 35th ISICEM! Time has certainly flown by since the very first ISICEM back in 1980, with just 200 participants and five faculty members. This year we expect to welcome more than 6,000 active participants from more than 100 countries, with over 200 speak- ers giving around 700 different pres- entations throughout four-days! Intensive care medicine has also evolved and one interesting ses- sion will cover the key changes in clinical practice and understanding that have occurred during the last 35 years and the likely or possible changes for the next 35. With such a full programme, it is always difficult to select so-called ‘highlights’, but one important aspect of our meeting is to provide participants with the results of the very latest clinical trials in our field. In this year’s meeting, the results of The Protocolised Management in Sepsis (PROMISE) study will be pre- sented for the very first time. This trial compared early goal- directed therapy (EGDT) with usual resuscitation in cases with early signs of severe sepsis or septic shock, arriving at emergency depart- ments in the United Kingdom. This is the third large, multicentre study to have evaluated the potential ben- efits of this approach to patient man- agement and the results are eagerly awaited, particularly as the first two studies, Protocol-Based Care for Early Septic Shock (ProCESS) and Australian Resuscitation In Sepsis Evaluation (ARISE), found no spe- cific benefit of the EGDT approach on mortality compared to current standard practice. Another recently completed clini- cal trial, the results of which will be presented at the ISICEM, is the Age of Blood Evaluation (ABLE) Study designed by the Canadian Critical Care Trials Group. There has been considerable discussion regarding optimal blood transfusion triggers over recent years with an initial trend towards restricting transfu- sions as much as possible now swinging back towards a realisation that this restrictive approach may not be beneficial to all. Does the age of the red blood cells being transfused influence the equation? Red cell storage has been suggested to decrease the oxygen carrying ability of red cells, but does transfusion of older red cells influ- ence patient outcome? Data have been conflicting and the results from this randomised controlled trial comparing transfusion of stand- ard issue red cells with transfusion of red cells stored less than eight days should help provide answers to this important question An important but less often men- tioned field is that of medical ethics. Recent years have seen increasing openness regarding the once taboo topics of death and dying. As the vast majority of ICU deaths are now preceded by an end-of-life decision to withdraw/withhold life-support- ing therapy, it is crucial that these topics are openly discussed with patients, relatives and the ICU team. Several sessions will cover ICU ethical issues, including how to inte- grate palliative and intensive care, differences in approaches around the world, how best to communicate with relatives, and ethical and prac- tical approaches to organ donation. Belgium is one of several coun- tries where a special law permits euthanasia to be conducted in cer- tain individuals and the latest data regarding numbers of patients who have requested and undergone euthanasia will also be presented. Finally, for this brief selection, sep- sis and septic shock remain impor- tant causes of death among ICU patients and the search continues for effective therapies. One approach that has been attracting increasing interest is the use of extracorporeal therapies to remove inflammatory mediators. Multiple extracorporeal techniques have been developed and tested with the aim of reducing the circu- lating levels of inflammatory media- tors like cytokines and chemokines. However, some mediators are beneficial, so questions remain regarding which technique is opti- mal, when it should be started, and in which patients. Data will be presented on the potential place of these tech- niques, including a completely new approach, in the current manage- ment of septic patients. The diverse range of subjects will certainly provide plenty to interest all our participants at the ICISM and we look forward to welcoming you to Brussels. Jean-Louis Vincent PD PhD, Chairman of the Dept. of Intensive Care, Erasme Hospital, Université Libre de Bruxelles Representation of the evacuation plane Medecac A340 Robert Koch sealed isolation unit ©NordwestBoxGmbH Report: Anja Behringer The ‘Robert Koch’ plane for medi- cal evacuations (MedEvac) is the winged equivalent of a German hospital isolation ward. Within it, medics with viral haemorrhagic fever while working on the Ebola outbreak in West Africa, receive intensive medical care during any stages of the disease, while being evacuated. The concept was developed by experts at the Robert-Koch-Institute for infectious and non-communica- ble diseases, under the supervision of the Federal Foreign Office. Previous, smaller transport isola- tion units, such as those used in standard air ambulances, can only safely transport patients who are still in the incubation phase of the disease, i.e. those who do not dis- play symptoms yet. Rescue helicop- ters are also not suitable to trans- port infected patients because they cannot be comprehensively disin- fected due to on-board electronics. Pilots and flight crew, two medi- cal teams, two technical teams and a chief of operations man, the MedEvac-A340 Robert Koch Airbus A340-300 containing its large iso- lation unit. Team members with patient contact wear protective clothing. Patient and staff enter and leave the treatment area via a decontamination chamber to pre- vent spread of the pathogens. The isolation unit has a vacuum and is hermetically sealed – a set-up presently unique on board a plane. A large pressure compensation tank in the rear of the plane ensures that even in the rare case of an air emergency, e.g. sudden loss of pressure, the isolation unit remains intact. Due to these measures the release of the Ebola virus is deemed impossible. Germany’s Countrywide isolation wards The Federal Republic of Germany has seven specialist treatment centres with isolation wards and laboratories in Hamburg, Berlin, Dusseldorf, Leipzig, Frankfurt, Stuttgart and Munich, providing 54 beds in total. To transport infectious patients, in early 2015 these centres were allocated 10 specialist ambulances ventilated with filters and easier to clean than conventional ambu- lances. A large number of specially trained staff, wearing protective clothing, accompanies all transports in these vehicles. Due to the large number of staff needed to handle infectious diseases cases, a maxi- mum ten patients can be treated simultaneous in this country. At the request of the World Health Organisation (WHO) the first patient with Ebola virus disease was trans- ported to Germany at the end of August 2014. The epidemiological bulletin published on the Robert- Koch-Institute website in December explained the treatment process from the point of view of the Hamburg Public Health Office. The infected patient’s sealed in-flight area An outer chamber has a changing area; the inner chamber contains a decontamination unit

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