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Wednesday, March 30, 2011

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...

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