The Eckland Effect

Posted on July 8, 2014 by K Eckland

It’s been a while since I’ve written – but sometimes between maintaining two blogs, a series on health for Examiner.com, answering emails from potential medical tourists, traveling and working long hours on assignment – I sometimes feel a bit like a candle burning at both ends.

But I am happy to report – that I recently completed my latest assignment and am back home in my native Virginia (for a few days) before heading back to Colombia.

I’ll spend the next couple days getting ready; contacting potential interviewees, researching articles,

The downside of frequent extended travel is the piling up of all the inevitable errands and hassles. Sometimes its just stuff like sorting through a couple of months of mail, but other times it’s paying property taxes (in person because I live in a small town) or renewing my driver’s license (now good until 2022!)

But now that we’re all caught up – we can get back to work (and writing!)

The Profiteer Model

Several interesting articles and posts have been written about medical tourism lately. We will talk about some of the other issues in future posts but today, I wanted to share this article by Stacy Hsu from the Tampai Times. This article takes issue with the “Profiteer’ model of many so-called “Medical Tourism” hospitals and clinics.

VIP Medicine

As we’ve mentioned in previous posts, the idea of exclusive hospitals designed solely for the wealthy foreigner is both a noxious and popular one. To many people, the idea of a resort-like or decadent atmosphere that caters to the every whim of the monied tourist or “Club Medicine” is a charmed one. VIP/ Executive health programs thrive around the world – from the hallowed halls of academic medicine like John Hopkins, the Cleveland Clinic to the Planet Hospital branded facilities around the world.

Much of the medical tourism industry has been based on this context. Programs are advertised on the basis of desirable location, gourmet cuisine menus, luxurious accommodations and nightly turn down service; not surgical skill or publishable clinical outcomes. No one hypes a short-length of stay or low re-admission rate when catered meals, high-speed internet and cable television are part of the selling points.

VIP versus Concierge: Not entirely the same

Don’t want to travel? But want your health care needs catered to? There are whole branches of primary care practices (ie. the “Royal Pains” practices) that are now based on this principle. On the surface, it doesn’t sound like much – patients pay extra money to have their doctor actually give them the time and attention they deserve* (during visits, phone calls and emails) but in reality, it can very quickly turn into something else as this ‘bonus’ pay approach changes the patient – provider relationship.

But “concierge medicine” as it is called in primary care medicine is a far cry from the VIP and Executive programs offered as part of medical tourism programs. In concierge medicine, patients still have a long-term and established relationship with their physician – and it is this relationship that can actually improve health care outcomes along with patient satisfaction. That’s because having more time with your family doctor means that s/he will spend more time answering questions and explaining care to patients. In turn, the patient is more likely to fill their prescriptions, take their medications and otherwise follow this doctor’s instructions.

*Instead of delegating more personalized care to people like me; the nurse practitioner (NP) or physician assistant (PA) which is more commonly done in standard medical offices.

But is ego-tickling medicine good for your health?

According to the scant amount of existing research, the answer is often no, when we are talking about short-term patient-provider relationships like the one-day executive physical or the spa style surgery service. In fact, patients often receive unnecessary and even potentially harmful, expensive tests and procedures (like the famed “Full body CT”).

I liken it to “T he emperor’s new clothes” syndrome, where the patient is seen more as a consumer / purchaser of goods than a person seeking health services. In this scenario, the healthcare provider is more concerned with keeping the customer satisfied than explaining why many of these tests and procedures are not necessary or may even be harmful.

Remember: First do no harm!

The customer is always right!

These contradictory objectives may become a conflict when the needed health advice isn’t what the patient wants to hear*.

Not even the humble fools dare tell the emperor the truth.

The ‘Eckland Effect’

But it looks like this may be changing. Several new research projects as well as recent articles are showing a move towards data collection and measurement of objective outcomes in regards to medical tourism. Instead of patient satisfaction surveys, researchers are asking about the incidence of complications.

Other organizations are talking about implementing more accountability, transparency and formal accreditation for medical tourism programs and facilities. Of course, accreditation is only as valuable as the organization offering it.

*Certainly this dynamic was at play in the care and death of pop star Michael Jackson under the care of Dr. Conrad Murray.

Additional articles for interested readers:

Al-Lamki, L. (2011). Medical Tourism: Beneficence or maleficence? SQU Med J Nov 2011, 11(4): 444-447. This is an excellent editorial that offers a concise overview of many of the ethical issues we have discussed here at Latin American Surgery including brain drain, transplant tourism, quality assurance, continuity-of-care and the overall impact of medical tourism on local communities.

In a related article, ” A European perspective on medical tourism: the need for a knowledge base” Carrera & Lunt (2010) argued for the urgent need for record-keeping and statistical data collection in the medical tourism industry. While this article is not available for free on-line, a related presentation by the authors is available here.

For readers interested in learning more about the correlation between patient satisfaction and clinical outcomes, I encourage you to read the works of JJ Fenton.

Fenton JJ, Jerant AF, Bertakis KD, Franks P. (2012). The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13. This study in particular is a must read: in this study, Fenton et al. followed a group of more than 36,000 patients and found that high patient satisfaction was correlated with increased health costs, greater rates of inpatient admissions to the hospital and a higher overall mortality. Fenton et al have also conducted several additional studies examining the relationship between patient satisfaction and quality of care. The findings of these study question the utility of new programs linking patient satisfaction with provider compensation (ie. pay-for-performance) and question the commonly held beliefs that patient satisfaction = high quality care. It may be that the best care comes at a price: unhappy patients. But then again, isn’t not a popularity contest – or at least, it shouldn’t be.

Medscape subscribers can also view a series of articles on this topic including an inteview with Dr. Fenton on his body of work. Medscape has a series of articles examining both sides of the argument linking patient satisfaction with provider compensation.

Patient satisfaction is overrated – an excellent editorial about the cost to patients (in health and money) related to demands for ‘patient satisfaction”.

100% sugar-free!

Posted on February 5, 2014 by K Eckland

I am currently on assignment in Massachusetts – and we’ve had our share of snow in the last few weeks. It certainly makes me long for Latin America..

on assignment in the northeast

But while I may be in the northeast for the next several weeks, it doesn’t mean that I am hiding under a rock – so I continue to talk / read/ and research issues in medical tourism.

One of the newest reports comes out of the United Kingdom. The UK has embraced medical tourism to a greater degree that Americans have, and UK researchers are some of the forerunners in the field. (There are multiple reasons for the ready adoption of medical tourism by large numbers of British citizens but that’s a different topic entirely.)

No candy coating!

The latest news from the Yorkshire Post is a timely and necessary reminder for all potential medical tourists and facilitators out there. The article discusses the recently published paper, entitled, “The three myths of medical tourism” as well as interviews with medical tourists.

Research into the medical tourism industry

The paper is based on results of a study conducted at York University. Researchers at York University have an ongoing medical tourism project looking at multiple aspects of medical tourism including financial/ economic, as well as quality and continuity of care issues.

Much of what the researchers at York are studying are topics we have discussed previously on our site:

Quality Control

– the lack of standardized guidelines for ensuring quality of care (and continuity of care from the moment the patient leaves home until recovery)

– the lack of accountability for facilitators/ tour operators/ medical tourism companies for patient safety and outcomes (this means that companies can send you to the cheapest surgeon)

– the lack of recourse for patients who experience complications/ serious injury or inadequate care. (It’s a black hole for medical malpractice at present).

– The potential financial costs of complications: While some surgeons require their patients to purchase ‘complication insurance’ to cover treatment of complications (if they occur) in the home country, there is no universal requirement.

Papers in-press

Unfortunately, much of this work (by Lunt & Smith) is currently in-press. I’m anxious to see their reports but I am also wondering what sort of regional differences may exist. Medical tourism by British residents is often to neighboring areas of Europe, Eastern Europe, India and Israel. I’d be fascinated to see how that compares with outcomes and experiences for medical travelers to Latin America, and different South American countries in particular.

In any case – it’s a timely report. Hard scientific information is dearly needed since the majority of data over the last decade has been anecdotal in nature or statistical “projections/ estimates / guesstimates”.

Hard data is particularly important when it comes to allegations regarding poor post-operative care/ and increased incidence of infections (specifically in medical tourists from the UK who traveled to India). Many of these complaints arise from local plastic surgeons and may have little supporting data. If there is a problem, we need actual numbers, not case reports (particularly if we are dealing with antibiotic resistant infections).

The industry has also been plagued with numerous biases on both sides.. – Biases towards the perception that all overseas medical care is cheaper (not always the case)

and/or that cheaper = inferior

Quantitative data would also be helpful when discussing patient satisfaction and quality of care. Most of the time, statistics are bandied about from the Deloitte Institute – but I want to hear what patients think from other sources. How did patients rate their experiences in Britain? In California? Where were the patients going? What countries? What clinics were mentioned repeatedly?

Other issues – Patients poorly informed

Researchers also found that medical travelers were poorly informed or ignorant of the risks involved with medical tourism.

In some cases, patients were ‘willfully ignorant‘ and relied on social media and friends for all of their health information. A subset of these patients also traveled for unproven/ unregulated medical treatments (such as bovine stem cell injections).

Many patients were ignorant of the risks or potential complications of the surgical procedures themselves (lap-band was specifically cited numerous times) as well as the problems that arise when your surgeon is thousands of miles away.

Patients were also unaware/ poorly informed about the financial implications of developing/ treating complications in their home country – (or the costs involved if they needed to return to their surgeon). Some of the financial issues mentioned in this (and previous data I’ve encountered) is more specific to British residents with their National Health Services and it’s reimbursement structure.

However, it’s not unimaginable to picture similar circumstances for uninsured medical tourists, or tourists seeking aftercare at an “out-of-network” facility once they returned to the USA.

Ignorance of health care information – an ethical/ safety issue

Some of this ignorance may be directly attributed to the way that many medical tourism companies operate – with patients being funnelled overseas thru a “facilitator” versus referring physicians and nurses. During a recent conference on medical tourism, I was astounded when a prominent American medical facilitator brushed aside my concerns about the lack of medically trained personnel, stating, “I’ve been a paralegal for 22 years in a malpractice office – I know all that anyone needs to know about surgery.”

But what about the ‘caregiver’?

Facilitators and medical tourism companies often tout the use of ‘caregivers’. This terminology is misleading in my opinion.

Since “doctor”, “registered nurse”, and other healthcare personnel are professions that require certification and educational degrees – companies often label their assistants ‘caregivers’ since it’s illegal to use the title of nurse. In reality, the term ‘caregiver’ is more akin to ‘paid companion’. These individuals have no medical or nursing training and may actually be a source of misinformation (as this paper states.)*

In the usual course of surgery – as part of the pre-operative process, patients receive information, education and instructions during their initial consultation/ and pre-operative visits. This also gives patients a chance to ask questions, in-person to a medically knowledgeable person. Skype, and email just can’t replace this critical component.

Many times, critical information is obtained (and given) by the surgical team during the physical examination and history-taking on the initial consultation. If the referring service is a layperson, and the initial (in-person) consultation takes place after the patient arrives in the destination country, these crucial education opportunities are lost.

Call for Regulation for patient safety

As readers know, I believe that regulation is both necessary and desirable to improve/ promote and grow the medical tourism industry. This regulation needs to be undertaken by knowledgeable people/ institutions outside of the industry.

Other research in medical tourism –

Simon Fraser University – British Columbia, Canada

*In a related aside, one of the more popular Canadian medical tourism facilitators uses her unemployed sister in the role of ‘caretaker’. While the sister has no medical or nursing training, the facilitator bragged that it allows her to put her family on the payroll and bill the client for these services.

CBS news on the cons of medical tourism

Posted on November 4, 2013 by K Eckland

CBS published a refreshing take on medical tourism – an article reviewing the pros and cons of traveling for medical care along with an interview with an American orthopedic surgeon, Dr. Claudette Lajam from New York University Langone Medical Center.

Video interview with Orthopedic Surgeon

While Dr. Lajam pretty much rejects any form of medical tourism – she made some excellent points in her interview. In the discussion, she stressed the need for facility AND provider verification. She also talked about the need for people to know specifics – and gives one of my favorite examples, “American trained”.

“American trained”

As she points out in the interview, this is a loose term that can be applied (accurately) to a Stanford educated surgeon like Dr. Juan Pablo Umana in Bogotá or in a more deceptive fashion to one of the many surgeons who have taken a short course, or attended a teaching conference within the United States. A three-day class doesn’t really equate, now does it?

The discussion (and the article) then turned to the need to ‘research’ providers.. Now, if only CBS news had talked to me.. That would have made for a more balanced, detailed and informative show for watchers/ readers.

(Telling people to ‘research’ their medical providers falls a bit short. Showing people how – or providing them with resources would be more helpful.)

“Off-label medical travel”

In addition, the print article should have gone a bit further in discussing the pros and potential consequences/ harmful effects of traveling for ‘off-label’ treatments instead of merely quoting one patient. Since the area of harm is actually far greater in this subsegment of the medical tourism population due to the amount of quackery as well as the sometimes fragile state of these potential patients – a bit more discussion or even a separate segment on “off-label medical travel” would have been an excellent accompaniment.

Speaking of which, several weeks ago, I interviewed with NPR (National Public Radio) as part of a segment on medical tourism. During that discussion we talked about all of the pluses and minuses mentioned on the CBS segment as well as the “Selling Hope” aspect of ‘off-label medical travel” and the potential harms of this practice, as well as some of the issues involved in transplant tourism. I am not sure how much of my interview, Andrew Fishman, the producer for the segment, will use – or when it will air, but I’ll keep readers informed.

Start here…

Posted on September 7, 2013 by K Eckland

This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing. Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site. Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor? What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results? or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be. Is the facility clean? Does the equipment work? Is there appropriate personnel? Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research. There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background). Sometimes I talk about the ethics of medicine as well. I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare. I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong. You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit. These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too. It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this? well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location. So you can look in plastic surgery, or you can jump to the country of interest. Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam. (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me. The information is still correct..

Thank you for coming.

the ethical, moral and health hazards of transplant tourism

Posted on August 3, 2013 by K Eckland

Re-visiting one of our classic posts on the ethics of transplant tourism – or ‘organs for sale/ steal’

Love, Life and Surgery in Latin America is now Colombian Culture & Cuisine

Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.

Bathtub full of ice

Everyone has heard ‘urban folklore’ regarding the unwary/ drunken/ duped young man who goes looking for sex, and wakes up in a bathtub full of ice.. Conventional wisdom is that these tales serve as a modern-day fairy tale with an underlying moral message. In this case – cautioning young people against the vices of alcohol/ drugs and anonymous/ promiscuous sex.. If only the truth were really just such a cautionary tale. But, as readers know, the truth is considerably darker – involving the exploitation and even outright murder of citizens around the world to feed the organ trade.

(For the first-person account from a Chinese doctor involved in organ harvesting, click here. )

“Transplant Tourism”

This…

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Just another reason for Latinamericansurgery.com

Posted on June 29, 2013 by K Eckland

Colombian plastic surgeons operating

because you need someone who is objective (and informed) that is looking out for you, the patient..

In this article, at International Journal of Medical Travel, Kevin Pollard talks about the need for regulation of medical tourism in cosmetic surgery. I wholeheartedly agree – in fact, Mr. Pollard and I conversed about this very topic in a series of emails last week.

After all – it is why I do what I do, and publish it here for my readers. The industry does need to be regulated – medical tourism companies shouldn’t pick providers by “lowest bidder” and patients need to be protected (from unsanitary conditions, bad surgeons, and poor care). But what form will this regulation take?

Will it be Joint Commission certification – which covers facilities and not the physicians (and their surgical practices themselves)?

Will it require facilities to pay a lot of money for a shiny badge?

Or will it be someone like me, low-key and independent, going into facilities at the behest of patients; interviewing surgeons and actually observing the process and talking to patients?

and who pays for this? The beauty of what I do – is that I am independently (read: self) funded. True, it hurts my wallet but I have no divided loyalties or outside interests in doing anything but reporting the unvarnished truth.

and ultimately – will this be done in a fair, open and honest way? Or it is really a witch hunt led by disgruntled American and British plastic surgeons? Will they bother to discriminate between excellent surgeons and incompetent ones who will it be by geography alone?

I guess we will just have to wait and see.

Colombian plastic surgeons answer back

Posted on June 23, 2013 by K Eckland

Chairman of International Society of Aesthetic Plastic Surgery questions the ethics of medical tourism, Colombia responds.

Colombia is now 11^th in the world for plastic surgeries by volume according to the International Society of Aesthetic Plastic Surgery (ISAPS) but that may change if Dr. Igor Niechajev, Chair of the Government Relations Committee of that same organization gets his way. ISAPS, who ranked Colombia among the top 25 countries for plastic surgery also printed an article by Niechajev in the spring edition of its newsletter condemning medical tourism.

Chairman discourages medical tourism, stating that medical tourists are victims of inferior care

The strongly-voiced piece accused surgeons outside of European and North America of providing inferior medical care, inadequate pre-operative evaluations and operating in substandard facilities.

States bad outcomes wouldn’t happen at home

In his editorial, Dr. Niechajev provides anecdotal evidence of a botched procedure that occurred in Asia, and stated that “such a tragic outcome” of [procedure cited] “is highly unlikely had the patient not been a medical tourist.” Dr. Niechajev cites these concerns, not as a surgeon losing business to his competitors but states that he is concerned about the costs of caring for patients with possible complications once they return home.

Not limited to national borders

His concerns don’t stop at national borders, Dr. Niechajev also suggests that surgeons limit themselves to their immediate local vicinity. What this may mean for a rural patient requiring extensive reconstructive surgeon is not addressed by Dr. Niechajev.

Statements based on limited data

He bases the majority of his opinions on the shoulders of Dr. Ritz, the Australian National Secretary for Health, who cites one specific incident as the trigger for changing Australian legislature to prohibit this practice. Additional evidentiary support of gross episodes or a mass epidemic of malpractice by international surgeons appears to be limited to 11 cases in the United Kingdom. No other data was cited.

International Society debating the issue; Niechajev recommends financial sanctions against patients

These concerns have the officers of ISAPS considering changing the code of ethics of the organization to discourage the practice of medical tourism by its member surgeons. However, Dr. Niechavej does not seem content to stop there, instead he advocates for governmental announcements advising the public about “increased risks associated with medical tourism” and that “surgery overseas practically means that they [patients] are giving up all their rights.” He also advocates for financial penalties for patients who experience post-operative complications after surgery overseas, stating, “No preventative measure is as effective as hitting someone’s purse.”

Colombian plastic surgeons respond

In an exclusive interview with the President of the Colombian Society of Plastic Surgery, he answered many of the allegations by Dr. Niechajev.

Regarding Dr. Igor Niechevaj’s statements on the lack of regulations and substandard facilities in countries that are popular medical tourism destinations, the President of the Colombian Society of Plastic, Esthetic and Reconstructive Surgery, Dr. Carlos Enrique Hoyos Salazar replied that, “All facilities, and hospitals in Colombia are regulated by the Ministry of Health. There are minimum standards that must be met. Any facilities that are interested in participating in the medical tourism business have additional standards and qualifications for certification by national agencies. Anesthesiologists, and medical doctors are required to have additional training to perform pre-operative evaluations for International plastic surgery patients”.

Reports safety and patient protections for medical tourists

He refutes claims that patients receive minimal post-operative care before returning home. In addition to medical advice from Colombian physicians, he cites agreements with Colombian and international airlines to encourage international patients to stay a minimum of 15 days after their surgical procedures to ensure optimal recovery.

Additionally, several plastic surgeons specializing in medical tourism and medical tourism companies offer ‘complication policies’ to pay for any expenses a medical tourist may incur in both the destination and home country should they develop complications post-operatively. In fact, an advertisement for one of these policies shares space with Dr. Niechevaj’s article. These policies effectively negate one of Dr. Niechevaj’s (and Dr. Ritz’s) strongest arguments, that medical tourism incurs costs in the home country when patients develop post-operative infections or other problems after returning home.

ISAPS Chairman defending his own wallet?

When asked about Dr. Niechevaj’s position on medical tourism and possible changes to the ISAPS code of ethics, Dr. Hoyos stated, “This is not right. This has nothing to do with the quality of surgery in Colombia and other countries. This is about the expensive costs of surgery in Europe and the United States. If a surgery costs $6,000 (USD) over there and only $3,000 – $3,500 in Colombia, then those doctors are losing money due to medical tourism.”

Good and Bad is a global phenomenon

As we’ve pointed out here on our site (and related work) – good and bad surgical outcomes are certainly not limited by geography, and Dr. Niechajev certainly seems to paint the rest of the world with a wide brush with his call to action.

A more reasonable, and fair response would be continue to encourage work such as mine – using outside, independent and unbiased observers to evaluate surgeons wishing to participate in medical tourism.

In an ideal world, companies such as Blue Cross/ Blue Shield who wish to broaden their international physician base would hire independent medical professionals to review surgeons who wished to be included under their health plan. This way both consumers and third-party payers would have more information before patients went ‘under the knife’ so to speak.

Patients wouldn’t be shuttled to surgeons who submit the lowest bid (to insurance companies, and private parties) but to surgeons whose qualifications had been authenticated. All parties would know about the quality of hospital facilities, anesthesia, pre-operative evaluation and post-operative care.

Doing my part

Readers know that I do what I can, in a very small way, to add to the body of knowledge about the quality and care of patients who receive treatment from the surgeons who consent to let me observe, evaluate and report my findings.

Now we just need this on a large-scale, multi-national level.

The cardiac OR

Posted on June 22, 2013 by K Eckland

If you’ve never been to the cardiac operating room – it’s a completely different world, and not what most people expect. For starters, unlike many areas of health care (particularly in the USA), the cardiac operating room is usually very well staffed.

Just a few of the people working in the OR. (photo edited to preserve patient privacy)

For example, there were eight people working in the operating room today:

Dr. Luis Fernando Meza, cardiac surgeon

Dr. Bernando Leon Urequi O., cardiac surgeon

Dra. Elaine Suarez Gomez, cardiac anesthesiologist

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient’s privacy)

Ms. Catherine Cardona, “Jefe”/ Nurse who supervises the operating room

Ms. Diana Isobel Lopez, Perfusionist (In Colombia, all perfusionists have an undergraduate degree in nursing, before obtaining a postgraduate degree in Perfusion). The perfusionist is the person who ‘runs’ the cardiac bypass machine.

Ms. Laura Garcia, Instrumentadora (First Assist)

Angel, circulating nurse

Olga, another instrumentadora, who is training to work in the cardiac OR.

This is fairly typical for most institutions.

Secondly – it’s always a regimented, and checklist kind of place. (I wish I could say that about every operating room – but it just wouldn’t be true.) But cardiac ORs (without exception) always follow a very strict set of accounting procedures..

For starters – there are labels.. For the patient (arm bands), for the equipment (medications, blood products etc..) even the room is labeled.

Sign on operating room door (edited for patient privacy)

Then come the checklists..

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

The general (WHO) operating room checklist. The perfusionist’s checklist.. The anesthesiologist’s checklist.. and the big white cardiac checklist.

by then end of the case, this board will be full..

by the end of the case, this board will be full..

The staff attempts to anticipate every possible need and have it on hand ahead of time. Whether it’s nitric oxide, blood, defibrillation equipment, or special medications – it’s already stocked and ready before the patient is ever wheeled in.

Most of these things are universal:

such as the principles of asepsis (preventing infection), patient safety and preventing intra-operative errors – no matter what hospital or country you are visiting (and when it comes to surgery – that’s the way it should be.)

Today was no exception..

In health care, we talk about “OR people” and “ER people”.. ER people are the MacGyvers of the world – people who thrive on adrenaline, excitement and the unexpected. They are at their best when a tractor-trailer skids into a gas station, ignites and sets of a five-alarm fire that decimates a kindergarden, sending screaming children racing into the streets.. And God love them for having that talent..

But the OR.. that’s my personal area of tranquility.

This orderly, prepared environments is one of the reasons I love what I do.. (I am not a screaming, “by the seat-of-your-pants”/ ‘skin of your teeth’ kind of gal). I don’t want to encounter surprises when it comes to my patient’s health – and I never ever want to be caught unprepared. That’s not to say that I can’t handle an emergent cardiac patient crashing in the cath lab – it just means I’ve considered the scenarios before, (and have a couple of tricks up my sleeve) to make sure my patient is well taken care of (and expedite the process).

That logical, critical-thinking component of my personality is one of the reasons I am able to provide valuable and objective information when visiting hospitals and surgeons like Dr. Urequi’s and Dr. Meza’s operating room at Hospital General de Medellin.

In OR #1 – cardiothoracic suite

As I mentioned in a previous post on Hospital General de Medellin, operating room suite #1 has been designated for cardiac and thoracic surgeries. This works out well since the operating room itself, is modern and spacious (which is important because of the area needed when adding specialized cardiac surgery equipment like the CPB pump (aka heart-lung machine). There are muliple monitors, which is important for the video-assisted thoracoscopy (VATS) thoracic cases but also helpful for the cardiac cases. The surgeon is able to project the case as he’s performing it on a spare monitor, which allows everyone involved to see what’s going on during the case (and anticipate what he will need next) without shouting or crowding the operating room table.

Coordinating care by watching surgery

For instance, if the circulator looks up at the monitor and sees he is finishing (the bypasses for example), she can make sure both the instrumentadora and the anesthesiologist have the paddles and cables ready to gently defibrillate the heart if it needs a little ‘jump start’ back into normal rhythm..or collect lab samples, or double check medications, blood products or whatever else is needed at specific points during the surgery.

More on today’s case in our next post.

Why quality of anesthesia matters: who is administering your anesthesia?

Posted on May 15, 2013 by K Eckland

I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring. But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.

There is a saying among medical professionals about our patients.. We want them all to be boring and routine. That is what I strive for, for each and every one of my readers – safe, boring and routine.

Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas. In real life, it means something has drastically and horribly gone awry. Unlike many of its fictional counterparts – outcomes are not usually good.

this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure. While we don’t know the circumstances behind this case – (and don’t really want to speculate on this specific case), it does open the discussion on the quality of anesthesia and anesthesia-monitoring for non-general anesthesia procedures. This includes procedures using sedative-hypnotics, epidurals and anesthetic combinations. This is often referred to as “twilight” or “conscious sedation” procedures.

People tend to think of these procedures as being entirely safe – whether it is so-called “sleep dentistry’ or any variety of scope procedures (endoscopy, colonscopy, bronchoscopy). In fact, many of these procedures are often done in out-patient settings; dentists’ and doctors’ offices without the services of an anesthesiologist or CRNA (nurse anesthetist) and/or appropriate monitoring.

This is extremely troubling – especially since a slew of research papers over the years have clearly demonstrated that this is not safe. In an eye-opening paper published several years ago, over 70% of non-anesthesia trained physicians underestimated the patient’s level of sedation during gastroenterology procedures. (While I can not find a copy of this article online – its publication led to changes in the recommendations related to administration of anesthesia by non-anesthesia providers).

In an notable survey published on dental anesthesia, 35% of respondents providing anesthesia during dental procedures had no formal training in anesthesia.

Too often, the medical professionals (non-anesthesia specialty) underestimate the level of anesthesia achieved and critical safeguards to prevent potential patient injury are not taken. One weekend course, or online continuing education course is not sufficient training.

In the case cited above, a young woman underwent an endoscopy procedure. During this procedure – the patient became hypotensive (low blood pressure) and hypoxic (oxygen-starved) resulting in severe brain damage and disability. The patient is now unable to see, or speak. This devastating outcome is a clear example of the risks during these types of procedures due to anesthesia.

While the details of the case above differ (patient was in a hospital) the family is now suing claiming that the patient did not receive prompt medical attention when these events occurred.

Unconscious, overmedicated and unmonitored in the office: Recipe for disaster

More concerning in my view, is for all of those patients undergoing these very procedures outside of hospital facilities – away from trained experts. In many cases, the office patients are given medications without any continuous monitoring devices such as continuous telemetry and oxymetry (which detect low blood pressure and hypoxia immediately) versus ‘spot-check’ methods that office staff may employ.

For example; several years ago, one of my good friends worked as a nurse in a gastroenterologists office. While she was a well-trained and excellent nurse – she was not a trained anesthesia provider – nor was she provided with the adequate equipment to monitor or treat anesthesia complications.

What equipment, you ask? The office had no cardiac monitoring – (hemodynamic monitoring). There were no reversal agents available in case of oversedation, no supplemental oxygen for respiratory depression/ hypoxia – and most critically – no crash cart in case of cardiac or respiratory arrest. (While the law requires this in some states, that doesn’t guarantee that the provider has the appropriate equipment.)

In the office where my friend worked, the nurse administered a set amount of sedation under the guidance of the gastroenterologist. During the procedure, vital signs were checked every 15 minutes (giving the patient 14 minute intervals to develop serious procedures unnoticed by anyone).

Was this the right or safe way to care for patients? No, absolutely not – but it remains a common practice in doctors’ offices around the country.

The death of Michael Jackson

Another more extreme but famous example of the dangers of ‘unmonitored anesthesia’ is the death of Michael Jackson during the administration of propofol by a Dr. Conrad Murray in Mr. Jackson’s home. During the investigation, it was noted that not only was the patient (Michael Jackson) without continuous hemodynamic monitoring (and oxymetry) – he was left unattended for significant periods while Dr. Murray conducted business and placed numerous telephone calls. While this is an extreme example – it also demonstrates the dangers of anesthesia administration without qualified personnel, appropriate monitoring or rescue equipment.

In 2009 Metzer et. al. reviewed all liability claims and summarized this along with their previous research regarding related anesthesia injury and concluded, “Data from the American Society of Anesthesiologists, Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.”

If you are planning to have any sort of procedure requiring any sedation or anesthesia (other than local anesthesia like lidocaine), ask the following questions:

– Who will be administering my anesthesia/ sedation? What are their credentials and training in anesthesia?

– How will I be monitored during this procedure? Who will be monitoring me? What type of safety protocols are in place for peri-procedural monitoring?

– What if there is a problem? Do you have the equipment necessary to reverse sedation? perform urgent intubation? resuscitation?

If this procedure is being performed in a doctor’s office or outpatient surgery center: – What happens if a complication develops during this procedure? Is there a hospital nearby for emergencies?

References / Resources

Boynes SG, Moore PA, Tan PM Jr, Zovko J. (2010). Practice characteristics among dental anesthesia providers in the United States. Anesth Prog. 2010 Summer;57(2):52-8. doi: 10.2344/0003-3006-57.2.52. (free full text – linked in article above).

Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. (2006). Trends in anesthesia-related death and brain damage: A closed claims analysis. Anesthesiology. 2006 Dec;105(6):1081-6. (full text available). This study clearly showed the benefit of continuous pulse oxymetry and other hemodynamic monitoring to prevent catastrophic complications.

Cohen, L. & Aisenburg, J. (2008). Endoscopic sedation: Preparing for the future. Gastrointestinal endoscopy clinics of north America; 18(4).

Hangsheng Liu, PhD; Daniel A. Waxman, MD; Regan Main, Soeren Mattke, MD, DSc (2012). Endoscopies and Colonoscopies and Associated Spending in 2003-2009. JAMA. 2012;307(11):1178-1184. doi:10.1001/jama.2012.270 The authors attempt to estimate the frequency in which qualified anesthesia providers are used during gastroendoscopy procedures.

Metzner J, Posner KL, Domino KB (2009). The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8. doi: 10.1097/ACO.0b013e32832dba50.

Paspatis GA, Tribonias G, Paraskeva K. (2010). Level of intended sedation. Digestion. 2010;82(2):84-6. doi: 10.1159/000285504. Epub 2010 Apr 21. Article discussing the issues regarding sedation during endoscopy procedures.

Robbertze R, Posner KL, Domino KB. (2006). Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42. Review.

Catastrophic surgical mistakes – and bold red headlines…

Posted on March 9, 2013 by K Eckland

Many of you may have seen the bold red headlines for the weekend edition of USA Today, which screams, “What surgeons leave behind.” If you haven’t read it, this article by Mr. Eisler makes for riveting reading on one of surgery’s most catastrophic mistakes.

(The other catastrophic surgical mistake is a topic we’ve covered before, Wrong-site surgery (wrong side, etc.) Readers will remember the previous stories about an American neurosurgeon who was found to have performed wrong-sided surgery, on not just one – but several patients. Readers will also recall that said surgeon has a habit of moving from state to state as each medical board catches up to her*.

The How and Why of Retained Surgical Items is our own contribution to the topic – over at Examiner.com, where we review much of the information regarding retained surgical items or forgotten foreign bodies including risk factors for this phenomenon, and how current practices may actually inhibit efforts to prevent this from occurring.

* This surgeon was previously mentioned by name in both my posts, and several news stories about her numerous medical/ surgical errors.. Of course – disclosing her name on this site led to multiple threats of legal action – quite the long story, for new readers.

the ethical, moral and health hazards of transplant tourism

Posted on March 3, 2013 by K Eckland

Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.

Bathtub full of ice

(For the first-person account from a Chinese doctor involved in organ harvesting, click here. )

“Transplant Tourism”

This division of medical tourism, “Transplant tourism“, is the sanitized term for organ selling, or diversion of transplantable organs to wealthy consumers (outside of the formal donor networks like UNOS).

Transplant tourism/ murder for organs is making headlines again this week as Taiwanese legislators try to ban the practice among their citizens and residents. The Taiwanese lawmakers are trying to prevent the practice of wealthy patients (and companies making money from the sale of organs/ transplantation) using China as a ‘spare parts’ playground.

As widely reported over the last several years – China has become notorious for widespread ethical violations, including the murder (execution) of political prisoners for organ sales and transplantation to wealthy buyers. Many of these political prisoners are people accused of such crimes as the practice of the religion, Falun Gong, or for expressing ideas that challenge the traditional Chinese culture or current government practices.

Not illegal in the United States

Unfortunately, despite multiple scientific, medical, governmental papers and sporadic media coverage of this issue – it is not illegal for Americans to engage in this practice, nor for American companies to offer transplantation services based on these practices. (It is illegal for organs to be sold in the USA, but not for people to travel to engage in these practices.) While the United Nations, New Zealand, Australia and now, Taiwan have begun addressing this practice – the US government remains silent.

Protecting citizens from the wealthy foreigner

Other nations, like Pakistan have acted to try to prevent their citizens from becoming donor sources for wealthy foreigners. Just today, a new law was passed to prevent organs obtained in Pakistan from being given to non-Pakistani residents. While these laws will not eliminate the practice outright, these countries and their citizens have taken a moral and legal stance against the practices. Now, it’s our turn.

Resources/ More information on this topic

More about the people “criminals” the Chinese government is executing – and taking organs from – Washington Post, November 2012

List of famous Chinese dissidents – Wikipedia

More about the murder and torture of practitioners of Falun Gong

The Ugly Side of Medical Tourism – a related post with links to scholarly articles and media reports regarding transplant tourism in China and Latin America.

A look at why transplant tourism is not safe for recipients, either.

Patients with passports – another post on law, ethics and medical tourism discussion focused on the publication of a book by the same title. Includes links to several articles by Dr. Delmonico – the foremost expert on illegal organ transplantation.

Medical Tourist death under inquest

Posted on February 24, 2013 by K Eckland

Was it a medical mistake/ an accident of fate / or…. was it the Cocaine? An inquest is held on the intra-operative death of an Irish medical tourist..

In a recent inquest, the wife of an Irish tourist who died while undergoing liposuction with a well-known Colombian plastic surgeon talked about her husband and his decision to pursue plastic surgery with Dr. Ricardo Lancheros Pedraza.

In a published story by Gareth Naughton of the Irish Independent, the wife of Pierre Christian Lawlor detailed her husband’s decision to undergo cosmetic surgery with the Bogotá surgeon due to unhappiness with his physique.

During her testimony, she also conceded that her husband had taken cocaine in the days and hours immediately prior to surgery – despite being advised specifically to refrain from smoking, alcohol or taking medications.

In a story published in Irish Central – Ms. Andrea Galeano, the Venezuelan-borne wife of Mr. Farrell reported that her husband had taken cocaine on several occasions after arriving in Bogotá for his surgical procedure.

Mr. Farrell is believed to have died from intra-operative myocardial infarction (heart attack during surgery).

Additional Information

This Daily Mail article from 2012 describes how the use of cocaine can cause heart attacks, and sudden cardiac death.

Medical News Today article

Scholarly articles:

Finkel JB, Marhefka GD. (2011). Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011 Dec;86(12):1198-207. doi: 10.4065/mcp.2011.0338.

Schwartz BG, Rezkalla S, Kloner RA. (2010). Cardiovascular effects of cocaine.

Circulation. 2010 Dec 14;122(24):2558-69. doi: 10.1161/CIRCULATIONAHA.110.940569. Review.

Dear Edward

Posted on January 17, 2013 by K Eckland

In the middle of all the news about Lance Armstrong and his upcoming interview with Oprah Winfrey – where he has reportedly expressed his apologies for his years of lies and cover-ups over blood doping and steroid use, came this interesting piece by Lance Pugmire at The Los Angeles Times. In the article, several of Armstrong’s teammates and their families talk about what they consider to be the worst aspect of this entire scandal – the years of intimidation, threats and forced silence. Armstrong committed these abuses of the system, and flagrant cheating for years, and got away with it for over a decade. Not only that – but he had a team comprised to maintain this conspiracy of silence, of lawyers and such to protect Armstrong – while his unwilling colleagues paid the price for their honesty and integrity..

In a similar, but much smaller scale – I am publishing an open letter here at Bogota Surgery. As my regular readers know – we have had our own legal encounters (with threats and intimidation) over several of our previous posts about patient safety.

This all started due to a blog post on patient safety – based on an article from another website, verified by the original news agency and the original investigative reporter.

These fact-based, well-researched posts with supporting documents told the story of a surgeon who had committed multiple surgical errors including several different ‘wrong-sided’ surgeries. This surgeon, after being reported to the medical board in her state answered this action by moving to another state (where malpractice charges are now pending) and ultimately moved to a third state to practice.

However, one of the limitations of having state-based medical regulatory boards (versus a nationalized system) was that these complaints did not follow the doctor.. Meaning that when current patients / hospitals/ potential employers investigate or look up her licensure or credentials – they will have no idea of the previous charges against her. However, by publishing a blog post about this individual and re-posting links to original news articles and court documents, her lawyers threatened me with legal action to enact my silence.

So this is my response – in an open letter to her lawyer:

Dear Edward;

First, I would like to extend my sincerest sympathies to you. I am guessing that you are a nice person, and are working hard to perform your occupation to the best of your abilities. But by taking on this client, you are doing yourself and American patients a great disservice.

Your client has been found to be medically negligent in multiple cases in the state of Colorado. She acknowledged that through her own actions, and she now stands accused of the same in Illinois. Not only that, her brazen disregard for the health and safety of the unfortunate people who came under her care led to changes in the laws and regulations of the Colorado Medical Board. She may claim that she did not ‘lose’ her license in that state, but it was her actions that demonstrated to the medical board that there were significant loopholes in their processes that allowed physicians who admitted guilt, like your client, to move on to another state without penalty.

However, all of this is fact, and it is public record, so you and your client have no cause or claim against me for writing about these published facts. In my previous writing, I included supporting articles and documents to demonstrate that what I reported, was indeed, fact.

One of those facts in particular, is that – yes, you are targeting and bullying me. It is bullying and an intimidation tactic to threaten to sue someone for writing an established truth. It is bullying and a targeted attack, when it has been confirmed that you have not approached or sent similar letters to major news outlets such as the news agency that wrote and produced the original story, or another large agency that republished the story. But then again, large agencies have legal departments. So, yes, it is a targeted intimidation when you threaten me.

You may be just doing your job today, but what about tomorrow or ten years from now? Unfortunately, you are just part of a bigger problem in regards physicians and medical malpractice, which is what the heart of this discussion is really about; a surgeon who makes repeated surgical mistakes and then denies they ever occurred. That may not affect you, personally today but what about when one of your loved ones needs care for heart surgery, cancer or maybe even a brain tumor? How much confidence can you have in a system that allows surgeons such as this one to continue to practice? How much confidence will you have, knowing how easy it is to threaten others into silence?

My heart goes out to you, but my only advice is – give the money back to your client. Take no part in her actions and let people like myself continue our efforts; of trying to promote patient safety, education and protect this public, and people like you.

Know before you go: Medical tourism and patient safety

Posted on January 17, 2013 by K Eckland

The file download for the latest radio program, “Know before you go” with Ilene Little is available. It’s from the Christmas broadcast with Dr. Freddy Sanabria.

Image courtesy of Ilene Little

(I am on the periphery of the show – introducing Dr. Sanabria and talking about safety guidelines and intra-operative safety protocols. (Same stuff I talk about here – just a different medium.)

Dr. Sanabria, plastic surgeon

Dr. Sanabria joined us to talk about his experiences, and his clinic in Bogotá, as well as his ongoing projects and patient safety protocols. It was nice to be able to share some of my observations from my visits to his operating room.

Click here to connect to the Radio show archives