Life in the fast lane: my most recent assignment

No medical tourism or Latin America this winter, but as my latest assignment finishes, it’s been an interesting journey!

New friends, new places, and new experiences!

Co-workers in the PACU

Co-workers in the PACU

I spent the last few months working in the intensive care unit on the trauma service at a large, busy trauma hospital outside of the nation’s capitol.  It wasn’t quite what I expected – for all of my world travels and travel nursing, I still tend to revert back to Chicago Hope in my mind sometimes.. This was a lot more like St. Elsewhere – meaning that as a person from a rural background, I always expect to be somewhat overwhelmed in larger facilities but by the first week, it was surprisingly familiar and kind of homey feeling.  Instead of a cast of thousands, and a sea of unknown faces, it become a daily chorus of ‘good mornings’ to a close-knit group of providers.  (I was there quite a bit, which probably helped).

the view from the call room

the view from the call room

But somethings were definitely different, and it was more than just monuments, politics and presidents, and the “newsworthy” aspect of some of our patients.

just outside the federal district - and a whole different world from cardiac surgery

the federal district – (and a whole different world from cardiac surgery!)

Crash course in major trauma

Running from the police seems to be a frequent requirement for some of our admissions.  Bad jokes aside, where cardiac surgery is planned, detailed and precise, the world of trauma is often chaos, tragedy and upheaval.  A split-second accident, or fall becomes a forever life altering event.  All of the ugly of the world; crime, abuse and assault comes to our door.  Innocence smashed, so often without any sense of rhyme, reason or fairness.  Working here makes me confront my mortality in a way I’ve never had to before.

Doctors in the ICU

Doctors in the ICU

Scheduled chaos

Sure, many people have unexpected heart attacks – even people we tend to think of being ‘low-risk” – and nonsmokers have no guarantee of avoiding a lung cancer diagnosis.  But, for the most part, that’s the beauty and elegance of cardiothoracic surgery – it’s a calculated, orderly world for those of us working in it.   Cardiac surgery feeds the math-loving, logistical and analytical side, while thoracic surgery with its cornucopia and ‘catch-all’ of chest pathophysiology is a never-ending journey of the Jules Verne variety.

As comforting as this can be, it can also become a hindrance if we stay in the familiar for too long.  Sure, it’s nice to have the experience, to know most of the answers, most of the time – but these brief glimpses outside cardiothoracic surgery are crucial for staying engaged, and involved in medicine.  Even if I feel silly or stupid at times, it’s important to continue to learn new things (and dredge up older knowledge that’s been unused for a while).

The good thing is that the essentials, and the principles of caring for people never really change even if the hospital, the staff, the city and the specialty service does.   I don’t know why that surprises me anymore, but it still does.

So now that the assignment is over – I am back home.  I am planning for my next big trip (Asia, this time for a big thoracic conference), catching up on medical journals, and  a bit of continuing education while awaiting my next assignment.

Until then – we’ll get back to our usual programming!

Interview with Dr. Borraez, Bogota Bag: 27 years later

One of my new articles on Dr. Borraez has been published to Yahoo! (associated content section) – it’s shared content with the site..  I’ve also written two other articles, one of original content, so I’ll let you know if they get published.  I thought it might get a little more exposure this way.  I’ve written this trio of articles for Yahoo! as a trial run, so we’ll see how it goes..

Note:  Due to recent changes at Yahoo! this article link has changed.  I have updated the link to the new article link. Please let me know if you have difficulty accessing this article.

Dr. Oswaldo Borraez, Trauma Surgeon

Most of you will never meet Dr. Borraez, a trauma surgeon at hospital San Blas, one of the public hospitals in the poorest neighborhood in Bogota, but now you will have heard about him.  In March of 1984, when he was a second year surgical resident Dr. Borraez , training at San Juan de Dios, Dr. Borraez was assisting in a surgical case with a patient that had a serious infection preventing closure of the abdomen.

Dr. Oswaldo Borraez, Trauma Surgeon, The Bogota Bag

(In cases of severe abdominal trauma, infection or necrosis closure of the abdomen can lead to the patient’s death due to compression of the abdominal compartment – leading to a sequelae of abdominal compartment syndrome —> internal organ hypoperfusion —-> organ failure  —-> respiratory distress —> death.  So basically all the swollen abdominal organs crush the blood vessels and other structures..)

During this case, the attending surgeon and the other operating room staff were looking for something to use to close the abdomen*.  Sometimes surgeons used sterile operating room towels but that increased infection and allowed for massive fluid losses, and the synthetic films were prohibitively expensive (and not without their own problems.)

So while he was in the OR, Dr. Borraez spies the IV bag, and starts thinking.. He then took the largest bag made (a urology fluid bag – 3 liters) sterilized it, and placed it in the abdomen.  And it worked – perfectly, as if it had been designed for that purpose..  It was clear, which allowed surgeons to monitor the wound, it was hypoallergenic, it prevented infection, it’s strong yet flexible and most of all – it was cheap (about 2 dollars) and available in any hospital – world-wide.

Since then, he has been recognized internationally for its use, especially after noted Atlanta trauma surgeon, Dr. David Feliciano came to Bogotá and saw this technique in use.  He wrote about it in standard American trauma textbooks used worldwide, gaining some well deserved recognition for this kind Bogotá physician, who continues to work and innovate (for the last 27 years) in this humble hospital serving Bogotá’s neediest patients.

He now speaks at conferences world-wide, talking about the Bogotá bag – and different ways it is now being used.  Hundreds of research studies and case reports have confirmed his findings.  His contribution was recognized as one of Colombia’s top ten innovations in Medicine, along with the Hakim valve (which we mentioned in another post.)

He has successfully used the Bogotá bag as a permanently implanted internal closure device (placed between the muscle and the intestines) in 55 patients with no problems.

He continues to innovate for more affordable and practical wound closure devices.  Currently, he has adapted a colostomy bag, along with a natural sponge and a suction canister as an effective wound-vacuum closure device, which mimics the success of the cost-prohibitive ‘wound vac’ (KCI) but only costs about a dollar to implement.  (Wound vacs can be several hundred dollars per day of use.)

Yet, somehow, in between seeing patients, surgery, creating affordable solutions and teaching residents – he found time to sit down, explain all of this to me – and show me several patients with their “Borraez bag” in place.

* a temporary measure until swelling / infection subsides and allows for surgical closure.

In other news, I want to say hello to one of ‘my patients’ – (I know he is reading this) Cristian, a very nice thoracic surgery patient that I met during rounds one day.  I tried to take a picture (he was very gracious and granted permission instantly) to show what a great guy he was – I met him as he was walking down the hall, chest tube canister in one hand,  and puffing on his incentive spirometer in the other.)

He, too, made time for me, a strange American nurse, speaking bad Spanish – to answer my questions and tell me all about why he was walking the halls and puffing on this little box.. He gave me a tour of the hospital while we walked, and he puffed intermittently, as I thought about how everyone, doctors, nurses and patients have been so welcoming to me here.  This kindness has certainly made this project not only possible, but a wonderful experience, that I will greatly miss when I return to the USA in a few days.