Details, details, details...

I just want to highlight a couple of things that may be helpful for future UNC students in Porto.

1. Passport Photos
Bring 5 or 6. You'll need them.

2. Bring/buy an umbrella
It rains quite a bit, so have an umbrella and bring a coat.

3. Get the ESN Porto card
This is the Erasmus student network card and it will gain you entrance to all of their events. All you need is 5Euro and a passport photo.

4. Student ID
You will be issued a U.Porto ID card when you register. This card will gain you free entrance into museums, city events, etc. Take the time to find out where you can use it, or just ask about student discounts when you go places.

5. Have a phone
When you register, you will receive a Mosh SIM card and a 30Euro voucher for a TMN phone. The Mosh allows you to make unlimited calls and texts to any other Mosh user (all the Erasmus students) for only 5Euro a month. If your phone won't accept the SIM card (mine did not), use the voucher at any TMN store to buy a phone. My phone cost 20Euro after the discount.

6. Monthly metro pass
Think about getting a monthly pass for the metro. That way you have unlimited rides on the metro, buses, and trolley for the time that you are here.

7. Go to the Museums!!!
There are a lot of museums to visit! Many have free admission on Saturday and Sundays, and some also have free admission with your U.Porto student ID.
There are also other places to visit of course, so visit them!

8. Have Fun!!!
It's a great month. Everyone is really nice and the schedule is more relaxed than at UNC, so make the time to get to know people and the city!



Some pictures from the gardens of Serralves. Admission to the museum and the gardens is free with your U.Porto student ID.

Last Week in Porto

My last week in Porto...

1. Monday: Dinner with the Bastos
Dr. Basto and his family invited me and the residents and attendings that I worked with to their home for dinner. It was a lot of fun! We had bacalhau com nata, and of course some very good Port with desert.

2. Tuesday: Matosinhos
On Tuesday, I met with Dr. Pinheiro from the Unidade Local de Saude de Matosinhos. Matasinhos is a neighboring town to Porto, and there Dr. Pinheiro showed me his vision of how the public health system should function. It is a completely integrated system with a hospital, primary care centers, diagnostic centers, and continuing care centers. Most of the integration is achieved by a very sophisticated computer system. Patient information, etc can all be accessed at all of the associated centers, that way there is better continuity and efficiency of care for the patients.
The primary care centers approach to the patient is very holistic one, and it involves the entire family. They really work hard to take care of the patients and keep them out of the emergency room and hospital. The center that I visited was very nice. All of the facilities were state of the art. It is organized such that each physician (Family practice physician) is paired with a nurse, and each physician-nurse team is responsible for 2000 patients. The set up seems very efficient. The computer system has particular programs that monitor hypertension, diabetics, CAD, etc. For example, a diabetic patient has a flow sheet and tracks their glucose levels, A1C, blood pressure, weight, cholesterol, etc. It is all organized in such a way that it is not only very easy to keep track of all of the information, but also this information can be shown to the patient in a chart format which is very easy for them to understand.
The hospital is a community hospital and therefore is quite smaller than HSJ. It is however only 10 years old and resembles any typical hospital one would find in the US. It serves as a referral center, that way if there is something that cannot be managed by the family physician, the patient can then be referred for further workup or to see a specialist.
Also very important to the system is the continuing care center. This center also works as a way to keep patients out of the hospital. As is it is not a hospital, there is more patient to patient interactions, and patients are also encouraged to spend time in common areas outside of their rooms. This center provides specialized care to patients that have suffered stroke, or any other debilitating illness that may require intense rehabilitation. With more intensive care, patients can return to their homes faster and with better results. The center is also for those patients who are receiving palliative care and cannot be managed at home.
Overall, Dr. Pinheiro has made me a believer in this system. I hope that a model similar to this can be implemented for our future national healthcare system.

3. Visit to InstitutoCUP
Instituto CUP is a private facility with primary care consultations, imaging, dermatology, GI, oncology, radiation oncology, ophthalmology, rehab, and day surgery. It is only 2 years old, so it is very new and it is very state of the art. They have almost everything you can imagine: an MRI, 2 CTs, equipment for lasix, a lab, a cafe, and even a nuclear accelerator. The director, who gave me a tour of the facilities, stressed that it is not a hospital, although with all of the services they provide, one may think just that.
The patients seen here are patients who have private insurance, however the national health system can also send patients to receive services here when those services are not available in the public system. But for the most part, this center is for patients with private insurance.

The biggest difference that I noticed between the public and private clinics where not the quality of the facilities, as both facilities where quite new and very well equipped, but more so the attitude of the healthcare workers about the patients. Of course, both clinics treat their patients very well and do what is best for them. But the public clinic's attitude was more of "we are all in this together". In the hospital, the physicians and healthcare staff eat the same food as the patients, and patients and physicians cross paths quite frequently, whether it is in the hallway, elevator, or lobby. However, in the private clinic, the director stressed repeatedly the fact that the patients and physicians are always separated. There are separate entrances, hallways, elevators, eating facilities, etc. EVERYTHING is always separate. The patients and physicians only cross paths during the consultations.
I don't think one approach is better than the other, just different. I guess what I'm used to is the environment at UNC where we all use the same elevators, the same cafes, hallways, etc. For this reason the environment at the private clinic seemed strange and a bit cold.

Overall, it was a busy week, but also the most interesting. On Thursday, as the rain stopped for a couple of hours, I also had the chance to go back to the coast :)

EMERGENCY!!!

Just a couple of things that got me thinking...

1. There are no paramedics in Portugal.
When someone calls 112 (the "911" of Portugal, as well as, most of Europe) the call goes to a call center, and the operator at the call center assesses the situation and sends help.
One of 2 things will occur based on the situation:

1. An ambulance is sent to the location. The ambulance is ONLY to transport the patient to the hospital. The people in the ambulance are NOT medically trained staff, they are simply transporters.
2. If the operator determines that the situation requires immediate medical attention, then in addition to the ambulance, a separate car containing a nurse and a medical doctor is sent to the scene.

As an outsider who is used to a system where the ambulances are staffed with specially trained medical personnel (Paramedics) that are sent to every medical emergency, I found this system to be a bit problematic:

Operator at the call center The call center operator is not medically trained, yet he/she has the responsibility of determining whether or not a medical emergency requires a doctor at the scene. Mara told me that the job of an operator requires a short amount of training that is probably not adequate given their level of responsibility. For example, there was a case where an operator told a patient suffering stroke that he did not need an ambulance. The operator did not recognize sudden onset of slurred speech as a possible stroke, but instead told the caller that the patient was probably just drunk.

To be fair, I'm not exactly sure what level of training 911 call center operators in the US receive. However, the critical difference is that if an ambulance is sent to a medical emergency, it is always staffed with paramedics. This way, the call center operator is not who determines whether or not a particular case warrants medical personnel or a trip to the hospital.

I'm an open-minded person, and therefore I realize that there are pros and cons to most things. I've only heard the "con" side to this system. I'm very curious to find out the "pro" side because this has been around for a while (there is also a similar system in Spain), so obviously it gets the job done.

2. There is no Emergency specialty in Portugal!
I had lunch with Mara last week, and we got to talking about her schedule. She works one day a week in the ED. At UNC, the medicine residents rotate through the ED, so I just assumed that it was a similar system. But in fact, it's not...
The ED is basically run by internal medicine. Patients are triaged (using a color coding system) and sent to different areas of the department. The most emergent patients (traumas, etc) go directly to the surgeons. The non surgical emergent cases (MI, stroke, seizures, etc) are seen right away by one of the internal medicine physicians. And of course the patients that are not emergencies at all, must wait. I spent a little bit of time in the ED, and it is quite nice. It is completely renovated, so everything is new. The yellow zone (non emergent) is set up like small consultations. There are divided work stations for each physician. Each station has a computer, exam table, and anything else they physician may need. It really looks more like an outpatient clinic than an emergency room. I also visited the "A Flu" area, which is in a separate building. Patients with fever and any respiratory complaints are masked and sent to this building for further questioning.

Ok, so back to Portugal not having an emergency specialty...The next day, I asked Dr. Basto about this, and he didn't really think an emergency specialty is necessary. He believes that internal medicine docs can manage acute MI's, seizures, and other non surgical cases, while the surgeons can manage anything potentially surgical. He has a point...He did add, however, that he feels that Portugal will adopt an ED specialty in the future.

Third Week: New Team

I've finished my 3rd week here in Porto.
I started with a new team this week! We are Medicine Team A on the 3rd floor, and we care for male patients. The set up is almost identical to the women's ward, there are big rooms with several patient beds.
I talked a bit already about what I perceive as a lack of privacy with the current room/bed arrangement in the medicine wards. Today, one of our patients who suffers from heart failure had a "spell" of shortness of breath with a lot of anxiety. He also had other complaints that were suspicious for an acute coronary syndrome, so we had to do vitals, EKG, aspirin, morphine, etc...The point is that there were 2 nurses, 2 med students, 2 residents, and our attending crowded around this patient's bed. Keep in mind that there is another patient within one arm's length of our patient's bed. I knew that my focus should be on our acutely ill patient, but I found it very difficult not to be thinking about this other patient who not only has to witness all of this activity, but also was almost completely involved due to his proximity!
Well, coincidentally, this other patient soon became directly involved in the activity. Once our patient was stabilized and arrangements were made to transfer him to intermediate care unit, I made a quick run to the restroom. As I was leaving the bathroom, I heard a lot of activity around the room. My first thought was that our patient was having another spell. I ran into the room to find that the patient in the bed adjacent to our patient had coded!!! There were now about 10 people, a crash cart, and and EKG machine surrounding the patient's bed. Now, OUR patient, by his proximity, was directly involved in the scenario! At that point, I was worried not only for the coding patient, but also for our patient having to witness all of this. Would the stress be too much for him? Well, to my surprise, he was resting comfortably in his bed. Maybe he was just "morphinized" (as my resident likes to say) and was oblivious to his surrounding. But I looked around and there were 4 other patients in the room, and they were all just going about their business. One guy was eating his lunch and did not seem at all phased by the events going on around him...Anyway, luckily the patient survived the code, and our patient is still "morphinized" and resting comfortably in the intermediate care unit.

Um pouco de turismo...

Since I've been here, not all of my time has been spent in the Hospital. I've had the chance to get to know the city a bit.
1. Campanhã
I mentioned in my first blog posting that I live in the area called Campanhã. I like it! It's close to the center of town, and it is very well communicated with buses, metro, and a train station. The station has local, regional, and long distance trains so you can travel almost anywhere in Portugal from Campanhã!

Campanhã also illustrates very well my favorite thing about Porto: the contrast between the traditional and the contemporary.



























I like to start from Campanhã, walk to the center of town, and then make my way down to the river. For me, it's a good way to get to know my way around the city. It's about a 20min walk to the center, and then a short walk to the river.

2. Centro
In the center of the city, one can find amazing architecture, museums, monuments, and churches. It's great for just walking around, visiting museums, or just stopping for a pingo and a pastry at a cafe. But if you can go with someone who knows the history of the city well, it's even better! I spent an afternoon walking through the center with my intern, Mara. She explained the history behind many streets and buildings, the different architectural styles of the churches, and we even went to a bookshop just to see the staircase (Lello & Irmão" bookshop; it is the most amazing bookshop I've ever seen!).













































































































3. Rio Douro
For me, the most amazing part of the city is the Ribeira. The homes are amazing! Although some are crumbling, they are still beautiful. The local government is in the process of renovating them, one by one. The amazing things about this area is that local people live here, and have lived here for generations. I was told that it is difficult to buy a home here, not necessarily because of cost, but more so because there are not many for sale. They are usually passed down within families. Or like my attending told me, if you really want one, "you just have to wait for the old people to die".
From Ribeira you can also see the Port Wine houses across the river, as well as the Cais de Gaia riverfront. The best views are from one of the many bridges that crosses the river. Just don't get run over by the metro!






































































Ok...so these are just a few pictures that I've taken (I have hundreds!). I've also gone to the coast with Mara, but that was the ONE time I did not have my camera. If I get a chance, I'll go back and take some more pictures.

Second Week at Hospital São João

I've completed my second week at Hospital São João. My team is awesome, they have really make me feel included (even when we are just talking about football!). I will be starting with a different team on Monday, and will be with them for the remainder of my time here.
This week, I met with Dr. Basto just to talk about how things have been going. We talked about me seeing different parts of the hospital and different departments. The hospital is celebrating 50 years, and it is also undergoing renovations. The medicine wards are in the original form of the hospital while some other departments have already been updated.
Dr. Basto took me to the stroke unit where I will be spending some time on Tuesday. I was curious to see the stroke unit because on the internal medicine service we receive many stroke patients. Why do some stroke patients come to internal medicine? Why not to the stroke unit or the neurology service??? Well, I went down the the stroke unit, and that question was answered for me...
First, I met the director and he showed me around. It is a large room with 10 beds and a nursing station in the middle of the room. Everything is brand new. The director explained to me that there are many hospitals in Portugal that have thrombolytic capabilities, and therefore people that suffer stroke are usually able to get thrombolytics within the 3 hour window. This is good right?? Well, yes, but most of these hospitals do not have the facilities to adequately monitor the patients afterwards. They do not have a unit with trained staff that provides 24 hour monitoring specifically for stroke patients, nor do they have the rehabilitation facilities/resources necessary to ensure that these patients reach their full recovery potential. So, many hospitals have the most advanced therapy (thrombolytics), but lack the basic standards (close attention to the patients and rehab).
My understanding is that once the patients leave the stroke unit they either go to the neurology service or the internal medicine service. This is decided in a very arbitrary way: patients below the age of 45 go to neurology, and patients above the age of 45 go to internal medicine. Ok, it doesn't make a lot of sense to me that age is the only deciding factor...Well, it doesn't make sense to the stroke unit director either! The "logic" behind it is that patients older than 45 usually have more comorbidities (Diabetes/HTN/Heart disease, etc) that can be better managed by internal medicine, while patients younger than 45 usually do not have as many comorbidities and therefore are managed by neurology.

This week, I also had the chance to see the Infectious Diseases ward which is also brand new. There are private and semi-private rooms, and all of the rooms have negative pressure ventilation**. In addition, they also have their own unit (ICU) that is fully equipped with ventilators and trained staff. There is a day hospital within the ward where patients can come and get infusions or any other treatments that must be done in the hospital. And they also have their own consultations (outpatient clinic) within the ward that is separate from all of the other services which have their consultations in a particular area of the hospital. Basically, the ID department has their own hospital within the hospital!!!

**Tuberculosis is still a problem in Portugal.
While in the Infectious Disease ward, I was told that the incidence in Portugal is greater than 30 in 100,000, while the average in Western Europe is less than 12 in 100,000. (The incidence in the US is about 4 in 100,000).
In Portugal, it seems that TB is just another occupational hazard for healthcare workers. It is not uncommon for nurses and doctors to become infected. The resident that told me this just finished 6 months of treatment for TB, and the resident's attending has also already had TB. In the medical school, there are about about 3 cases per class per year.























Since I didn't have any relevant pictures for this post, I've attached two pictures of Hospital Geral Santo António which is in the center of town. This is the older part, there are modern facilities behind this building.
...I will have more pictures in the next post!

Let's get to work...

Monday, Oct 26 was my first day in the hospital. Dr. Basto left me an envelope at my residence in Campanhã, which I received upon my arrival. The envelope contained my ID badge for the hospital, and detailed directions on how to arrive, when to arrive, and who to look for upon arriving to the hospital. I had to be at the hospital at 9am, so I left my room at 8:15 to give me enough time. To get to the hospital I have to take the train to the center of the city (Trindade), there I change to a different line that takes me directly to the hospital.

The Medicine beds are on the 3rd and 4th floor. I was to go to the 4th floor. There I met my team: Dr. Pestana (attending), Mafalda (senior resident), Mara (intern), and Antonio and Rui (6th year med students). By 9am, they had finished rounding on their patients. Mara introduced me to the nurses caring for our patients, to the other medicine teams that share our work room, and she also gave me a brief introduction to how things work.
Here is a brief explanation:

1. Rounds start at 8am.
Our team sees all of the patients together as a team. The medical students ask the questions* and do the exam, while the residents supervise.
*Everyone on my team speaks English, but our patients do not. My team is very good at translating for me, and keeping me involved. I don't ask the questions, but I do the physical exams.

2. Our team works on the women's side of the medicine wards.
All of our patients are/will be female.
There are 4 teams on the 4th floor. 2 teams work on the women's side and 2 teams on the men's side.

3. Patient information
H&P, labs, imaging studies, etc can be found in the paper charts as well as on the electronic medical records on the computer.

4. Coffee
After rounds, we go for coffee and discuss the plan for our patients.
My usual: A croissant with café pingado. The lady at the counter doesn't even ask me anymore, she already knows what I'm going to order!

5. New patients
The medical students do the detailed history and physical exam, and also write the report. The residents write the daily notes.

6. Snack
Between 11:30 and 12, we go downstairs for a snack break.
My usual: Pão cereal com queijo (Bread with cheese). Delicious.

7. Conferences
If there are conferences, we go.

8. Our day ends at 2pm.
Med student schedule for medicine rotation is M-F 8-2. I was told that Medical students do not take call, nor do they work in the hospital on the weekends. Medicine residents do take call and work on the weekends, but they are not to exceed 42hrs a week.



The rest of my first day was spent meeting people:

• I met our patients (we only had 2)
• The internal medicine professor for the medical students (I've forgotten his name)
• Dr. Sofia Gramaxo (she is in charge of the international/ERASMUS/visiting medical students)
• I met most of the Erasmus** students at a meeting later that afternoon
• I also met a lot of other doctors and administrators, but I don't remember all of their names and what all of them do. BUT, I do remember that they were all very nice.

**ERASMUS (European Region Action Scheme for the Mobility of University Students) is a European student exchange program for students (and teachers) from the EU and a few other European countries. It's very popular, every year about 150,000 students across Europe take part. Dr. Gramaxo said that there are nearly 100 medical Erasmus students at U.Porto right now!


















Our patients are on the 4th floor of the medicine wing. The rooms are large and open, and they each have about 8-10 beds that are pretty close together. My first thought was that this set up does not allow for any patient privacy. There are dividers that are placed when something (a procedure, changing a foley, etc) that requires more privacy is being done.
Mara and I talked about this, and she was surprised that at UNC there were private and semi-private patient rooms, and that the floors are not divided by gender. She could not understand how nurses can have more than one patient if the patients are separated in different rooms.
She gave me a different perspective on the room set up. She told me that they allow for the patients to talk to each other, look after one another, and also witness things that may happen to other patients (seizures, falls, etc) and tell the medical team what happened. HOW INTERESTING! I would never have seen it that way! Mara gave me a good example:

Last week, she had a patient who was admitted for heart block. The patient was instructed several times not to climb out of her bed. One night she suffered a fall. One of the other patients saw what happened and pulled the cord to call the nurse. When the medical team arrived, the heart block patient told the medical team that she doesn't remember what happened, but she thinks she just rolled off of her bed while sleeping. As she was saying this, the patient that pulled the cord and witnessed the event interrupted and told the medical team what really happened. She said that every night the heart block patient would wait for the nurse to leave, then climb out of her bed and wander around the room. Unfortunately, this time she wondered a bit too much and was not able to make it all the way to the bed before falling to the ground. Luckily she was ok.
So, the room set up can allow patients to help each other out, but it can also cause interesting situations. For example, we had a stroke patient that was discharged on Tuesday. Mara told me that after we finished informing her that she could go home that day, the patient in the next bed over (who belongs to the other team which is just a resident and attending) told her nurse that she is very angry because it was unfair that our patient could go home. It was unfair because from her point of view, our patient had 6 doctors, and she only has 2. So since our patient had 6 doctors, she was able to get better faster, and therefore go home earlier.
I think it's fair to say that there are pros and cons to every system, and just because something is different doesn't mean it is better or worse. I think it's the differences that make things interesting!