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Sunday, February 27, 2011

I found our Surgeons

Like all other good vacations in Brazil, this trip too includes a long wise tale about a women and a beauty parlor.  As I lay on the table, all my other memories came flooding back.  However, much to my surprise hidden in the four cement walls of the neighborhood beauty salon (a.k.a, someone's house), I found Belem's most prominent surgeon.  Upon entering the waxing room and being dressed in my hair net, the beautician dressed in full "sterile" garb, hair net, mask, gloves, and gown.  If I didn't know better, I thought I was going in for surgery.  Furthermore, from all the hospitals I have visited, this was the best example of sterile technique I had seen yet.  It sparked an idea in me that maybe instead of nurses and doctors all we really needed is a good beautician.

As she meticulously plucked each eye brow hair, the intense focus and concentration on her face was something to marvel  at.  Either I have the most complex eye brows to wax or else this was her game face.  Envision her furrowed brow, squinted eyes, and I am sure pursed lips behind her mask as she silently completed her work.  One hair at a time.  

With what followed next, I might have been more concerned or self conscience, if this was my first experience in Brazil.  But much to my own comfort it was not.  The hot wax all over my face in fact was a soothing sensation.  Why when you ask for an eyebrow wax do they feel at liberty to include your entire face?  Either I am the hairiest ape Brazil has ever seen or else it's the common practice.  No one said being Burnett was easy.  

As time passed, I finally thought I would make it through with no cultural surprises.  It wasn't until the end that I suddenly found my self back at square one, nervous, sweaty, and stumbling out my poor Portuguese of, "no wait, what is that?  I don't understand, I don't speak Portuguese!" But despite my best pleaing efforts, the beauty surgeon lifted her cauterizing, facial blow torch, and began her work.  Similar to all good surgeons, do now and have the nurse explain later.  As sparks zapped the hair, an unpleasant twinge of pain could be felt radiating through my body.  I swear the only reason for the sterile garb was to hide the slight grin of pleasure I could feel oozing from behind her mask.  

But what would be a trip to the Salon with out a good story.  And if nothing else, I have found a solution to our problems.  How do you think she'd fair as a surgeon because if you ask me its the best chance Brazil has. Infection, leg hair, arm hair, beard, mustache, sideburns, eyebrow, and peach fuz free I am truly Brazilian now!

What Brazilian women can endure, it is no wonder they are tough enough to rule the world.  Well, at least the country for now...

Saturday, February 26, 2011

Cidade das Mangueiras

Wrapped in disguise, Belem's streets are lined with enormous trees, low hanging branches, with bright green foliage and heavy red and yellow mangoes!  In addition to meaning Mango Tree, mangueira is also the name of a famous Samba School in Rio de Janeiro (conveniently the one I danced for two years ago!).  Just my luck, mangoes being my favorite food, it was the first sign this place was made for me!  And with Carnival fast approaching I thought what a bit of Brazilian knowledge to share with the world!


Mangueiras (Mango trees)

Samba School Mangueira

Belem is the capital of mango fruit in all of Brazil.  Originally from Japan, mangoes can now be found on the streets, cars, and heads of the people of Belem.  Make sure to always be looking up, you never know when it could be your last.

This place is a land full of wonder.  Today, it is a metropolitan city that is home to over 2 million people.  Sitting near the mouth of the amazon, Belem traditionally has some of the most exotic and delicious cuisine in all of Brazil.  Walking through the streets you discover Amazonian Brazil.  The mixture of indigenous people and Portuguese influence, makes Belem like no other city in the world.  But with this beauty comes great challenges.

The view of Belem from Marcia's Friend's House.

The Amazon Forrest takes up 62.1% of all land in Brazil with most of that Forrest covering the States of Para (were Belem is found) and Amazonas.  The river is the life line for the millions of people that live here.  It is the source of all things, work, food, and water.  In essence it is life.  You can imagine the constraints this region has on providing healthcare, clean water, and education.

Yesterday, I visited the Instituto Evandro Chagas.  The people from Belem call it The Olympus.  A 200+ bed hospital dedicated solely to cases of Infectious Disease.  IEG has a pediatric floor, a 10 bed ICU, an entire ward for AIDS patients and a whole designated hallway for TB cases just to name a few departments.  This tarnished and decrepit building houses some of the most interesting cases in ID, in the world.  I saw disease I never knew existed.

In addition to several AIDS, Malaria, and TB patients, I saw cases of Chagas Disease, Leishmaniasis, Leprosy, Dengue, and even a COBRA BITE!  Most conditions being transmitted by mosquito bites, flea bites, and actually poorly prepared Acai (Acai being native in this region, it is the most popular consumed food here.  A large source of income and claim to fame for the state of Para as well).

Chagas Disease can present as swelling in the effect area, headache, fatigue and fever.  It eventually leads to enlarged liver and spleen and if it is not treated will lead to death.

Leishmaniasis presents as lesions and as it hides in your macrophages it is protected from your antibodies many times developing into a chronic condition.  It can be fatal for immunocompromised patients. Hence the challenges of Transplantation in the Amazon.

Beyond the interesting cases of infectious disease you couldn't help but notice the desperation and despair of the people.  The people there were poor, very poor.  Most patients live deep within the Amazon Forrest and suffered great lengths before arriving at Instituto Evandro Chega.  One case, a 5 year old boy had an unrelieved headache for over a YEAR.  His family went to the health clinics several times but where always sent home.  It wasn't until the boy started to go blind that they made the diagnosis.  Now, permanently blind, his family had to return to work 6 hours away while he continued his 6th week recovering in the pediatric ward.  

This poor boy's story was not alone.  Each patient we met had a similar experience, 3 months of symptoms, 6 months, 9 months, before they found proper care.  Besides the geographical challenges of the amazon, the posto de saude (healthcare clinics) struggle to find adequate providers.  Most patients I talked with lived anywhere from 3 hours by car to several days by boat away.  Because of the distance, and the needed length of days for IV therapy must patients stayed within these crumbling walls anywhere from 2 weeks to 6 months.  With no resources for home care or optimal clinics in the indigenous regions, patients sit alone finishing treatments waiting to return home.  

With so many hurdles for improving the health care system one wonders where you find hope?  It isn't enough to provide "free" healthcare if one can't access it or finds it suboptimal for sustainability with life.  

Before I left, I met with a friend who has spent most of his medical life abroad in undeserved areas such as Nicaragua, and I asked him, "Do you ever see progress?  Can you maintain hope when it seems so dismal?"  and he replied, that of course you do, you just have to measure progress in a different way. 

For me, the hope lies in the people.  Listening to Marcia and Mauricio's passion for helping others is profoundly moving.  In the face of diversity, overcoming problems such as geographical hurdles, infectious disease, education, and cultural stubbornness, these two have battled through.  Their Liver Transplant Program for the Northern Region of Brazil will be a legendary accomplishment.  Pioneering transplant through the Amazon Forrest.  From their friend Fabio, who constructing a hospital out of a boat, travels along the Amazon River providing primary care, to the hard working heroes of Belem that every day work to make it better.  

Furthermore, having dinner tonight with Marcia's cousin, a public defense attorney for the indigenous people of the Amazon, you can't help but feel a sense of renewal and purpose as he passionately explains the absolute neccesity of stopping the building of a dam in the Xingu River to directly save the lives of over 20,000 people, effecting 5 different tribes, and one huge city.  It is our commitments now that shape our future.  Our choices to look at total despair and inject hope.  If nothing more, being surrounded by such purposeful people has sparked emotions and drives in me to do more, seek more, and accomplish little goals for big changes.

Sometimes you need to ask yourself, what in this world seems impossible to change, and then prove the world wrong.

Our Team of Doctors for the Liver Transplant Program

Our Team of Doctors for the Liver Transplant Program

Wednesday, February 23, 2011

Post Script

I too am "open to what you have to say"

Suggestions welcomed! :)

The Daily Grind

Well, this experience is shaping into something completely different than I ever expected.  The hospital being constructed only 5 years ago, with a new administration in the last 6 months, CHANGE is of the essence!  Despite my original impressions and observations (such as 1 ICU nurse for a 10 bed unit, no central line dressings,  or 1 nurse of a 22 bed floor), there has been drastic improvements with the implementation of protocols and new policies.  Expecting to spend more time at the bedside, I have seemed to be engrossed with working in the offices.

Yesterday I completed my second project.   Translating their research paper on the need for small bowel transplants in Brazil and the Northern Region proved to be a challenging experience.  Knowing almost nothing about small transplants I started by conducting my own literature review.  In order to be well versed on common "small bowel transplant" lingo, I read several of todays leading research.  Then the translating started.  And here in front of me I have a well (I am biased) transcribed paper proving the need for Brazil to perform small bowel transplants with my name on the top as one of the contributers.  Check that off the list of things to do, not bad for a start.

In addition to translating, I spent most of the day yesterday receiving a more in depth tour of the hospital with the Head Nursing Coordinator, Everson.  I knew I was at home when I walked into the ICU.  The medical staff busy at work with the comfort of constant beeping and alarming brought me quickly back to 5E.  I visited each floor, the holding area, the OR's, the special burn department, and even materials management!  I learned about their systems, practices, and short comings.  With a big smile, Everson asked me to give a full report on my observations and my suggestions for improvements, "I am open to what you have to say!"


ICU: One large open room with 10 beds

    • 1 nurse for 10 bed unit 
    • 1 doctor for a 10 bed unit
    • 5 nursing techs for 10 bed unit
    • Almost every patient had a tracheostomy (patients are trached after 1 week of intubation, no exceptions!)
    • No central monitor
    • Standard ICU beds 
    • All orders/ documentation hand written
    • Nursing techs administering medications
    • Almost no one wearing gloves
    • Few sinks / fewer hand hygiene stations
    • No central line dressings
    • All patients lay supine
    • No limbs elevated
    • Almost no restraints
    • Heavily sedated
    • All patients in Depends
    • No Families
 Floor: A 20-24 bed unit with two rooms for males and one room for females
    • No nurse call system
    • Almost no families
    • All in minimal clothing
    • Minimal linen and no pillows
    • No ambulation or mobility
    • No Physical or Occupational Therapy
    • One sink in each room
    • No privacy 
    • One inmate patient with no guard. Handcuffed to the bed. With other patients
    • One TV
    • No staff providing care (However only observed during the short time I was there)
    • One pharmacy for the ORs and the ICUs
    • One Pharmacy for the burn unit
    • One Pharmacy for the rest of the Hospital 

These observations are just the basic environment differences I noticed.  In addition, I discovered the hospital has no policy and procedures for patient care.  There are no guidelines documented for nursing or nursing techs to follow.  There is no follow up on patient outcomes.  

I know what you are thinking...are they looking to hire new nurses?!  A nurses dream: no families, heavily sedated patients who we don't have to turn, with no charting or protocols and assistants to do all the dirty work.  But in all seriousness it is exactly that hard work we do every day that makes the UW a competitive hospital with good patient outcomes possible. Who would of thought I ever would have valued "competencies" and "accountability" the way I do now?!  It provides a whole different perspective and is a fresh reminder why we are required to complete these hours long, pain in the butt, agonizing tasks.  It makes for better nurses, better healthcare, and healthier patients.  In short, it's a part of saving lives.

Here in Belem, they have high occurrence of central line infections, poor hand hygiene, and bed soars.  If a central line stays longer than 10 days, almost EVERY patient becomes infected.  I have been asked to create a process for changing these problems.  So onto my new adventure.  Three months, to create a complete culture change, to establish competencies, policies, procedures, and standard nursing practice not just for our new Transplant program but the whole hospital!

Wish me luck!

Sunday, February 20, 2011

Old Town Market

We finally spent the day touring around old town Belem at their famous markets.  We started the morning early at the street fair.  The crowds were busy buying small piece of traditional Amazonian jewelry, art, crafts, and food.  After a few hours we took our treasures we had purchased and went to a more "local" market.  Located on the Amazon River, I was surrounded by the smells of traditional cuisine, fresh fruits, peppers and of course, live stock.  If this experience didn't redefine fresh for me, I am not sure what will.  Not that it made me eager to eat chicken any time soon!


Belem, was one of the original cities in the Amazon where the Portuguese had established a port.  Within almost spiting distance of the ocean, the city of Belem (which means Bethlehem) was the hot spot a mere 4 centuries ago!  Today mixed with a different hustle and bustle, you can still find some of the same goods they sold way back when.  Rows of fresh and exotic fruits, peppers, and vegetables line the streets.  Not far off you can hear the crowing of the chickens, roosters, hens, and other live stock made for a startling first experience.


A culture also heavily based on myths and magic have an entire section swarmed with old ladies convincing you their herbs, soaps, and bath oils contain the potion for anything your heart desires...love, lust, or even revenge.  I look my luck on a "few" of their recommendations :)


Saturday, February 19, 2011

Jacob and Tyler

It isn't a great picture but look what I found you.  These frogs, about as big as a golf ball, are EVERYWHERE at night and make about as much noise as a howler monkey.  If you aren't too careful, they will keep you up all night!  I will do my best to catch you two, one each.  But don't worry Jenny, they are fast little buggers :)

Friday, February 18, 2011

Life's not always a beach!

I have been working in the hospital the last few days and what an experience that has been.  My first day I went on a tour of the 200 bed hospital where we will be starting the liver transplant program.  Currently, they are the trauma/burn center of the Northern States of Brazil (ie the Amazon region), Hospital Metropolitano.  It is like our own little Harberview but add a few more states, like California, it needs to cover! Then put jungle, lack of roads, and rivers in your way and imagine how patients get to good medical care!

Hospital Metropolitano

The future Transplant Program and current Trauma center covers the State of Para, Amazonas, Acre and Roraima!

Walking through the halls I had a mixture of first impressions.  Much to my surprise, they had a fair amount of technology from a MRI machine (even though it is broken right now), CT machine, several ORs, to even a special burn ICU (only two beds). But the building was still humbled by its simple appearance, with almost a minimal sense of "state of the art". Despite this, the units were full of patients, nurses, and doctors busy at work.  The healthcare system is very different in Brazil.  In one ICU or on the floor you have far fewer nurses and far more nursing techs.  At any given time for the 14 bed ICU you have 1-2 nurses and about 5 nursing techs.  ICU internalists in Brazil are notorious for not being "eager" to work, so sometimes it's hard to even find a doctor.  There 1-7 ratio makes me feel blessed to work where I do.  

I met with everyone from the director of the hospital to the nursing officer to the director of Nursing Research and Education.  It is incredible to see a functioning institution where the administration is personable, present amongst the hospital staff and not locked away in an ivory tower.  I also was greeted by the director of finance, several doctors, and even more nurses.  I wonder if the US could learn a thing or two about how to conduct human interactive management.

The next day I had my big presentation at a different hospital.  After visiting this much older hospital, I later learned, contrary to my initial impression of the worn in Hospital Metropololitano, it was only built 5 years ago!  I was looking at the top of the line! It scared me for what lay ahead. The older hospital was built over a 100 years ago.  With social medicine, the government felt it would be cheaper to build a new hospital (Hospital Metropolitano) outside the city instead of fixing this one.  So with no renovations but still an overload of sick patients, the decrepit building still stands as a working hospital.  I have to say the only perk in the place was instead of cots for patient families, they all receive a hamick!  I think that would be the best improvement I could bring back to the US.  They take up less space, are easy to store, never break (unless you put two very muscular people on them...right Norm?), and provide a sense of tropical leisure to help decrease the anxiety.  All in all, a great idea.

We had come to visit a patient in need of a liver transplant.  Down a dark and dingy hallway with static from an old TV in the background, we entered into the patient's room.  He was a young gentleman in his 20's in full liver failure and no where to go.  He is the type of patient they are working to save.  The room was depressing, with paint chipped from the walls, an old gurney for a bed, and a single bag of IV fluid hanging from the ceiling.  He was to stay in the hospital another night for observation.  As we closed the door behind us, no one said a word.

This same evening, I held my first presentation ALL in PORTUGUESE.  Ok, not all...but most of it.  They even pretended to understand me! Not knowing what to expect I was a little shocked to walk into a small auditorium!  Present was the Director of Liver Transplant, the medical staff, nurses, and even physical therapists.  I shared about the UW's protocols, introduced the new idea of standardized order sets and showed a colorful power point about the nursing process.  They asked good questions and even sparked debate about our immunosupression practices in the US verses their beliefs.  The Director of the Liver Transplant program invited us to his house for dinner (for tonight) so I'd say it went well!

After our meeting we finally went to the downtown of Belem.  Old town Belem was breathtaking.  Covered with antique Portuguese buildings, sitting on the mouth of the Amazon River within reaching distance of the open ocean this poor city transformed into a beautiful piece of history.  Filled with open markets, historical land marks, and green grass parks with huge tropical trees, you can feel the essence of Belem.  We eat in an old Portuguese house right on the river with live music.  Belem is famous in Brazil for their love of live music and delicious cuisine.  I have to say, trying one of the typical fish dishes of the region, it was one of the best fish dishes I have had in a LONG time!  The tender white fish with Belem's herds and fresh pimento, I could eat that every day!

Belem, Brazil

Tuesday, February 15, 2011

There is a Toucan Outside my Window

I have arrived in Belem, Para (which is one of the states in Brazil, with the state of Amazonia, that makes up the Amazon Forrest)!  It has been two days and I am just getting my barrings.  It's surreal.  Stepping out of tropical paradise in Rio and into the impoverished, congested, city of Belem.  There is beauty in its own way but a whole different world.  Poverty surrounds you.  From the infrastructure to the eyes of the people, there is a sense of wanting, a need for more.  A good Brazilian friend said to me, "prepare your heart Lia."  I am sure with some exploration I will discover a different perspective, but for first impressions, it is hard to miss.

As always, Marcia and Mauricio, welcomed me with open arms making me feel right at home.  They must know me well.  The first thing  they did was enter their home open the fridge and say, "you are home, what is in here is all yours."  Ahhhhh home at last!  Quickest way to my heart, is to feed me!

Marina e Eu.  Daughter of Marcia e Mauricio.  She loves to play and not let me work!  Who could resist?

Belem, is a MUCH bigger metropolitan city than I ever imagined.  It serves 2 million people in the greater area.  It is the biggest city in the Amazon.  Now that being said, you don't have to travel far to find remote Amazonian culture.  In fact, I discovered, besides the large in voice but small in stature frogs outside my window, I have several toucans that live in the tree outside my window!  Pam, how do you like that for birdwatching?  I am still trying to get a good picture of them.  It takes patient waiting.  And we all now that isn't my "strongest" feature!

My Backyard!

I also found out Belem is back on the Northern Hemisphere so I am back to winter season.  Which sadly means rainy season.  This humid, tropical down pouring isn't the sunny Rio I just left.  Oh the shame.  At least it won't distract me from work.  And it should be changing soon.  The first day I arrived I felt the burning of the Equator Sun.  I might be begging for this cooler weather, come summer time!  Good thing Erin has taught me years of proper sunscreen wearing :)

Well I better get back to work.  I have a big presentation tomorrow for the Hospital staff.  Medical director, Hospital Administration, Nursing Research/ Educator, medical and nursing staff included!  All I need to do is complete my power point presentation and learn perfect Portuguese.  No problem. 

Over and Out!

Saturday, February 12, 2011

Meu Coração, Minha Familia

I have arrived!  Safe, exhausted, and hotter than I thought possible!  I think my whole heart sank when the pilot announced it was 39 degrees.  Over 102 F and that's not including the humidity.  I have to say the good news was it only gets hotter from here!  I am so blessed to have picked a city on the equator!  That wasn't on their welcome website.  They should really give that disclaimer to people before they make such big commitments! 

I have spent the last few days PACKED with wedding planning, family, a little beach, dancing samba, and more family.  With my cousin having the first GRAND CHILD a few months ago, we all gather on
Saturdays with the family for big lunches!  The family in Brazil is something to marvel at.  The connections, passions, and love in the room is like nothing else you have felt.  The heat that resonates from the cramped room filled with so many people, is a warmth you welcome.  

There is something to say about the embrace between father and son and brothers and sisters.  They hug, hold each other, and kiss.  I think if more people practiced love like this, the world would be a better place.  

Last night, my cousins and I went dancing Samba.  The beat of the drum resonated through the floors and seemed to lift the dancers.  Gallotte, a musician friend of my Uncle, played till 6 in the morning.  The building was an old Portuguese House with exposed beams and intricate stone walls. Half way through a dance my cousin said to me, "You see that wall?  It is like my mind.  At first, it appears to have no order, but it can hold up a building.  It makes complete sense, you just have to know how to look at it."  We moved across the old tile dance floor as 8 musicians sat around an old wood table and only stopped to refill their beers.  A country surrounded by poverty, fill their lives with the joy of music.  If I died, I would want it to be while dancing Samba. 

Just as I start to feel at home, I am off again tomorrow.  I will be taking a 6 hour flight to Belem, Brazil.  An old colonial town, at the mouth of the Amazon.  I will see what my new adventure has in store.  Sweating through it will be the only guarantee I have!

I miss you all...BEIJOS!

Thursday, February 10, 2011

Let the Adventure Begin

Here I am February 9th at 9 at night about to board my last lag to Rio de Janeiro, Brazil.  I started this long day at 5 am Seattle time!  I haven't made it very far, but have already received the expected 15 phone calls from my Dad with his last minute advice, guidance, and words of endearment, "money in your front pockets, no jewelery, be careful, I love you, be careful, bags in front of you, don't take the taxi offered inside the airports, don't go to the beach, work, take care of the things, have fun, oh and be safe, I love you." :) It's comforting to know after all our years of travel, he is consistent!

So there I was, two HUGE suitcases, two HUGE carry ones, oh and my wedding dress.  Two hours later and a friendly feel from our beloved TSA, and I was on my way.  As I walked to my flight it finally hit me.  I am leaving everything that is comfortable, my friends, my family, and my job, to move to the city of Belem with little understanding of what lies ahead.  This lit an unexplainable excitement in me and I knew I was making the right decision.  I have spent many years waiting for this opportunity and part of me can't believe it is finally here.  There are few times in your life you are filled with such raw and apposing emotions from elation to anxiety and confidence mixed with fear.  But if not now, then when?

I'd like to take a few moments to give background to how I ended up here today.  I have always loved Brazil.  When I am there, I feel at home.  The energy, positivity, and celebration of life that defines the culture calls to my heart.  Despite the hardships, poverty, and human suffering, Brazilians never stop dancing to the samba beat.  When I finished college I wanted to move to Brazil to live for a year or so.  I wanted to become fluent in Portuguese, samba dancing, and the Brazilian way of living.  With my Mom sick at home that wasn't a reality.  Erin and I planned our trip for short two months all over Brazil combining vacation with volunteering at my Dad's school, Quero Ser.  It was an experience I could never put into words.  The children we worked with, the people who welcomed us into their homes forever changed us.  I returned to the US and immediately started my job at UWMC.  I loved my life, but a part of me felt empty with out this full experience.  Four years later, having the nursing experience, the support of the UW, my incredible family, and an amazing man pushing me to achieve great things, I have the perfect combination to prepare me for this experience.

With everything aligned, I will be spending part of my time helping the medical team in Belem establish their liver transplant program.  I will be educating nurses on Post-op Liver Transplant management.  The other part of my time, I will be taking a boat down the river providing primary care to remote communities in the Amazon.  That is all I know...no more and no less.  So, as I sit in the Charlette Airport, I will close in saying...here goes nothing!