A guest post by Dasha Kenlan, UK M4, and soon to be anesthesiology resident at University of Utah.
Their propofol is just colder, #amirite??
During our medical adventure in Norway, Josh and I were lucky enough to spend a week with the Anesthesia (Anestesi) Department at the University of Northern Norway (UNN) in Tromsø. This experience included normal ‘OR’ days, following the ‘Trauma’ shift resident, evening call, responding to codes, and a shift on the LuftTransport fixed wing plane ambulance. It was an amazing experience, and a huge part of me wanted to immediately apply to their residency program (too bad I’m already contractually bound to NRMP). But for the purpose of Josh’s blog, I thought I would muse on the similarities and differences that we observed in our time with the department. Granted, some of the differences might have been lost on us due to language barriers, but overall, I think some aspects were coldcut (pun intended).
Hierarchy & Teamwork
Maybe one of the first differences that I observed in the operating theaters was the lack of hierarchy and status that is often oppressive in the US operating rooms. I was a foreigner, a newcomer, and a well-trained US medical student, that knew to jump out of the surgeon’s way as soon as he walked through the door. But at UNN, I could look around mid-operation, and NOT be able to tell who the surgeon, scrub tech, and nurse were. The only obvious person was the nurse anesthetist, who maintained his or her position at the patient’s head with the anesthesia machine. The surgeons never walked into the theater yelling or barking orders. They slipped in quietly, gowned up, performed the surgery, and disappeared without a word sometimes. The anesthesia team was in charge of the patient, and no one challenged that. Furthermore, the anesthesiologists worked well with the anesthesia nurses. The doctors were often present for induction, and if there was trouble, but for the most part, the ‘nurses’ managed the anesthesia for the case. They also assigned 3 nurse anesthetists per 2 rooms, so there was always a buddy to help during induction. The nurses don’t mind being called ‘nurses’, whereas in our US hospital, a CRNA would bristle at the thought of being called just a nurse. In both countries, becoming a nurse anesthetist takes several extra years of training beyond nursing, but in Norway, being a nurse is an honor (as it should be). This lack of hierarchy has been noted by others. Finally, even though we clearly did not belong and could barely say hei på norsk, no one was rude to us, and often even welcomed us into their workspace with their best english and smiles. Overall, UNN could teach us a thing or two about teamwork.
In a country of only 5 million people spread over vast mountains and fjords, there are undoubtedly unique aspects to providing acute care in Norway. Most notably, anesthesiologists provide the bulk of acute care in hospitals and critical care transport since there is no emergency medicine as a specialty (before Jan 9th, 2017). In the more rural areas, general practitioners (GPs) take turns doing shifts at the local legevakt (urgent care of sorts). Road ambulances are available but are less practical in large transfers since it takes HOURS to go around the mountains/water on a two lane road, especially in northern Norway. They have a unified plane and helicopter system, and we experienced a shift on 1 of the 8 planes in the entire country (#livingthedream). In the hospital, anesthesia responds to and takes control of all codes, whereas in the US, this is hospital dependent (sometimes anesthesia, sometimes EM). Overall, the scope of Norwegian anesthesia practice encompasses all acute care + the normal OR + pain + ICU = which sounds like my dream job. For Søren Stagelund, the anesthesiologist on my flight shift, for example, it’s a job worth living in Tromsø for even when his family lives in Denmark. His thoughts on EM in Norway were that the population and volume did not warrant an Emergency specialization, like in the US. He had seen the same process evolve in Denmark when they created the Emergency Medicine specialty. Either way, it is yet to be determined how the new specialty in Norway will develop in conjunction with the GPs and anesthesiologists. It is notable that even though anesthesia residency training includes all the different subspecialties, ultimately an anesthesiologist chooses whether to become an OR/acute doctor, subspecialized in cardio/thoracic or neuro, or an ICU doctor.
All the Small (Big?) Things
Then there are the other differences, which I will list out for convenience.
- There are multiple break areas with coffee and delicious juice concentrates – that you can get away with taking into the OR AREAs (mind-blown).
- Wear rings/earrings/watches into the OR areas? Unlike in the US, where anesthesiologists are stereo-typed for their fancy watches, heck no.
- Gloves for putting lines into patient – optional. No one has HIV or Hep C. No one in Norway even has liver disease! How? Everyone in KY has liver disease!
- They have superficial arterial lines that are more like peripheral IVs than our US arterial lines. Complete sterile technique not required.
- Did I mention that a doctor only makes about 2x the salary of a janitor? There’s little difference in the salary between a nurse and a resident, a resident and a consultant.
- The work week is 37-45 hours!
- They use target-controlled infusions (TCI) for many of their anesthetics, which are not approved in the US. A more detailed discussion of this coming on a future post.
- I do not have the numbers, but I suspect there is a difference in the percentage of anesthesia methods used in our respective hospitals, and a difference in the ASA patient breakdown.
- Anesthesia charting is still on paper, but is in the process of soon being converted to an electronic system. Few academic residency programs in the US are still on paper charting, but it definitely still exists.
- Their twitch monitoring is more involved than our train-of-four monitoring. Their monitor reports back a percentage of paralysis. I need to dig deeper here, but it was a notable difference.
I have spent a good bit of text on describing the differences in our anesthesia health care, but rest assured, many things are very much the same. The operating theaters look similar with the same equipment. Most medicines are the same. The nurse anesthetist-doctor system is present. Patients still need cholecystectomies, and are having C-sections in the middle of the night. The PACU / Oppvåking area still holds post-op patients until they are ready to go to the floor / ICU / home. The anesthesia residents do regional blocks for patients in the hospital, and consult on those patients. Of course most importantly, like in the US, the anesthesiologists and nurses are the best people in the hospital 🙂