The Fellowship of Pico

The Female Fellowship members (minus myself)

There are not enough words to describe climbing up Pico... I can however say that we started off as a Fellowship of 6 and were able to conquer Pico together as 6.

The beginning of Pico!

Oh hey pico!

One - Madeline - aka Gandalf

Two - Advaita - aka Samwise Gamgee

Three - Anya - aka Frodo

Four - Katrina - aka Aragon

Five - Adriana - aka Legolas

Seis - Tome - aka Gimlee

6 hours of climbing in the dark + 1 flashlight & 4 phone lights + 2 hours waiting for the sun to rise (FREEZING OUR BUTTS OFF) + 4 hours of climbing downhill = ONE amazing journey to the top of Pico and back and a lifetime of (stupid) memories.

Sunrise at the top of pico! (6:30am)

The Fellowship made it!

Yes we were under prepared... we had no sleeping bag, no real flashlights, no tent, and were not dressed properly... but we made it!

GI + Endoscopies + Colonoscopies = Pretty interesting stuff

This past week I have spent my time in GI and was pleasantly surprised to find that it was quite interesting. I spent most of my time in the endoscopy lab with the nurses and Dr. Paula. Typically our day began around 9am and ended around noon. The GI unit itself was not very busy due to most of the doctors being on holiday. The nurse that I spent most of my time with was Nurse Gilda who did a spectacular job of tackling English so that I could understand what was going on. The doctors and nurses on GI had such a great relationship! They seemed to really value each other's opinions and worked really well as a team. They were especially good about helping one another find the appropriate words in English to describe the situation or procedure.

Patients were normally positioned on their left side with their knees bent. Local anesthetic was given (Lidocaine) via a lubricant that was put in and around the anus as well as on the scope. Most patients were above the age of 60. In the Azores people normally get their first Colonoscopy around 60 years of age unless they have a family history of polyps or some other GI disease. I was really surprised that patients were only given a local anesthetic during the procedure because in the US they give general anesthesia. I saw several Colonoscopies. Each colonoscopy I saw had either a biopsy of tissue or a polypectomy. These were really interesting to watch and were also quick. Inserting the tube throughout the whole colon took the most amount of time and seemed really uncomfortable for the patient despite the use of local anesthetic.

This is a before and after of a polyp found in the colon of a 73 yo male

The actual device used to remove polyps

Something else that was really interesting was watching an endoscopy. Much like the Colonoscopy, patients were given a local anesthetic via an oral spray and then with a Lidocaine lubricant. A plastic tube was then strapped to the patients mouth to stabilize the scope. Patients were laid on their left side as well. The endoscopy I observed was on a 65 year old male who was an ex-smoker with esophageal cancer. He had been diagnosed 6 months prior. The idea of this particular endoscopy was to expand the esophagus via an angioplasty. Dr. Paula fed the balloon into the esophagus while the nurse expanded the balloon. Unfortunately they could not expand the balloon to its full capacity due to the risk of perforation. Dr. Paula then chose to end the endoscopy because the scope was still to pass through the opening.

After endoscopies and colonoscopies in the lab, Dr. Paula visited her various patients on the GI unit. While on the floor I got to meet many nurses who were at first shy about speaking English but opened up quickly. They described the unit to me briefly and said that it was generally slow. I did get to meet a 16 yo female who was diagnosed with Crohn's Disease when she was 8 years old who was not taking care of herself. In the past 4 months she had lost 5.5kgs which the doctors and nurses were concerned with because she was already very thin. She did not seem to care about the weight loss and when told that she needed to make sure she got enough calories in her diet she said she was fine. Unfortunately my contact with patients was limited due to the language barrier. It really made me relate to patients that we see in the US who do not speak English as their first language...

I was also able to see a liver biopsy which was pretty amazing. First the area was cleaned with betadine and draped with a sterile draping. A sterile field was then made on top of a medicine cart where the doctor put on a sterile gown and gloves. The nurse set up the field for her and put out her supplies. The doctor percussed the intercostal space on the right side of the patient to locate the liver which gives off a dull sound rather than tympanic (which is indicative of air). Local anesthetic was used to numb the area. A needle was then inserted just above the selected rib in the intercostal space. Saline solution was injected into the space, the needle was then inserted fully, and the syringe pulled back on to create a vacuum. A string of liver about an inch long was removed and placed in a biopsy container. I was really surprised by how quick and easy the biopsy was. The patient was then instructed by the nurses to remain supine for 24 hours.

Unfortunately there is not a typical day on the GI unit over the summer. Like most of the hospital, the GI unit is "slow" during the summer because many people leave Terceira for holiday. Nonetheless, when the unit became excessively slow, or all the nurses and doctors were charting for several hours I was able to go home. They were all very welcoming! I have seen hostility between nurses and doctors in the hospital (like all hospitals) and was glad to be on a unit where everyone was generally friendly. I do however not think that Dr. Paula knew her nurses names which kind of bothered me. When she addressed Gilda she would just call her nurse. This could be a cultural thing but it still made me a little uncomfortable.

Saving our bodies first... then the environment

Tonight at the Atlantis Project discussion with Sarah we spoke about the different projects around the island to promote green living and being environmentally friendly through reusable energy and initiatives on the Azores islands. Something that I noticed during the discussion was the amount of people smoking cigarettes. How can environmental engineers and/or environmentalist in the Azores ask the islanders to be environmentally friendly when they themselves can not or will not take care of their own bodies?

From my time in the Azores I can honestly say that 85% of the population smoke cigarettes. Smoking like pollution does irreversible damage to our bodies and affects us on a personal and direct level whereas pollution in the environment may take decades to show lasting effects. It is silly in my opinion for people to promote saving the environment when they themselves are polluting their bodies. I believe it is hypocritical and that the environmentalist who smoke should first consider the similarities between smoking and polluting the environment.

I am all up for saving the environment... but I believe we should first save our own bodies. Yes this is a rant but I believe smoking is a type of pollution not only for the environment but also for our bodies.

Rekindling that cardiac fire...

The past 2 days I have been shadowing the nurses and cardiologists on the cardiology unit at HSEAH, and let me tell you it has been amazing. I have not been around patients on a cardiac unit since my first semester of clinical on 3 Anderson at UNC Hospital. I enjoyed my time on 3 Anderson because my favorite organ is the heart. I find it to be fascinating and utterally amazing. 2 days on the unit has rekindled my love of cardio.

The first day was a little slow at first because several patients had to be discharged so most of the nurses and cardiologists were stuck in the office doing paperwork. Dr. Renata Gomes was really great about explaining the different diagnosis of each patient and their course of treatment thus far. I am proud to say that I understood each diagnosis and general condition, lab work, etc.

The second half of the 1st day was spent watching patients get cardiac stress tests. Cardiac stress tests are used to measure the heart's ability to respond to stressful stimuli in a controlled environment. There are 2 general methods of inducing stress: exercise or drug stimulation. The exercise portion (which I saw) consists of having patients walk on a treadmill (or pedal on a bike) with a gradual increase in speed and incline which forces the patient to work harder. Throughout the process you are hooked up to an electrocardiogram (ECG) and your heart rate (HR) and blood pressure(BP) is being monitored. These parameters are measured during maximum exertion and at rest. The goal of the stress test is to get to a "target" HR. The target HR is 85% of the maximum HR for a specific age. There is no specific time for which the stress tests lasts... rather its based on the pts ability to reach and stay above the target HR for an extended period of time. This number can be calculated with the following formula.

220 - pts age in yrs = Maximum HR

Max HR x 85% = target HR

ex: 220 - 49 = 171 max HR 171 x 0.85 = 145 target HR

2 out of the 3 stress tests that I observed were normal. One ECG showed 3 spikes on one of the leads attached to the pt showing slight ventricular fibrillation. The cardiologist was not concerned with only 3 spikes of vfib but noted it in her analysis. I have seen several stress tests in the US and I have to say that they are very similar. Yes the equipment is a little more up to date at UNC Hospital but the tests went off without a flaw.

The 2nd day on the unit was even better! I got to shadow a nurse for a little bit and was able to ask questions about the unit. I also watched her do a blood draw and do teaching for a patient who was just prescribed Lovenox (a low molecular weight heparin). Even though the teaching was in Portuguese I was able to follow the gestures and body language exchanged between nurse and patient. Then the nurse had the pt lift their shirt and explained how you must take an alcohol wipe and clean the area on the abdomen, pinch the subcutaneous (SQ) tissue, and insert the reloaded syringe with Lovenox at an angle into the SQ. She then made the motion of changing injection sites by circling the umbilicus in either a clockwise or counterclockwise position. Afterwards I asked if I would be able to help with blood draws and that I had experience from clinical in the US and also started IV's in the OR at HSEAH. I left the unit to watch 2 pacemakers get put in before I was able to assist with blood draws and IV's so my hope is that I will be allowed to tomorrow.

I also got to watch 2 pacemakers get put in! The general idea of the pacemaker is to send electrical impulses via electrodes into the hearts various chambers to regulate the beating of the heart. The first pt was a 39 year old (yo) male with Down Syndrome, who was getting his pacemaker replaced for the 3rd time because his electrodes were not in the correct position. He was put under general anesthesia and local anesthesia (Lidocaine). The process was amazing! The x-ray technician was really great about explaining what was going on and what I was seeing on the screen. One of the nurses also spoke beautiful English and was able to explain in further detail the procedure. This specific patient was getting a 2 electrode pacemaker which according to the cardiologist afterwords performing the procedure is a special type and is not used as often as a 1 electrode pacemaker.

The 2nd pt we saw was getting a pacemaker for the 1st time. The pt was a 78 yo female who was partially def and was given only local anesthesia (Lidocaine). I have not seen a pacemaker get put in in the US, but I thought it was strange that only local anesthesia was given to the pt and MOST pts receiving a pacemaker. Throughout the procedure the pt was anxious and moving and had to be held down. This pt received a 1 electrode pacemaker.

Being around cardio again makes me want to work in the cardiac intensive care unit (CICU) sooooo bad after graduation. It is my plan to work in either a CICU or a Pediatric intensive care unit (PICU) after graduation for 1-2 years and then eventually go back to school for nurse anesthesia to become a certified registered nurse anesthetist (CRNA). I had just finished up my pediatric rotation before I left for the Azores and the PICU was the front runner in my mind for after graduation... now I'm not so sure. I have always loved the heart... it is an amazing organ... and now CICU is looking pretty darn good.

São Miguel!

It is interesting how many of the friends I have made in Terceira were worried that we Americans would love São Miguel over Terceira. Yes São Miguel is more modern (there is a mall and a theater) but there is something magical and beautiful about Terceira... its become a home away from home.

While on São Miguel we did many fun and exciting things despite the fact that we were unable to see any of the lakes. We rented a car and drove up to Lagoa do Fogo (Lake of Fire) and Lagoa das Sete Cidades but were unable to see anything because both lakes were covered by clouds. The interesting thing about the lake is that it is a twin-lake complex where one side is green and he other is blue. CRAZY!?!?! But like I said we did not get to see it because of the clouds. Despite not being able to see the lakes the drive up the mountains was amazing and getting out and standing at the edge of which should have overlooked Lagoa do Fogo was crazy! The wind was so intense that after standing outside for 10mins our clothes were drenched from the cloud around us. Breathtakingly awesome in a different way.

Food cooking in the hot spring pits at Furnas

We were however able to visit the Furnas which are hot springs. All around the Furnas there were pits that people put food in, cover, and let cook for several hours. The whole area smelled of sulfur and eggs... believe me when I say getting a face full of sulfurous steam in your face is not pleasant. Most of the day was spent driving around and enjoying the view of the coast. The beaches near Vila Franca were clean and sandy white. I was surprised to see white sand because the archipelago was made from volcanoes.

Warning sign at Furnas

Our main reason for visiting São Miguel was to watch Harry Potter Deathly Hallows Part 2 which did not disappoint. Yes there could have been certain things added and deleted but over all I was very pleased with the end result. Something strange about the movie was that halfway through the movie there was an intermission for about 15mins! Who needs an intermission when a movie is less than 2.5hrs!?!?!?! Needless to say I was agitated that the movie was put on pause and also with the fact that we had to watch it in 3D. The 3D glasses made everything really dark in an already dark theater and dark movie... kind of silly. But our tickets were only 7 euro which was a GREAT price.

Surprisingly enough I did not LOVE São Miguel the way that I thought I would... I had heard many good things about it but in the end Terceira is still my favorite island. Rest assure Azorean friends that if I ever come to find myself living in the Azores or buying a cozy shack... it will NOT be on São Miguel. Like all larger cities there is more crime and sketchy people. Never would I walk alone at night in São Miguel. Even walking with 2 other girls back from the bar to the Residencia we were followed by a car with 4 boys yelling profanities at us... we walked with a purpose on and eventually they drove of. This is something that would never happen in Angra. Larger cities just attracted scummier people. Next to the Residencia in the "projects" there was "Turists are terrorists!" spray painted on the walls... which was kind of unnerving.

In the end after a good 3 days in São Miguel I was happy to come home to Terceira... my new home away from home.

A difference in practice...

I’ve only been in the hospital 7 days but already I have noticed quite a few differences in that way nurses and physicians practice medicine. Now I will confess that I have been pampered at UNC Hospital with all the bells and whistles of technology and therefore I must try really hard not to pass judgment on how things are done in a different country. That being said… the nurses and doctors here do not seem to have a concept of contamination or transmission of disease via blood. YES they know disease may pass through blood products… but for some very strange reason they do not wear gloves in normal everyday handling of blood.

Countless occasions I have seen nurses start IV’s without gloves. They iodine the skin and retouch the area with bare fingers that have not been washed. They also do not wear gloves when removing IV’s as well. Now according to the nurses, they can feel the vein better without gloves… while this makes sense I still believe it is unsafe to handle needs around patients without the use of gloves. I for one am not up for accidently sticking myself with a contaminated needle. Another example is with blood transfusions. One of my friends became severely anemic and required multiple blood transfusions and platelets. Of the 5 or 6 nurses in charge of her care over 3 days, only one nurse worse gloves when hanging and taking down old bags.

My third example is from the operating room. YES the doctors where gloves for surgery… so please do not think otherwise. My 2^nd day in the OR I got to observe a hip prosthetic replacement surgery. There were 2 orthopedic surgeons that removed the old implant and put in a new ball and socket. I have never seen doctors be so brutal to a patient’s body. Removing the implant took a lot of work and there was quite a few blood splatters on both surgeon’s faces. To my surprise the surgeons did not have glasses on or a plastic shield over their eyes. On multiple occasions the circulating nurse had to wipe blood off of their foreheads and around their eyes.

I feel like I am being very critical about this topic on blood, but I do not think it is safe practice not only for the patient but for the nurses and physicians. As health care providers we must also take care of ourselves and protect ourselves from unnecessary contamination. Perhaps it is health costs or the fact that gloves are not part of protocol for the hospital or regions. Maybe they are not concerned about such things as we are in the US? Standard of care is different all over the world and it is interesting to see and experience different ways of practicing medicine… I look forward to seeing other differences as well as similarities!

Peak into the Pediatric Unit!

So the pediatric unit at the Hospital de Santo Espirito de Angra do Heroismo is very small and quiet. The equipment is very dated and needs updating. Unit beds are all hand cranked, there are no private bathrooms or rooms, and there is very little privacy between beds. Here are a few photos that I took of the unit.

Medicine cart that is kept unlocked at all times. Medications that are patient specific are kept in small envelopes with the patients name. All medication records and patient records in general are hand written. Flipping through the various patients notebooks, I found the medication pages exceptionally difficult to read. From what I am told, a new hospital is to open next summer and will have an electronic medication dispenser much like the machines at UNC Hospital. Patient records will also be stored electronically for nurses and physicians etc. to access.

Much like the Children's Hospital at UNC, the corridor and rooms are painted and decorated with pictures. There were 5 rooms on the unit. The first 3 rooms contained 2 beds each. The last 2 rooms held 3 cribs each... accommodating a total of 12 patients total. During my care on the unit there was a maximum of 5 patient.

There are no private rooms on the Pediatric Unit, however each room is decorated for a specific age group. This specific room was designed for young children. Other rooms held larger beds and had cartoon characters such as The Simpsons painted on the windows. Something that I found interesting is that the nurses station is a room between the 3rd and 4th patient room so that they can look into patients rooms... while in theory this is wonderful because nurses are able to keep an eye on their patients, patients get very little privacy from one another.