Kidney Transplant

While the surgeons do many technical operations here, this one might be the most spectacular. It requires two teams of 4 surgeons and 2 different rooms. And, as an observer of the surgery, I had the privilege of watching each part and moving room to room.

The surgery began in the room with the nephrectomy of the donor. It was a very clean surgery, taking only 30 or 40 minutes. I had been so accustomed to surgeries where large tumors were removed after traversing 3 inches of fat. This was nothing like that. Simultaneously, in the room next door, the surgeons removed the diseased kidney from the recipient and were preparing the site for the transplant. When both rooms were ready, the kidney was removed. According to the doctor, the kidney can go a little over an hour without oxygen before the risk of failure begins to climb. The clock was ticking... First, the kidney treated with an electrolytic solution called Bretschneider solution. After about 15 minutes of treatment, the kidney was moved to the other room and placed in the recipient. First, the surgeons attached the renal vein and followed with the renal artery. Without a blood supply, the kidney had turned almost white. The moment all the blood vessels had been reattached, the doctors released the clamp on the renal artery and vein, and the kidney quickly turned a dark red. It was the moment of truth for the surgeon. It told them that everything was connected right. The surgery finished up with the connection of the ureter, which delivers urine from the kidneys to the bladder. Despite being only one vessel, this part actually took almost an hour. Since the ureter, like the blood vessel, must be hollow to function properly, it took a lot of precision. All in all, the surgery took about 4 hours.

X-ray of the ureters of the donor.

Nephrectomy on donor.

Nephrectomy on donor (part 2).

Kidney in electrolytic solution being prepared for the transfer to recipient.


The kidney being moved to the recipient from the solution.


The surgeons connect the connective tissue to the new kidney.

After the clamps were released on the blood vessels, the kidney fills with blood and turns the healthy red. It was the moment of truth for the surgeons.

The surgeons are preparing the ureter on the kidney to be connected to the ureter of the recipient.

Pátzcuaro

This past weekend I left Morelia for the first time since I arrived over a month ago with 4 friends. It was great to finally get outside of the 5 mile radius around my house. We travelled to two places during the day.

First was the island of Janitzio, which is known for its famous monument of Morelos, a founding father of Mexico. Once we arrived, we hiked along the narrow and winding cobblestone streets to the base of the monument, which towers over the island at the summit. For $0.60, we got to go inside. Inside the monument is a spiral staircase with five with five levels. Each level has separate murals that capture the life of Morelos. When we reached the top, we could see a 360 degree panorama of the whole island and the lake.

While the monument was amazing and it was great to see the history of the Mexican independence captured through murals, it was actually the climb up to the mountain that I found most memorable. The streets are untouched by modern life. They are narrow and windy and crowded with little tiendas. It was like walking back in time - even many of the woman are dressed in the traditional clothing. I tried to capture this through the photos and video, but I don´t think they do it justice. It honestly felt a little surreal.

The second place was the city of Patzcuaro. This city, like Morelia, was established after the Spanish conquest and has many of the same features as Morelia. I didn´t find it as photogenic as Morelia, so I don´t have any pictures. However, in Patzcuaro, we had deep fried quesadillas and icecream. It was delicious!

Like always, I still miss you guys, but I am settlled in and having a good time. Feel free to leave a comment. I actually read them.

Video 1 (On the boat)
http://youtube.com/watch?v=rfr9yDGO8IA

Video 2 (At the statue)
http://youtube.com/watch?v=WGDSUgvPZCE

Video 3 (In the streets)
http://youtube.com/watch?v=IM548m7l0bc

Lobectomy

For the past week the doctors have been waiting to operate on this patient with lung cancer. Monday, they finally lowered his blood pressure enough to operate, and they let me in on the surgery to observe. Anytime you enter the theracic cavity, it is a high risk procedure. There is a reason you have ribs protecting this area of your body, so I was pretty excited to be able to watch.

As you can see from the CT scan of this man´s lung, his left lung had a tumor the size of a softball. (On the CT scan the left side is black and normal, the middle white blog is the heart, and the right white blob is the tumor). In order to get to the lung, the surgeons had to operated on the man´s side and remove a rib to gain access to the lung with cancer. This was one of the most fascinating parts for me. The surgeons used a tool that looked like a gardening tool to snap off a rib in two places. When the surgeon actually made the cut, the sound of the ribs breaking resembled the sound of branches being cut, but with a little bit more crunch. I posted a picture of the rib after it had been removed.

Next, the surgeons opened up a bigger space by using a tool that worked like a jack to separate the ribs. After this, they entered the lung tissue and were able to remove the defective lung. At one point in the surgery, the surgeon stopped and let me take a picture of the hole in this man´s chest. While I don´t thinks it is visible in the pictures, I could actually see part of the man´s heart through the whole in his lungs. All in all, despite losing a lot of blood (over a liter) and needing a couple blood transfusions, the surgery went pretty smoothly.

Day 2 and 3

Day 2

My second day at the hospital was completely different than the first. I started my day off in a classroom full of all the surgical residents, but we quickly moved to the operating rooms. Since I´ve never observed a surgery in the U.S., I don´t know how the rooms are setup; but here the 5 operating rooms are all side by side connected by a long private hallway for the doctors and nurses.

The first surgery I observed was fairly simple. While only taking 20 minutes, the doctor removed a cancer of the skin from this bridge of this ladies nose. Since it was my first surgery I ever observed, I was thrilled. However, it´s the second surgery of the day that I will be remembering for a long time.

The second surgery started around 10 and would end 4 hours later after a number of complications. The patient was a 60 year old woman with a tumor the size of a melon near her kidney. The first hour of the surgery was going really well. They had had gotten through about 2 inches of fat and entered the abdominal cavity. However, at about 11.30, I watched as her abdominal cavity filled with blood. They had struck the inferior vena cava, the largest vein supplying the heart. I could tell that the doctor´s were generally concerned. Her blood pressure had gone from 150/100 to 60/40. That´s really low! The doctor´s quickly sealed the whole they had sliced and stabilized her with dopamine and a blood transfusion, and the surgery finished around 2. During the course of the surgery, the patient had lost almost a liter of blood. I don´t know what was more shocking, seeing a women´s abdminal cavity completely exposed with all the organs or knowing that she was close to dying right in front of me. You see it in movies and tv shows, but when the person is laying in front of you halfway between life and death, you realize that the stakes are high in medicine.

Day 3

The third day at the hospital took me outside the operating room to treat patients. Since I am currently doing a surgical rotation, many of the patients I see are pre or post operative and need wounds cleaned and redressed. Between the diabetic feet and the large surgical wounds, this job can be unsightly at times. I did not realize how bad it could be until I got to this 80 year old woman near the end of my third day.

When I entered the room, it appeared like another regular case with a simple wound on her foot. I peeled back the dressing from the day before letting the typical thick odor of rotting flesh escape. Underneath the wrap was a wound 4" by 2" and fairly deep. As I began scrubbing the wound with soap, large sheets of brown dead skin came with my rag. I finished cleaning and redressing her foot, when the doctor pointed to a much more sightly cut on her knee. I used a light alcohol rinse to sanitize the area. The moment I put the gaze to her knee, she screamed ¨Me duele...me duele,¨ which mean ¨It hurts me!¨Until this point she had been silent with her eyes closed. This sudden outburst caught me by surprise and I looked at the doctor. She told me I must keep going. This was the first time that I caused a patient unconsented pain. It was not fun.

Working in a hospital has made me realize how emotionally taxing this job can be. While amazing things happen in hospitals and almost all the patients leave better than when the entered, there is pain and death everywhere. A doctor was telling me how one day she saw 6 patients die! I have realized, not only how intellectually demanding being a doctor can be, but also emotionally taxing as well. Hospitals are wonderful places, but the reality is that people suffer and sometimes die in hospitals. Before my stay at IMSS, I was committed to being one of the doctors that was connected with the patients and pledged that I would never view them as just a number. I thought those doctors that did not connect were just lazy or uncaring, however, I realize now that they distance themselves from the patient not out of laziness, but as a way of coping. To become intimately connected with the lives of your patient can become extremely emotionally taxing when things go wrong.

I thought I was done with the 80 year old patient when the doctor pealed back her diaper, revealing a prolapsed rectum. My next job was to use our soap to clean the prolapsed rectum of this 80 year old woman. Clearly it was gross, but the gross feelings were muted by an overwhelming sense that I was doing something meaningful for this woman. While not technical or very remarkable, this 5 minute appointment with this 80 year old woman has been one of the most memorable moments for me and reaffirmed my excitement about service in the health care field. While death and pain are all around you, it is moments like these that make service in health care worth it.

First Day at the Hospital

The first day at the hospital went really well. I found it both challenging intellectually, mainly due to communication breakdowns, and emotionally. The experience is very hands-on and is shown me what it is like to work in a hospital. I posted a video of the before and after at the bottom of the page.

The following is part of the essay I´m required to do for the internship. I hope you like it....

I do not know if I will ever forget the person in bed 323. His name was Arturo, and he was just one of the number of patients during my memorable first day at IMSS hospital in Morelia, Mexico. I first met Arturo when I entered his room and a group of doctors were discussing his condition and different options for treatment. I had difficulties understanding the Spanish, but I did not need it. I knew it was serious. The doctor told me that Arturo had fractured his femur and sustained massive neurological damage in a motorcycle accident. Three hours later, I went to check on Arturo with Dr. Guadelupe. This time his family and girlfriend were there. I stood there painfully watching his family discuss his condition with the doctor. I could not understand their words, but the expressions on their face could not hide their pain. An hour later I could not get Arturo out of my mind. Wondering whether he would be able to communicate again or walk again, I asked the resident about Arturo´s future. She gave me a thumbs down and told me he was probably going to die soon. I knew he was in bad shape, but I thought we could do more. That day I learned a crucial lesson - medicine is incredible, but it has its limits. The reality of being a doctor is that you are around people who are dying everday.

While the experience with Arturo was not hands-on, Dr. Guadelupe gave me the opportunity to clean and re-dress some of the patients wounds. The patient with the diabetic foot was my first patient and the most memorable. Despite wearing a mask, as I pulled back his dressing of the day before, I was over-whelmed by the smell of rotting flesh. When all of the dressing was removed, I realized he was missing a good portion of this foot. Where there should have been two toes, I could see straight to the bone. After applying iodine and disinfectant to the area, I recovered the open wound. While this might be a simple task for a resident, I was excited to be able to deliver medical treatment to a real patient.

As a public health major, I could not help to evaluate the IMSS system and the Mexican health care system as a whole while I was there. Mexico has three branches to its health care system. There is a baseline care provided to all Mexican citizens. While only useful for emergencies and serious illness, it does provide free universal health care. The second is ISSSTE, which is health care provided to all federal employees. The last in IMSS, which provides health services to all employed persons in Mexico and somewhat resembles the U.S. Medicare policy. While I cannot speak to the first two, the IMSS hospital in Morelia was packed with people. The literal line was 2 or 3 hours long. In the U.S., you may have to wait to see a doctor, but usually you are sitting in comfortable lobby with a magazine. In the IMSS hospital, you have to stand. Another striking difference was that there were at least 2 patients per room, usually 3. Privacy is a lesser concern. I want to note that despite these differences between health care and Mexico, the Mexicans at the IMSS hospital in Morelia do a lot with the little they have. That hospital is always working at maximum efficiency. Quality of care might be lower in Mexico, but they do a great job at reaching the masses of people on a way lower budget. I must point out that Mexico spends 6.2% of their GDP on health care, while the U.S. spends 15.2%. One can only imagine how good the Mexican health care system could be if it had the kind of resources available in the U.S.

First Day (Before)
http://youtube.com/watch?v=4MwPQTxnc1c

First Day (After)
http://youtube.com/watch?v=CVMBZTTvl2g

Cathedral

I want to keep this post short, because the pictures speak for themselves. Two big things stick out from last week, I visited the cathedral and I went to a Native American dance. The cathedral is one of the largest in Mexico and it boasts one of the largest organs in the world (kinda cool I guess). And the dance, while it was artsy and not quite my style, it was interesting to see the culture in the dance. The dance was actually a mockery of the Spanish colonization. As you can see from the picture and the video, the faces were white and they walked hunched over.

On a personal note, things are going pretty well. I now have about 10 people I can call friends/acquaintances. The first week was tough without having you guys around, but I´m starting to settle in. I miss you guys and feel free to send me an email or leave a comment!

Cathedral Video
http://youtube.com/watch?v=EpC-GgIxV-I

Native American Video
http://youtube.com/watch?v=S6sJc12AbRc

Discoteca

The night life is kind of a big thing down here. Last night I went with my host-sister and host-brother to a dance club. They call the ¨antros,¨ which actually means dump. But this place was probably the most modern place I have seen in Morelia. There were lights and smoke and tvs everywhere. It was a little intense. It would be fun with a bunch of people I knew, but it was not quite my thing. The loud music was not especially conducive to learning Spanish. It was also incredible how many American songs they played. People would sing these songs having no idea what the words meant. The pictures above are from that night, except the last one, which is from a nearby market. I thought it was funny. Yes those are dead chickens.

This video is the second part to my house that you were not able to see last time. You might not find it that cool. It´s more just to document the trip. Anyways, send me an email if your bored! I´ll be sure to email back!

Video of House (part 2).

http://www.youtube.com/watch?v=qEPpfhCrqYs