OUTGOING STUDENT EXCHANGE REPORT

ERASMUS MC
UNIVERSITY MEDICAL CENTER ROTTERDAM

Erasmus University Rotterdam, Rotterdam-Netherlands

July 18th – August 12th, 2016























By:

NABILA ARNEST AMORITA

13 / 346254 / KU / 15707

FACULTY OF MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2016

OUTGOING STUDENT EXCHANGE REPORT

Name : Nabila Arnest Amorita

Student Number : 13 / 346254 / KU / 15707
Period of Clerkship : July 18th – August 14th, 2016
Duration of Clerkship : 4 weeks
Place of Clerkship : Erasmus MC University Medical Center Rotterdam, Netherlands
Department : Anesthesiology and Surgery
Supervising doctors : 1. Markus Klimek, MD, PhD, DEAA, EDIC
: 2. Robert Minnee, MD, PhD
Expertise : 1. Anesthesiology – Neurosurgery
: 2. Vascular and Transplantation Surgery
Total hours spent : 147 hours

A. AIMS OF THE OUTGOING STUDENT EXCHANGE PROGRAM

1. Improving and learning the medical skills and the knowledge in a specific area of
practice according to the department.
2. Learning the improvement of the medical science in other country.
3. Experiencing difference in patient’s background, language, illness, and also treatment
plans.
4. Adopting professionalism and attitude from medical professionals in other country.
5. Understanding the healthcare system in the host country.
6. Having more knowledge of the medical education system in the host country.
7. Identify any differences in public health regionally and nationally in the host country.
8. Be the representative of Universitas Gadjah Mada and Indonesia in foreign hospital
(Erasmus MC University Medical Center Rotterdam).
9. Bringing and introducing Indonesian culture and language to other countries while
learning foreign culture as well.
10. Creating the international networking among medical students worldwide.

B. PROGRAM DESCRIPTIONS
1. Welcoming lunch were held by the international office and there were two buddies
who company the student to know more about the hospital and to help with the
administration stuffs.
 2. Student did an internship with local medical students in Anesthesiology Department
for the first two weeks, then continued to another two weeks in Surgery Department
in Erasmus MC University Medical Center Rotterdam, Netherlands.
3. The internship mentioned above occurred on Monday to Friday for 4 weeks.
4. The average time spent in the hospital is 7 hours / day.
5. In Anesthesiology Department, it was obligatory to attend the morning report
everyday, which mostly discussed what happened in the night shift.
6. Student was involved in pre-operative and post-operative assessment everyday.
7. In Anesthesiology Department, student was allowed to do IV line catheterization, pre-
oxygenation masking, laryngeal mask airway placement, and inject some anaesthetics
medication under the doctor’s supervision.
8. There was an Anesthesiology class every Tuesday at 2pm for all co-assistants, interns,
and also first-year residents, usually discussing certain topics in Anesthesiology field.
9. In Surgery Department, student was allowed to join the operation in order to observe
and assist in the surgery.

C. GENERAL OVERVIEW
1. Erasmus MC University Medical Center Rotterdam
Erasmus MC University Medical Center based in Rotterdam, Netherlands,
affiliated with Erasmus University and home to its faculty of medicine, is the largest
hospital in the Netherlands (after completing its new building in 2017). Receiving,
every year, 38.000 inpatients and 364.000 outpatients, Bibliometric indicators place
Erasmus MC in the top 20 of clinical medicine worldwide; its publications are cited
1.75 times the world average.
Erasmus MC is committed to a healthy population and excellence in
healthcare through research and education. It excels in various research fields,
studying fundamental and clinical domains as well as public health and prevention.
Research at Erasmus MC is at the heart of society, resulting in innovation, quality
improvement and more effectiveness in patient care. Everyday, more than 13,000
dedicated employees are contributing to its results in cure, care, research and
education.
In addition to scientific research, patient care and education are core tasks of
Erasmus MC. It is the top referral center for a region of about five million inhabitants.
The complete spectrum of medicine is offered, from disease to health and from
 individual to public healthcare. Erasmus MC is also the largest medical school in the
Netherlands, with ~3,100 medical students and 227 PhD graduations in 2014. It offers
BSc, MSc and PhD programs to train the next generation of medical practitioners and
researchers. Together, the students and employees at Erasmus MC improve the
individual patient care and public health of tomorrow.

2. Netherlands Medical Education System

The Netherlands medical education system is quite similar with Indonesian
system in the terms of bachelor level. First, medical students have to do 4 years of
pre-clinical education which included lectures, practical works, discussions, field
visits, and also elective exchange program. Each topic is divided into blocks, and
every blocks has different duration depends on how heavy the topic is. In the end of
bachelor level, they also have to do research as their final assignment. After that, they
also have to do clinical rotation for another two years, but the difference is that in
their last three months of clinical rotation, they have to choose one specialty that they
find it most interesting, so that after the co-assistancy has finished, they can continue
straight away to the residency program. Finishing the clinical rotation program makes
a medical student get a master degree, unlike Indonesia which we are still considered
on a bachelor level.

3. Netherlands Healthcare System

There are lots of excellent hospitals in the Netherlands with high standards of
care all over the country. Each hospital (ziekenhuis) used to offer a range of
specialisms but they are becoming more specialized.
There are different types of hospital. Those attached to universities and
carrying out medical research unsurprisingly have the most advanced medical
equipment and treatments, and can offer the most specialized care. Teaching
hospitals, training medics and nurses also offer some specialized treatments. General
hospitals deal with more routine conditions.
Going to the hospital in the Netherlands
Unless it’s an emergency, you will need a referral letter from our general
practitioner. You will be asked to provide details about your medical history and
lifestyle, and be registered on the hospital database.
You’ll be given a registration card (ponsplaatje) which you’ll have to show
 each time you visit – it’s a means of bringing up your details and passing on bills to
your insurance company.
Hospital admission
If you are admitted as an in-patient – and unless it’s an emergency, this could
take months from your initial appointment – you may find yourself in a shared room
or ward of up to six beds (mixed sex). You’ll probably have a TV and phone line but
there will be a charge. Bring your own clothes and toiletries. Strictly enforced visiting
hours vary from hospital to hospital. If you prefer access to private rooms, you may
consider taking out private insurance.

D. PROGRAM DETAILS
WEEK 1
1. Monday, July 18th, 2016 (9 hours)
a) Attended the morning report in Anesthesiology Department for the first time
and introduced to all the staff by my supervisor and also the head of
residency program, dr. Markus Klimek, PhD.
b) Introduced to the operation room facilities, rules, and regulations.
c) Learned how to do pre-operative patient care (patient preparation, installing
an IV line, ECG patch and pulse oximetry device, preoxygenation, mask
ventilation, and intubation).
d) Learned all the kind of drugs and stuffed used during the operation, including
how the ventilation machine worked.
e) Observed a neurosurgery on hypophysis adenoma.
f) Learned how to do post-operative patient care (check patient’s response to
stimuli, take the patient to appropriate care)
g) Brought the patient to Intensive Care Unit (ICU).

2. Tuesday, July 19th, 2016 (8,5 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patient (installing an IV line,
ECG patch and pulse oximetry device).
c) Observed when the anesthesiologist did the epidural anesthesia and installng
the central venous line.
 d) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
e) Observed a HIPEC (Hyperthermic Intraperitoneal Chemotherapy) procedure
on colorectal carcinoma.
f) Learned all the kind of drugs and stuffed used during the operation.
g) Discussed different methods of anesthesia used based on the patient’s
indication.
h) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to ICU.

3. Wednesday, July 20th, 2016 (7,5 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Observed 4 urology procedures; transurethral resection of bladder, closure of
the urethral fistula, perineal urethroplasty, and diagnostic cystoscopy.
e) Learned all the kind of drugs and stuffed used during the operation.
f) Discussed about ASA classes.
g) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to Post Aneesthesia Care Unit (PACU) or recovery room (based
on the patient’s condition).

4. Thursday, July 21st, 2016 (8 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Observed when the anesthesiologist did the epidural anesthesia.
d) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
e) Observed a diagnostic laparoscopy on Whipple tumor.
f) Discussed about pain management and WHO Pain Ladder.
 g) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU.

5. Friday, July 22nd, 2016 (8,5 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Observed 3 different kinds of surgical procedures; total thyroidectomy and
removing ileostoma, lymph node biopsy, and cholecystectomy.
e) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU.

WEEK 2
1. Monday, July 25th, 2016 (8 hours)
a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Adjusted the ventilation machine for sedation.
e) Observed 2 urology procedures; perineal urethroplasty and ureterorenoscopy,
and lithotripsy.
f) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to recovery room.

2. Tuesday, July 26th, 2016 (9 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Observed the anesthesiologist installing the central venous line.
 e) Observed the kidney transplantation procedure.
f) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU.
g) Attended a discussion group contained some co-assistants and first-year
residents about fluid management.

3. Wednesday, July 27th, 2016 (7 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Observed the anesthesiologist installing the central venous line.
e) Observed gynecology procedure on debulking.
f) Discussed the principles and indications of blood transfusion.
g) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU.

4. Thursday, July 28th, 2016 (7,5 hours)

a) Attended the morning report in Anesthesiology Department.
b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Installed a laryngeal mask airway (LMA).
e) Observed 2 gynecology procedures; laparoscopic hysterectomy and excision
of ovarian cyst, and curettage.
f) Adjusted the ventilation machine for sedation.
g) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU and recovery room.

5. Friday, July 29th, 2016 (9 hours)

a) Attended the morning report in Anesthesiology Department.
 b) Assisted the anesthesiologist to prepare the patients (installing an IV line,
ECG patch and pulse oximetry device).
c) Did the preoxygenation, mask ventilation, and observed when the
anesthesiologist intubated the patient.
d) Installed a laryngeal mask airway (LMA).
e) Observed 3 different kinds of surgical procedures; 2 vascular surgeries and
an emergency abdominal surgery. Three of them used three different kinds of
anesthesia method (general anesthesia, sedation, and regional anesthesia).
f) Adjusted the ventilation machine for sedation.
g) Assisted the anesthesiologist to do post-operative patient care and brought
the patient to PACU and recovery room.

WEEK 3
1. Monday, August 1st, 2016 (8,5 hours)
a) Introduced to the staff of Surgery Department.
b) Learned the different approach of applying the aseptic procedures.
c) Observed 3 trauma surgeries:
- removal of external fixation on a TB-suspected patients (due to the risk
of infection, I had to wear a special protective equipment including
special mask, special robe, googles, and gloves)
- amputation on left leg due to severe osteomyelitis
- emergency procedure on a victim of car accident; right radial fracture,
left femur fracture, and right knee displacement.
d) Discussed the radiology images of the patients.
e) Discussed the different surgical approach based on the patient’s condition.

2. Tuesday, August 2nd, 2016 (6 hours)

a) Discussed the case, medical record, and radiology images of the patients.
b) Assisted in the HIPEC procedure on peritoneal carcinoma.
c) Discussed the different surgical approach based on the patient’s condition.

3. Wednesday, August 3rd, 2016 (6 hours)

a) Discussed case, medical record, and radiology images of the patients.
 b) Observed the liver resection procedure, but due to the metastasize of the
cholangiocarcinoma, the surgeon closed the wound and cancelled the
procedure (the tumor already spread to the other half of the liver and only
less than 25% left)

4. Thursday, August 4th, 2016 (6 hours)

a) Discussed case, medical record, and radiology images of the patients.
b) Observed a laparoscopic procedure of extended gastrectomy due to the distal
gastric carcinoma.
c) Discussed the different surgical approach based on the patient’s condition.

5. Friday, August 5th, 2016 (6 hours)

a) Discussed case, medical record, and radiology images of the patients.
b) Installing a urethral catheter.
c) Assisted in a laparoscopic pancreatic surgery on Whipple tumor.
d) Discussed the different surgical approach based on the patient’s condition.

WEEK 4
1. Monday, August 8th, 2016 (7 hours)
a) Discussed case, medical record, and radiology images of the patients.
b) Observed in 4 vascular surgeries:
- open aortic bifurcatio and putting prosthesis due to aortic aneurysm
- left leg amputation due to osteomyelitis on the maleolus lateralis
- hernia cicatricalis
- toe amputation due to necrosis
c) Discussed the different surgical approach based on the patient’s condition.

2. Tuesday, August 9th, 2016 (8 hours)

a) Discussed case, medical record, and radiology images of the patients.
b) Observed in kidney transplantation surgery.
c) Discussed the different kinds of transplantation procedure and its regulation
in Netherlands.
d) Assisted in vascular surgery on bilateral inguinal hernia.
 3. Wednesday, August 10th, 2016 (7 hours)
a) Discussed case, medical record, and radiology images of the patients.
b) Observed 3 vascular surgeries:
- porth-a-cath replacement
- aneurysm in left median vein
- toe amputation due to necrosis

4. Thursday, August 11th, 2016 (8,5 hours)

a) Discussed case, medical record, and radiology images of the patients.
b) Assisted in 3 trauma surgeries:
- removal of external fixation due to severe infection
- ulnar fracture
- hip fracture
c) Assisted in emergency abdominal surgery due to sepsis; the patient had an
ascites abdomen filled of pus after two days before underwent a lung
transplantation surgery.
d) Discussed the surgical approach in orthopedic cases and the tools used.

5. Friday, August 12th, 2016

a) Observed in a daycare surgery à the surgery scheduled was cancelled
because the patient decided to move the date.
b) Farewell to the staff in Anesthesiology Department and Surgery Department.

SUMMARY
After I did 4 weeks of clerkship in Erasmus MC University Medical Center
Rotterdam, I learned a lot of new knowledge and things especially in Anesthesiology and
Surgery field. My daily agenda when I was doing my clerkship was varied, but mostly I was
involved in bedside teaching with the doctors and nurses, engagement to the patient, and
learned more about how things worked in the hospital. In Anesthesiology Department, I had
to attend the morning report everyday which discussed some cases that happened in the night
round, then continued by pre-operative assessment in the holding room for all the patient
before they undergo the surgical procedure. Together with the staff, I brought the patient to
the operation room and they taught me some basic skills in anesthesia, such as IV line, pre-
oxygenation, mask ventilation, laryngeal mask airway, and all the medication given to the
patient. After the procedure had finished, I also brought the patient to the recovery room,
PACU, or ICU, depends on the patient post-operation condition.
In Surgery Department, most of the time I could only observe the surgery because
most of the cases in Erasmus MC are difficult cases and even not every co-assistant can join
the surgeon in the operation table. But in my exchange period, I got lucky because I got the
chance to assist in some procedures It was exhausting yet very interesting because you could
see up and close what exactly does the surgeon do. The most interesting operation I saw was
a kidney transplantation surgery. Not only because the procedure is quite amazing, but also
the surgeon is really keen on telling everything he did; which made me interested more and
more. I also got a chance to practice my Dutch skill and also taught some Bahasa to fellow
medical students who will join an elective exchange program to Indonesia this September.
Overall my expectations in this program are fulfilled and I learned a lot from this wonderful
experience.

E. CONCLUSIONS
Being able to join this exchange program was very amazing. This program
significantly broadened my knowledge, not only in medicine, but also in culture. I learned so
many things when I was in hospital: the aseptic procedure, anesthesiology, surgical procedure
and instruments, machines used in the operation theatre, and teamwork between medical
professionals. This exchange program will be one of the unforgettable memories I have ever
had.

F. ATTACHMENTS
Attachments are attached in other pages.

G. CONTACT PERSON
Markus Klimek, MD, PhD, DEAA, EDIC
Vice-Head Residency Training Program / Vice-Chairman
Departement of Anesthesiology Erasmus MC University Medical Center Rotterdam
‘s Gravendijkwal 230
3015 CE Rotterdam, Netherlands
Tel. +31 (010)-7033713
Fax. +31 (010)-7033722
m.klimek@erasmusmc.nl
ATTACHMENTS