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Wednesday, March 30, 2011

A Grand Love Affair

I am sorry Norm.  I love you but...

It all started two nights ago.  Another hot humid evening in Belem, you could see the steam rising from the pavement as the tropical rains subsided and left the thick moist air that was almost too dense to breath.  After another long day at the office, I quietly nodded off in the backseat and only rose when I felt the jolt of the emergency break and heard doors opening.  I stepped out into what appeared to be a botanical garden.  Surrounded by tropical trees and flowers, I spun around and found my self face to face with my new boo (do people still say boo?).  Now it wasn't love at first site per say, but an enticing beginning to what proved to be a long passionate end.

The building was made of dark, thick, Brazilian wood.  A large stair case wound you around, forcing you to it's doors.  Calling my name.  With further observation, the bottom floor appeared to be a museum of some sorts.  Small boats, carts, and art typical to the Para region.  As I took my final stair, I was high enough over the tree tops to see the Amazon river slowly drifting by.  As the moon shown and the stars lit the sky, how could love not be in the air.

I entered the restaurant.  It took my breath away for the first but not the last time tonight.  The high ceilings, and grandious room was perfect.  In the center a glass floor overlooking the museum and long pieces of bark from different Amazonian trees hung for everyone to admire.  I felt like I was in a painting.  As we sat down for dinner the white linens with wicker chairs made me feel right at home, my Brazilian home.

As all old black and white love movies go, there was foreplay, love, and a cigarette...for the interest in time, I will skip the foreplay.  Advised by the waiter, we each ordered the "chef's special."  The chef's smooth and sultry voice as he requested us not to eat the complimentary bread and explained our first course lit an excitement  within me.  Each course paired with each different cocktail, I embarked on this road.  There was no turning back.  Course one, a light pumpkin soup, course two a small salad with a grilled squid. Consecutively, courses three, four, and five only continued to lure me towards this sinful lust and excite my pallet with each new sea creature perfectly prepared, seasoned, and presented.  Each course being accompanied by the chef.  It wasn't until after the sixth and seventh that I thought I would be lost forever.  To enter and never leave.  How does one continue to live life normally after knowing this exists.  But it was the eighth course...a white fillet crusted in Brazilian nuts, laying on a seafood rossoto, with the light touch of jamboo oil drizzled perfectly over top.  And I caved.  Licking my plate clean, I sighed with relief knowing I had given in.  I was captured.  Lured into this heaven by the aromas and tastes of a four hour love affair.  We sat and sipped our port, no words could be exchanged.  It was the lit cigarette.  I knew it was over.  Far too soon.

But it is better to have loved and eaten, than never to have eaten at all.  So until next time my love, I will suffer eating bland and tasteless food.  But I need only close my eyes and I am right back there with you...white fish, squid, soup, salmon, shrimp, jamboo...like it was only moments ago...

Minha Vida...Belem, Brasil



Nurse by day, Surgeon by night

The next few days, I spent touring around the hospital, the clinics, and meeting the staff.  From the Director of the Hospital to the nursing techs, everyone welcomed me with kind smiles.  I spent most of my time with the Transplant Nurse coordinator.  Unlike the US, nurses here in Brazil have a more managerial position.  Flogging the administration with nurses for creating "protocols" and completing bureaucratic paperwork, I found more nurses in administration than I did at the bedside.

Even at the bedside, there is one nurse for each unit (usually 10 beds) where they oversee the work of the nursing techs.  In Brazil, nurses are required to study 5 years.  After their degree in nursing they can major in a specialty.  While, there are strengths to nurses in leadership roles, allowing them to dictate best nursing practice and change healthcare, there are also set backs.  No nurses at the bedside.  Nursing techs complete a majority of the care, including medication administration, all with ONE year and a half of education under their belt.  You can imagine the complications that result from less educated employees having the biggest impact on patients outcomes.  If you don't know the mechanism or the side effects of drugs, how can you safely ensure patient results when administering them?

I spent a few days specifically with the Transplant Nurse, who kindly walked me through her role, and the functioning, documenting, and process for their transplant patients.  One nurse for all Kidney, Pancreas, and Liver transplant patients!!  This in the setting of a team who completes about ...

Liver : 69 = 65 transplants from deceased donors and 4 from living donors
Kidney : 84 = 14 from deceased donors and 70 from living donors
Pancreas : 17 = all from deceased donors

EACH YEAR!  One nurse...170 patients!

In addition to spending time in the ICU it wasn't two days later, that I found myself, sterile and hands deep in a kidney transplant!  Observing for the first time, I was able to watch the surgeons hard at work and see the other, very important, side of what I do.  The first transplant I saw was flawless.  Here in Brazil they practice a majority of the kidney transplants from living donors.  So as the team finished with removing the kidney from the donor, we prepared the recipient.  An easy switchereru.  Although, "switchero" isn't exactly the right word.  Did you know that kidney and pancreas transplant patients don't have their insufficient organs removed?  We just add.  So you may meet people walking around with three kidneys and two pancreases.  A little bloated, one would think.

Our second transplant wasn't so smooth.  The patient suffered from juvenile diabetes, causing an increase in risk with any procedure.  The deposit of "extra sugar" caused a "hardening" of her arteries.  This sclerosis can become extremely difficult with any surgery.  As the new kidney was put in place, the anastomosis site complete, and the tourniquet released, the new Kidney didn't show signs of re-perfusion.  The air became so thick, you could taste it.  The change and increased urgency in the voices was a subtle indication something was wrong.  No pulse was reaching the new organ.  As we had already reheated the kidney we quickly had to re-cool it in hopes to minimize any ischemia damage, as the surgeons found the problem.  From my perch overlooking the patient I could only see hands and blood.  Several of both.  With a controlled speed, the two surgeons quickly re-patched her broken artery, enlarging it to hopefully promote better flow to her leg that had gone without blood flow for sometime.  As the second hand ticket, the surgeons meticulously stitched.  Stitch and tie, stitch and tie...With what seemed days but was only a matter of several minutes.  The artery was repaired and flow restored.  Pulses were found and the kidney looked perfect.

Much to our relief the patient's kidney was kicking in no time with liters of urine within the next few days.  But as 6 in the morning neared the corner, and my head finally hit the pillow, I thought what a wonderful night.  There is nothing else in this world quite like it...

Thursday, March 24, 2011

Becoming a Better Planner

Day one.  As my airplane landed in Sao Paulo, I was to be picked up by Regina, a dear friend of Marcia and prominent doctor at HEPATO (Transplant Organization in Sao Paulo).  Not knowing what she looked like, not having her phone number, and definitely not inquiring for her address, it was about 45 minutes of waiting till I realized I was upstream with out a paddle.  Now, 'call Marcia,' some of you might be saying.  That sounds easy if it weren't for the country code, city code, and out going Sao Paulo code I needed to know.  You can imagine, if I wasn't in-tuned enough to ask for Regina's address you know I didn't know ANY of these numbers.

But call me Sherlock Homes, because after about 10 minutes of asking around I was able to make contact with Marcia and connect my dots.  Regina thinking I arrived the following day, was just as surprised as I was, still being at the airport late Saturday night.  Luckily, Tercio (my sudo-host for the week and Transplant Surgeon at HEPATO) swooped to the rescue.  I was soon home in a comfy bed reading myself to sleep.

Unlike my leisurely weekends here in Belem, come Sunday afternoon we were off to tour the ICU at Hospital Bandeirantes.  We started and didn't stop.  People in Sao Paulo work a lot.  I could safely say they work three times as much as Americans and accomplish half what we do.  It isn't the people but the bureaucracy.  If anything I finally understand what my Dad means when he says, ,"Life here [America] is just easier".  Beyond the beautiful beaches, wild Carnival, rhythmic samba, and psychotic soccer fans, Brazil can be a hard place to work and an even harder place to succeed.  Watching the dedicated and compassionate team at HEPATO you have to marvel at how they can accomplish anything at all.  And I think how much easier it could all be.  But I guess that is something I hope to change.  With the protocols and policy and procedures, one can provide a standardization of care and not only be more efficient but improve patient outcomes. My goals for this week were to share with HEPATO and the nurses of Bandeirantes my experience with this organized system.  Through observations, conversations, and presentations ( a lot of -ations) I would share our process for management of liver transplant patients.

My Aunt having already told me about the importance of Bandeirantes for the city of Sao Paulo, I was excited to see the place.  Much to my surprise, I felt right at home.  Almost half of the hospital being newly built, the beautiful building was a nice change from the mundane architecture of Brazil.  A 200 bed private hospital with specialties including transplantation, cardiology, and oncology.  My initial impression was positive.  I was impressed by the display of advanced technology, the cleanliness of the facilities, and the organized system for providing care.  We visited Tercio's newly transplanted patient.  Two days prior to her surgery she had a MELD score of 39 (out of 40) and the day of surgery had a MELD score of 36.  For those of you that are not transplant savvy, that means she was sick as snot.  One difference I discovered and will dissect later was the selection process for their transplanted patients.  Proving to have a high effect on your outcomes and development of complications, this was one of the most important challenges this institution faces.  And with further research into the reasons for transplanting extremely sick patients, it showed a challenge for ALL Brazilian transplant institutions.

But much to Tercio's relief his patient was stable and well.  We continued on our rounds and called it a short work Sunday.  And no day would be complete in Sao Paulo with out a delicious dinner.  Meeting the rest of the HEPATO team, we started our long debates about healthcare, politics, culture, and of course Transplantation.  I met Tercio's partner, Marcelo, who is conveniently married to his sister, Nuninha, whom also happens to be the HEPATO administrator, and lastly Regina, their heptologist.  I could tell this was the start to a wonderful week.


Wednesday, March 23, 2011

Another shit day in paradise

As the high heals fell from my feet and my toes slid into the soft, flat, familiar havaianas, I couldn't help but feel at home after my week in nice clothes, long work days, and cooler Sao Paulo weather.  My skin still wet from the soothing sunscreen, I descended 9 flights to the ground floor of the apartment complex.  The doorman missing, I let myself out. A sense of warmth and laissez-faire attitude over came me.  With one havaiana touching ground and other soon to land, it wasn't three minutes that I was back, that a large, what appeared to be naked man side swiped me to the ground.  Feeling the moister of his belly sweat mixing with my sunscreen and from my new upward angle glancing at his once hidden sunga wedged between his butt, I knew I was home sweet home.  Rio has a fast way of welcoming you back to another, 'shit day in paradise'.

In fact, I believe I want to conduct a research experience of fat to sunga ratio.  The bigger the belly, the smaller the speedo. And I think that holds true for all genders.  But I will keep you posted on my results.

So here I am, post completion of my week long work experience in Sao Paulo.  And I loved it.  As it is nearing 1 am here I will keep this brief and write tomorrow about my experience.  However, in short, I spent my Sao Paulo days in the hospitals, holding lectures, sharing mock protocols, conducting research on fundamental nursing, and offering my observational analysis.  After work completed (7 am to 9 pm), I spent each night eating long dinners in some of the best restaurants in town, engaging in even longer conversations about the world.  Engrossed by the passionate opinions of my new found co-workers, I really learned about worldly views, personal experiences, and cultural differences.  The people I was so blessed to encounter there really opened up my eyes and my heart.   Being surround by those driven to make this world a better place, it becomes a contagious dream.  I really believe I have started my foundation for bringing about an international change to bettering the quality and longevity of transplant patients.  It has sparked a new found passion in me.

After Sao Paulo, I had my overnight stay in Rio.  Spending my day with my Aunt, I continued to have an emotionally evoking time.  I think being so moved from my Sao Paulo experience, with May 5th fast approaching, and my Aunt being the amazing person she is, it is easy to understand.  We spent the day shopping and the night eating snacks by the lake.  Getting eaten by mosquitoes and talking about my Mom and my amazing family.  When you think about it, with such strong examples before me I really have it easy.  My compassionate and generous Mom, my driven and undeterred brother, and my loving and supportive Dad, there is nothing I feel I can't accomplish in this world.

 The next day I hopped back on the plane and flew from Rio to Sao Paulo to Belem.  If anything these last few months, I am becoming an expert on airline peanuts.  Sadly this flight was soy beans.  Stepping off the plane, the 104 degree heat was a welcoming reminder of my new found reality.  With Belem transitioning into their 'summer months' I can only imagine the heat I will experience.  From the airport we went straight to a transplant meeting and ended our evening with good company, delicious food, and a breathtaking sunset over the Amazon River. Feeling like I hadn't seen Marcia and Mauricio in ages, we gossiped about Sao Paulo, shared our last few week's big events, and finally headed home to start another 'shit day in paradise'

Wednesday, March 16, 2011

There is no substitute for hard work.

Thomas Edison once said, "There is no substitute for hard work."  He obviously had never been to Carnival in Rio.  I think they have perfected just that.

For the last few weeks, along with the rest of the country, I took a small deviation from the daily grind and found solace in Rio.  Not having internet for my daily updates, I will now try to share this experience with you through photos.

Doused in rain, marching among thousands of people, singing, dancing, and holding onto 10 american fireman, these photos capture the story of my latest adventure.  From the alleys of Santa Tedesa to the Avenue of Carnival, I must say if nothing else Brazilians know how to celebrate the miracle of life.

 Our first night we went to a bloco in downtown Rio.  A bloco is a street party.  You can find them all over the city at any hour, weeks before and even days after Fat Tuesday!  They have a band with a parade of people that following them through the streets, singing, dancing, and drinking beer.  Blocos can have several hundred to hundreds of thousands of people at any given time!

 It wouldn't be Carnival with out men dressed as women, women as men, and me as the run away bride.  For Carnival it is custom that you have a "fantasia" or costume.  It is most common to dress up as famous characters from TV, the news, and movies.  Or if all else fails, a pair of harry legs in a dress does the trick.

At the Santa Tedesa Bloco, you have over 100,000 people each year.  Santa Tedesa is a neighborhood that sits on the hills of Rio.  Famous for its narrow streets, old houses, and breath taking views of the city. Bloco de Santa Tedesa is arguably one of the best days in Carnival.  Soaked from rain, sweat, and the residents hose water, you feel nothing but joy ringing from the singing voices.  You are crammed between people and hold desperately to those you came with or else loose all hope of seeming them again.  OD was the only surviver who made it through with Norm and I.  4 hours later you feel the true meaning of Carnival.  It even weens out the weak and weary by starting at 7 am.  That makes for an early morning and for us, with feijoada after and the 7 hour Samba School Parade starting at 8pm, an extremely LONG night!


The winner this year... Beija Flor! 

 In addition to all those costumes and feathers, you get your fair share of "skin"! 

And what would be Carnival with out a night at the Samba School Competition.  Preparing all year round, each school has 60 minutes to complete their performance down the Avenue of Carnival.  This street, lined with stadium and suite seating was made solely for this one weekend a year.  

Each school is comprised of thousands of dancers, composers, and singers.  The costumes are full of colors and characters, feathers as far as the eye can see.  The floats too are breath taking.  Larger than life, carrying samba dancing, drum beating Brazilians!

This year there was a tragic fire and several schools lost some or all of their costumes and floats.  In a team effort, every school (with their thousands of volunteers) worked together to rebuild what they could in 22 days!  Brazilians support their samba schools like they do their soccer teams.  The passion is seen in the tears of the winners and the devastating faces of the losers.  This competition is one of Rio's greatest shows!  The whole country waits and watches for the winner!