One small step for man, one giant leap for womankind

I just finished playing soccer in the neighborhood pick up game!  It was shirts verses skins.  You can imagine which team they tried to force me to play on.  Nice to know, some things are universal.  But despite their best efforts, t-shirt on, barefoot, on a soaking wet grass field, we played 6v6.  Good thing my cousins have me well versed in EVERY foul mouthed, Portuguese, swear word.  I understood everything.  So in short my story...

1. I asked to play soccer
2. I scored two goals in the first 5 minutes
3. I love winning
4. I love doing #2 and #3 when it is against all dudes.  I just schooled them.
5. They asked me if I played professionally in the US. My other favorite question.
6. They invited me to come "teach" them soccer again next Thursday.  I will remember to bring a shirt :)


So once again teaching men around the world, women can play soccer.  And as it seems tonight, better than men...

One small step for man, one giant leap for womankind.  Bring it.

My weekend in Photos

Another "shit day in paradise"

Downtown Belem, The Docks

The river side of my restaurant "love affair"

Live dancing show on the river boat

Sun setting on the Amazon River

Marcia, Marina, and Me...so many M's

One of many dances, many costumes, and many hours of live music while we floated down the Amazon River

A Little Bird Told Me...

In all my time here, I don't think I have CLEARLY explain the projects I am working on! So I thought what a better time than to do that.

Here in Belem, the group of physicians are creating a project called, Amazonia Transplante, where they are working on the decentralization of transplantation.  Equal to our system in the US, Amazonia Transplante is focusing on establishing a system with one major center and several smaller programs serving the Amazonian region.  The larger center will be for more complicated transplants, such as liver and pancreas, working congruently with several satellite centers for more straight forward transplants, such as kidneys and corneas. 

We currently have received approval from the State government to proceed and we are now working on the financial approval process.  Of course, I continue to work on the protocols and process for transplant.  It never stops.

As I explained earlier, in Sao Paulo I worked with a group called HEPATO. Partner of Amazonia Transplante, HEPATO has been working to create aTransplante sem Fronteiras (Transplant With Out Boarders) program here in Brazil.  In addition to their already established Transplant Program in the city, they dream to create transplant centers throughout the country, with a focus on the northern region  The team has spent countless years to lay the foundation for what is now happening.

So there you have it.  Summed up in a nice little bundle for you.  While I was working with HEPATO, I again focused on their current practices and shared our system.  This incredible exposure to all avenues of healthcare offered in Brazil has really opened up my eyes to the problems and the extent of change needed in this fast emerging country. 

Once I returned to Belem, I spent several days completing an observational analysis of the HEPATO program and the ICU at Hospital Bandeirantes.  I listed out similarities, differences, and of course my recommendations.  While the most important changes I suggested, appeared simple and common sense, they also highlighted the importance of practicing what we already know.  Starting a hand washing campaign, creating a system for documenting and implementing central line protocols and VAP bundles, the basic foundations of our nursing at the UW.  If anything I have learned the importance of nurses roles at the bedside.  The priceless benefit to patients and the ultimate cost effectiveness for healthcare.  Nurses help stop infections, nurses help improve patient outcomes, nurses save lives.  


Therefore, the majority of my recommendations were to bring nurses closer to the patients.  To help the staff at Hospital Bandeirantes save time with redundant documentation and make the nurses the central healthcare provider again.  


I think every program in this world has room to improve and room to learn from others.  It is why international exchanges are so crucial to improving practices at home.  Everyday our world becomes smaller and the one thing we share, independent of culture, is humanity.  It is our common drive to live and I believe to relieve the suffering of others.  I think a program shouldn't be measured by it's problems, but its ability to adapt, to change, and to grow.  That being said, a little bird told me yesterday, that big changes have already been brought from my observational analysis, with one (the one I am most proud of) being nurses presenting during rounds.  For all you NON-HOSPITAL friends and family of mine, that means...as the physicians visit the patient each day, the nurse presents the patient to the group.  She gives a summary of the last 24 hours by systems and problems.  She becomes the center of communication.  


I can't begin to explain the feeling of bringing big changes to an already well established and successful program.  If you close your eyes and listen closely...I think you can hear the world turning...

Soccer field in Sao Paulo.  You can find them anywhere.

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...

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.