Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons

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Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Radio Interview with Ilene Little

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Interview with Ilene Little, “Know Before You Go”

Last month I completed a radio interview with Ilene Little, talking about Colombia, thoracic surgery, and issues in medical tourism.  I’ve been waiting for the archives to be published so I could provide a link here for interested readers.

Hope you enjoy. (You might recognize some of the names.)  For more print information on the interview – take a look at the article on my sister site.

Wrapping up and saying “Thanks!”

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It’s a busy Sunday in Mexicali – presidential elections are today, so I am going to try to get some pictures of the nearest polling station later.. In the meantime, I am spending the day catching up on my writing..

a polling station in Mexicali

Lots to write about – just haven’t had the time..  Friday morning was the intern graduation which marks the end of their intern year – as they advance in their residencies.. Didn’t get a lot of pictures since I was at the back of the room, and frankly, unwilling to butt ahead of proud parents to get good pics.. This was their day, not mine and I was pleased that I was invited.

I did get a couple of good pictures of my ‘hermanito’ Lalo and Gloria after the event.  (I’ve adopted Lalo as my ‘kid’ brother.. Not sure how he feels about – but he’s pretty easy-going so he probably just thinks it’s a silly gringa thing, and probably it is..)

Dr. ‘Lalo” Gutierrez with his parents

Lalo’s parents were sitting in the row ahead of me, so of course, I introduced myself and said hello.. (They were probably a little bewildered by this middle-aged gringa talking about their son in atrocious Spanish) but I figured they might be curious about the same gringa that posts pictures of Lalo on the internet.. I also feel that it’s important to take time and tell people the ‘good things’ in life.  (Like what a great person their son has turned out to be..)

Same thing for Gloria.. She is such a hard-worker, and yet, always willing to help out.. “Gloria can you help me walk this patient?”  It’s not even her patient, (and a lot of people would say – it’s not our jobs to walk patients) but the patient needs to get out of bed – I am here, and I need some help (with IV poles, pleurovacs, etc.)  and Gloria never hesitates.. that to me – is the hallmark of an excellent provider, that the patient comes first .. She still has several years to go, but I have confidence in her.

She throws herself into her rotations.. When she was on thoracics, she wanted to learn.. and she didn’t mind learning from a nurse (which is HUGE here, in my experience.)

Dr. Gloria Ayala (right) and her mother

She wasn’t sure that her mom would be able to be there – (she works long hours as a cook for a baseball team) but luckily she made it!

Met a pediatric cardiologist and his wife, a pediatrician.. Amazing because the first thing they said is, “We want nurse practitioners in our NICU,” so maybe NPs in Mexico will become a reality.. Heard there is an NP from San Francisco over at Hospital Hispano Americano but haven’t had the pleasure of meeting her.  (I’d love to exchange notes with her.)

I spent the remainder of the day in the operating room of Dr. Ernesto Romero Fonseca, an orthopedic surgeon specializing in trauma.  I don’t know what it is about Orthopedics, but the docs are always so “laid back”, and just so darn pleasant to be around.  Dr. Romero and his resident are no exception.

[“Laid back” is probably the wrong term – there is nothing casual about his approach to surgery but I haven’t had my second cup of coffee yet, so my vocabulary is a bit limited.. ]  Once I finish editing ‘patient bits’ I’ll post a photo..

Then it was off to clinic with the Professor.

Saturday, I spent the day in the operating room with Dr. Vasquez at Hospital de la Familia. He teased me about the colors of the surgical drapes,(green at Hospital de la Familia), so I guess he liked my article about the impact of color on medical photography.  (Though, truthfully, I take photos of surgeons, not operations..)

Since the NYT article* came out a few days ago – things have changed here in Mexicali.  People don’t seem to think the book is such a far-fetched idea anymore.  I’m hopeful this means I’ll get more response from some of the doctors.  (Right now, for every 15 I contact – I might get two replies, and one interview..)

Planning for my last day with the Professor  – makes me sad because I’ve had such a great time, (and learned a tremendous amount) but it has been wonderful.  Besides, I will be starting classes soon – and will be moving to my next location (and another great professor.)

Professor Ochoa and Dr. Vasquez

But I do have to say – that he has been a great professor, and I think, a good friend.  He let me steer my education at times (hey – can I learn more about X..) but always kept me studying, reading and writing.  He took time away from his regular life, and his other duties as a professor of other students (residents, interns etc.) to read my assignments, make suggestions and corrections when necessary.    and lastly, he tolerated a lot with good grace and humor.  Atrocious Spanish, (probably) some outlandish ideas and attitudes about patient care (I am a nurse, after all), a lot of chatter (one of my patient care things), endless questions…  especially, “donde estas?” when I was lost – again.

So as I wrap up my studies to spend the last few weeks concentrating on the book, and getting the last interviews, I want to thank Dr. Carlos Ochoa for his endless patience, and for giving me this opportunity.  I also want to thank all the interns (now residents) for welcoming me on rounds, the great doctors at Hospital General..  Thanks to Dr. Ivan for always welcoming me to the ER, and Dr. Joanna for welcoming me to her hospital.  All these people didn’t have to be so nice – but they were, and I appreciate it.

* Not my article [ I wish it were – since I have a lot to say on the topic].

Mexicali: the city by the fence

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Back in Mexicali after a week away at the nurse practitioner conference in Florida – and I am surprised by how much I missed the city.

a view of the city

To be sure, it lacks the glamour and sophistication of Bogotá, Medellin or Buenos Aires.  It doesn’t have the 500 years of history or Caribbean flavor that makes Cartagena such a vibrant city.  Yet – despite this, Mexicali remains the city by the fence – and the city that makes me want to stay on the Mexican side of the border.

Maybe it’s the casual friendliness of the city that grabs me, and embraces me.  The lack of pretension, the very earthiness of the barren,hard packed dirt and dusty surroundings draw me in – with the hidden pockets of Mexicali that beg to be explored.  Every brightly lit taco stand, the mom and pop establishments, and the upscale neighborhoods tucked away in tree-lined streets..

So, today after clinic, and rounds – we left the hospital and explored Mexicali – looking for photos to represent the Mexicali that I am coming to know, and which are often unseen by weekend tourists.

the main artery, which criss-cross the city

Having the good doc as a tour guide was an unexpected bonus – he knows the city so well, and was able to give background and insight into all of our destinations. Despite being from Sonora, he attended school here – making Mexicali very much his home.

as the capital of Baja California, there are numerous excellent educational facilities

I find taking city photos one of the more difficult aspects of writing.. Monuments aren’t all that exciting, and often the most interesting parts of cities aren’t the most photogenic ones..

This is one of Mexicali’s better known landmarks – the stadium used for bullfights.  The Mexicali sign is actually made of mirrored tile which glistens in the sun..

Mexicali landmark: Bullfighting stadium

We stopped by the Military base, because I have been fascinated by the military presence during the preparations for the elections – soldiers guard the electoral offices to prevent any sort of voting shenanigans.  (I’ll try to get a picture of the soldiers soon)

The good doctor laughs when I ask about military efforts and involvement abroad.  (Just because I’m not aware of the Mexican military overseas doesn’t mean they aren’t UN peacekeepers.. )  So I ask my questions about it and it is several minutes before he can stop laughing enough to even answer the question.  Funny, maybe.  But then – when you think of it kind of nice.  Mexico doesn’t attempt to police the world, and that’s okay..

“No, there’s no navy,” he laughs.. (Actually, there is a navy – which is also involved in trying to fight drug trafficking and gang activity).  But it’s nice that it’s apparently low-key enough that it doesn’t dominate the public’s attention.

Military base in Mexicali

Their primary function is more like our national guard – fighting against unrest (and now – narco-trafficking) at home.  Safeguarding elections and the general populace.  Keeping the border safe (yes – safe from all the violence endemic to satisfying the American thirst for drugs, and the underground importation of American weaponry).  I feel a little nervous taking pictures of the base, but no one seems to notice or approach me.  (My first attempts were semi-surreptitiously, but then, with encouragement, I got a little bolder.)

Today is the last day that the political candidates are allowed to campaign before the election, so we passed supporters for PRI (Enrique Pena) and PAN (Vasquez Mota).  I didn’t see anyone out there for AMLO or Quadri, but maybe they just weren’t as well represented.  After this – the candidates have to lay low for a few days so Mexican citizens can ‘reflect’ prior to the elections on Sunday.  That’s kind of a cool concept too – no endless barrage of media like the mega-campaigns at home.

Of course, I wish we could have a real workable multi-party system, so it’s not always a ‘lesser of two evils’ situation at home.  Maybe if we weren’t limited by having just two choices and two main parties – we might have more ‘shades of grey’ instead of all this extremism at both ends of the spectrum.. But it’s interesting to watch here, all the same, and I am glad that I have been here to experience it.

I hope I don’t alienate readers at home with my talk of politics – after all, I am not really a political animal, so ignore my musings, if you like..

In other news – it’s a bit frustrating when you have spent several months here – only that have the New York Times swoop down.. and all the doors that were closed to you (That’s you, Omar Dipp) suddenly burst open since they are a major news agency.  Of course, they had the mandatory patient testimonial,  – it was just the usual “medical tourism lite” style story that so often dominate the news.   Didn’t you just love the “nurses warm your hand…”  more like advertising than real journalism, but whatever..  (In fairness – I write a lot of “news lite” articles myself for outlets like Examiner.com which actually prefer this style, but those are usually 400 word pieces – and I’m not at the NYT, so of course, I am envious..

But it’s good for Mexicali – and all the hard-working doctors I’ve met here..  They certainly deserve the exposure!

Hopefully readers who want the real scoop on operating room conditions, doctors , etc.  will still know where to come for in-depth information..

Nurse Practitioners around the world: 27th AANP conference

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I wanted to post some more information and links for people like myself, who are interested in a more global view of the profession.

On Saturday, several speakers discussed the state of advanced practice nursing and the role of the Nurse Practitioner in different countries.  All of the speakers were members of the International Council of Nurses, an organization created to help develop advanced practice nursing roles around the world.

Unfortunately, as is often the case at these conferences – there was no Latin American representation (even though there are several strong doctoral programs and advanced nursing in several Latin American countries – if not the actual NP role, per se.)  But that’s my bias, since I have a strong interest in both my profession and Latin America. (Be careful, Professor, given the opportunity – I just might not leave.. But alas!  No NPs in Mexico yet..)

Of course, none of the European NPs (outside of the UK) were present either, so if you want to be more involved with these nurses you have to attend the ICN or other Region – Specific* conferences.

The actual speakers were interesting and engaging and included speakers from the UK, Singapore, Canada and Australia.  (I was taking notes as fast as I could, so I didn’t manage to get complete titles for everyone, and I apologize).

Singapore

Madrean Schober at the Alice Lee Center for Nursing Studies presented information about nurse practitioners in Singapore.  As the role is quite new, she is a visiting fellow who is helping the National University of Singapore develop and implement this role.

In Singapore, the advanced practice nurse is a legally protected title, meaning that people have to meet rigorous standards to use the title, with penalties enacted for people who appropriate the title wrongfully.  This is similar to the USA but an important distinction that doesn’t apply in many countries.

The title and role of the APN is a hybrid of what we traditionally think of as both the NP and CNS (clinical nurse specialist) roles.

The first training programs were started in 2003 – and now consists of a 24 month program, with over 150 graduates so far.  The majority of graduates function in in-patient (or hospital-based) roles with the majority in intensive care units and mental health facilities.

In contrast to many countries, the push for the development of the APN role wasn’t due to an acute need, it was a deliberate effort to try to retain Singapore nurses and prevent a ‘brain drain’ as nurses from Singapore look for opportunities in other countries.

Advanced Practice Nursing in Singapore

Singapore Nursing Board

* Since the AANP is fairly region specific to the United States.

South Africa

Nelouise Geyer, CEO of the Nursing Education Association talked about the state of nursing in South Africa which is currently undergoing several changes in the classification of different levels of nursing.  There is no formally recognized NP role at present but there are advanced practice nurses such as midwives, clinicians in primary care and wound care specialists.

I found the new proposals for nursing classifications to be somewhat confusing and overly complicated as an outsider, but she was presenting a lot of information in a very short time.

Canada

Christine Buckley from Ontario presented information about Canada.  I find the situation in Canada to be quite encouraging despite having the usual growing pains with licensure requirements being fairly inconsistent across the provinces.  Despite being one of the newest countries to add nurse practitioners to the health care provider team – Canada has come on strong – with over 3400 NPs in just a few short years. (There were only 1129 in 2006).  Nurses in Canada have initiated a very successful (and catchy) slogan to encourage public interest in nurse practitioners, called “It’s about time!”

It’s about time!

Of course, they stress the use of NPs in primary care, but as the use of NPs grows in Canada – hopefully they will start to highlight some of the great things we do in specialty care too..  (They recently recognized a “NP in Anesthesia” role in British Columbia so it’s definitely on the way.)  They have done such an incredible job in just a few years – so kudos to our neighbors up north.  (As a Dalhousie graduate [non-nursing], I am particularly proud.)

Australia

I didn’t get the name of the Australian nurse practitioner (couldn’t write that fast!) but she did an excellent job outlining the history and the current state of the NP in Australia.  In a country of 22.3 million people, there are currently 740 nurse practitioners.  Unfortunately, only 71% (436) of these NPs are able to find work as a nurse practitioner due to a multitude of issues.

However, in the last few years, the NPs in Australia have been able to achieve national registration and well as reimbursement for their services.  (Prior to 2010, patients had to pay out-of-pocket to see an NP.)

United Kingdom

Jenny Ashton talked about the roles of the NPs in the United Kingdom, and explained that due to a lack of formal registration, there is no accurate count of the numbers of NPs currently practicing there.  While there is little consistency across the UK in general, she stated that both Wales, and Scotland have a more formalized process.

While there remain multiple barriers for NPs practicing in the UK, one of the biggest obstacles has already been overcome: NPs in the UK have full prescribing rights – which is something that not even all states in the USA have.

Unfortunately, from her presentation (and this is my interpretation) it sounds like one of their biggest obstacles is the Nursing Council itself which seems uninterested in examining (and resolving) the issues around standardizing educational requirements, formal title protection and registration and other policy issues.  Luckily, it sounds like the medical colleges are more than interested in playing a role in the continued development of APNs.  (Of course, that can be a double-edged sword as well.)

Hopefully, we’ll hear more news about our other nursing colleagues around the world soon – and maybe I’ll be able to attend one of the ICN conferences in the future (and be able to report from there.)

Future of NPs

In my mind, one of the biggest obstacles to the implementation and utilization of the nurse practitioner in other countries is lack of understanding of the role.  In many places, this is due to the perception that NPs can only function in a primary care role.  (This is extremely limiting in countries where there is no shortage or even an overflow of primary care physicians.)  In my [very limited] experience and interactions with surgeons in both the USA and abroad – this obstacle is quickly diminished as surgeons see the utility of having someone trained to handle all the ‘medicine’ aspects of surgical patients, so they can spend more time operating, and not worrying about managing co-morbidities or post-operative care.  This perception has been validated by several of the papers we’ve seen (and talked about before) from Germany, Japan and other nations where the surgeons themselves are trying to import the NP position to their home countries after working with NPs during their fellowships or other training in the United States.

References / Additional Information

The ICN / Nurse Practitioner & Advanced Practice Nurse Network – This organization is for the promotion and support of the development of the APN/ NP role internationally.  The above link takes you to the membership information page.  Membership is free.

The ICN website also contains information on the development of the NP role in other countries (Thailand, for example), a global definition of the NP role, and information about other nursing conferences worldwide. I recommend a look at the FAQ page which explains that the NP role exists (or is in development) in over 70 countries.

This is a link to the definition of the NP role in Spanish for all my friends/ colleagues and everyone else I’ve met who wonders what my job really is (for when my own explanations have them questioning my Spanish language abilities)..

27th AANP conference highlights: Poster Presentation

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As many of my readers here at Cartagena Surgery and my sister sites know – I came to the National Conference to present a poster on “Use of Social Media to Promote Specialty Practice.”

presenting my poster at the 27th AANP conference

The poster is about how the thoracic surgery website brings together thoracic surgery professionals (surgeons, NPs, PAs, Respiratory therapists) from around the world and how it connects patients with credible but easily understandable information.

While I was there – I got the chance to meet some of the other presenters.

Tulay Cakiner-Egilmez, ANP is an ophthalmology nurse practitioner at the Boston Veteran’s Administration.  She was presenting a poster talking about performing eye exams and screening for glaucoma and other eye conditions.   My poster was next to hers, so we were able to talk in-between visitors. She’s been a nurse practitioner for three years, but has worked in the field of ophthalmology for over 25 years so she has a lot of great experience!

Tulay Cakiner-Egilmez, ANP

Debbie Kantor, MSN, ARNP and Lt. Sherrin Whiteman, MA from Hero, Inc. had a great presentation so I wanted to be sure to mention them since they may be a good resource for our readers.   They were talking about “Health Education to Reduce Obesity” and their mobile patient / community health education program.

Sherrin Whiteman, MA and Debbie Kantor, ARNP, MSN of Mobile Hero provide health education to reduce obesity

They run a pretty cool program with a nurse practitioner, a fitness instructor and other health educators who travel around to different communities to provide people with information about fitness, exercise, diet and healthy eating to prevent/ reduce obesity and promote wellness.

Brenda Reed, DNP, FNP-BC, RN presents information of genetic screening and referrals for Ovarian and Breast Cancer

Dr. Brenda Reed, DNP, FNP-BC, RN is an absolutely delightful nurse practitioner who is on the nursing faculty at Texas Christian University (Harris College of Nursing and Health Sciences) presented a wonderful poster on the genetic screening for breast and ovarian cancers.  Not only was the poster visually stunning, but she presented a lot of great information.  I really enjoyed talking to her.  (I’m not sure if they give awards at the end of the conference for ‘best poster presentation’ but my bet is on Dr. Reed.)

I ran into one of my favorite professors from Vanderbilt. Dr. Joan King, PhD, ACNP-BC, RN (almost literally – I was a bit lost in thought at the time).  She was (and is) the director of the acute care nurse practitioner program.  She was lecturing at the conference, and surprisingly, remembered me immediately.  (It’s been more years than I care to admit and the Vanderbilt School of Nursing is a large school so I was very flattered that she recognized me.)

Lastly, I was thrilled to meet Dave Mittman, PA.  He’s the founder of Clinician 1 which is an online website/ community for nurse practitioners and physician assistants.  He’s really down to earth and charming in person, and didn’t seem to mind taking a few moments to talk to me.

with Dave Mittman, PA and founder of Clinician 1

27th AANP conference highlights: International

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Orlando, Florida –

AANP President, Angela Golden addresses a packed house

The new AANP president, Angela Golden was here to cut the ribbon and officially open the conference.

at the ‘Spanish for Nurse Practitioners” course

Away from Mexicali this week for the 27th annual American Academy of Nurse Practitioners (AANP) National Conference.  It’s been a fun couple of days; meeting and talking with nurse practitioners from several different countries and talking about issues in nursing.

The Nurse Practitioner  – International

Wedsnesday, I sat in on an international NP meeting with NPs from Canada, the UK, and New Zealand.  There was also a NP who is working in India, trying to promote advanced practiced nursing.  There are several more sessions on the role and status of NPs in other countries – so I will be updating this section over the next few days.

NPs are pretty new to the scene in all of these countries –

the UK recognized its first fifteen NPs in 1991, and continues to struggle with role recognition and role protection there.  The moderator of the meeting, who is one of the original British NPs explained that there is no restriction or requirements for a nurse to call themselves an NP,  whether they have qualified as an NP or not.

New Zealand first recognized NPs in 2003, and currently boasts 103 formally recognized nurse practitioners.  Currently, New Zealand has no established nurse practitioner specific master’s program or clinically based requirements, so that will be one of their growing pains..

Canada – is the newest of the bunch – but appears to leading the way – with Family nurse practitioners and a new acute care nurse practitioner program.   Unfortunately, much like the United States – each individual province has different licensure requirements (which are time-consuming and expensive).  Unlike the USA, despite a huge need for NPs – there are few jobs available due to the relative lack of private employment opportunities.  (The majority of positions are government-funded.)

(There are NPs in other parts of Europe, but none of their representatives were present.)

Vice President Angelino Garzon undergoes surgery

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Bogotá’s neurosurgeons are certainly staying busy.   Several days ago, the mayor of Bogotá, Gustavo Petro underwent emergency neurosurgery at Fundacion Santa Fe de Bogotá.  Now comes news that the vice-president of Colombia, Angelino Garzon underwent a similar surgery this week for a hematoma at Clinica Reina Sofia.  Details on English language news sites are somewhat sketchy as to his actual medical condition (which sounds like a hemorrhagic stroke), the surgery itself and his prognosis.

VP Garzon, who has a history of cardiovascular disease, underwent emergency heart surgery with Dr. Hernando Santos at Clinica Shaio just two days after he (and President Santos) took office in 2010.

Most recently, he was being treated for a urological condition and it was during follow up medical examinations that his condition was detected.

Update: 23 June 2012

The mayor of Bogota – Gustavo Petro is back at work after successful neurosurgery.

Meanwhile, Vice-president Angelino Grazon remains in guarded, if stable condition after being placed in a medically induced coma while he recovers from a recent stroke and subsequent surgery.

 

Neurosurgery at Santa Fe de Bogota

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Dr. Fernando Hakim Daccach (left), neurosurgery – Santa Fe de Bogota

As you can imagine, millions of pairs of eyes are turned towards Santa Fe de Bogota – and the department of Neurosurgery after the mayor of Bogotá, Gustavo Petro was admitted with a subdural hematoma, and subsequently underwent surgery.

Many people don’t know that Bogotá is actually the home to modern neurosurgery.  Dr. Salomon Hakim, one of the founders of modern neurosurgery and inventor of the Hakim shunt for hydrocephalus called Bogota home.  (Sadly, he died just last year.)

But neurosurgery in Colombia doesn’t begin or end with Dr. Salomon Hakim.  With five neurosurgery residency programs and over 150 practicing neurosurgeons in Bogotá – new innovations and treatments are being developed here everyday.

Many of these fine surgeons practice at Fundacion Santa Fe de Bogota such as Dr. Aristizabal – Chief of the Neurosurgery residency program, or Dr. Carlos Cure, Dr. Enrique Jimenez and Dr. Fernando Hakim .

Others such as Dr. Pedro Penagos or Dr. Juan Fernando Ramon are scattered throughout the city – treating brain cancers at the National Cancer Institute, or caring for the families of policemen at the Hospital de la Policia – and innovating in the field of neuronavigation.

While my heart goes out to the Mayor of Bogotá, and his family – hopefully the international media stories on his health will give some well-deserved attention to these fine (and humble) neurosurgeons.

 

References and additional information: Updated 17 June 2012

Gustavo Petro webpage

According to their website, they anticipate the mayor will be discharged home soon (in a statement dated today, June 17th.)  We are glad to hear he is making such a speedy recovery.

 

Saturday in Mexicali

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After all our serious discussions about TAVI this week, we’ve moved on to some more casual topics.. It’s a sunny, quiet Saturday in Mexicali – so we spent the day enjoying some of what the city has to offer..

First we stopped by the Betty diner for lunch – a Betty Boop themed 50’s diner that we stumbled across the other day.

Betty Diner

Av. Honduras #123

Esq. on Bogotá

Col. Cuauhtemoc Sur

Mexicali, B.C

(near the Plazita)

Open 8am to 9am – closed Mondays..

Betty Boop restaurant

I’m not usually a ‘food poster’ – so I don’t usually post pictures of food – but since we are talking about a restaurant, I’ll break some of (my) rules..  It’s a casual place – with a mix of Mexican and American style food.

with the requisite chips and salsa..

The owner, Francisco Padillo was there – and he was very nice, along with all of the servers.  I made my husband order his meal in his (worse than mine) remedial Spanish.  He also paid in dollars – with no eye rolls and/or  sighs from the staff..

the smiling staff at the Betty diner

All and all – it was a nice lunch.

Since, I was acting like a preadolescent girl, my husband (continued to) indulge me – and we headed over the Hello Kitty store just down the street – in the Plazita..

The Hello Kitty store

(Really – who can resist Hello Kitty!  – she’s just so darn cute!)

After that – we were off to do some of our regular errands..

Readers write in: TAVI

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Thanks again to ‘Lapeyre’, who as it turns out is Dr. Didier Lapeyre, a renowned, French cardiothoracic surgeon credited with the development of the first mechanical valves.

Dr. Didier Lapeyre was gracious enough to send some additional literature to add to our ongoing discussions regarding severe aortic stenosis and TAVI/ TAVR therapies.  He also commented that the best way to avoid these ‘high risk situations’ is by earlier intervention with conventional surgery – something we discussed before in the article entitled, “More patients need surgery.”

He also points out that ‘elderly’ patients actually do quite well with aortic valve replacement and offers a recently published meta-analysis of 48 studies on patients aged 80 or older.

As readers know, on June 13, 2012 – the FDA ruled in favor of expanding the eligibility criteria for this therapy.  Previously, this treatment modality, due to its experimental nature and high rate of complications including stroke and serious bleeding, has been limited in the United States to patients deemed ineligible for aortic valve replacement surgery.

Now on the heels of the Partner A trial, in which researchers reported favorable results for patients receiving the Sapien device, the FDA has voted to approve expanding criteria to include patients deemed to be high risk candidates for surgery.  As we have discussed on previous occasions, this opens the door to the potential for widespread abuse, misapplication of this therapy and potential patient harm.

In the accompanying 114 page article, “Transcatheter aortic valve implantation (TAVI): a health technology assessment update,” Belgian researchers (Mattias, Van Brabandt, Van de Sande & Deviese, 2011) looking at transcatheter valve procedures have found exactly that in their examination of the use of TAVI worldwide.

Most notably, is the evidence of widespread abuse in Germany (page 49 of report), which has become well-known for their early adoption of this technology, and now uses TAVI for an estimated 25 – 40% of valve procedures*.  Closer examination of the practices in this country show poor data reporting with incomplete information in the national registry as well as a reported mortality rate of 7.7%, which is more than double that of conventional surgery.  Unsurprisingly, in Germany, TAVI is reimbursed at double the amount compared to conventional surgery**, providing sufficient incentive for hospitals and cardiologists to use TAVI even in low risk patients. (and yes, german cardiologists are often citing “patient refused surgery” as their reason, particularly when using TAVI on younger, healthy, low risk patients.)

In their examination of the data itself, Mattias et al. (2011) found significant researcher bias within the study design and interpretation of results.  More alarmingly, Mattias found that one of the principle researchers in the Partner A study, Dr. Martin Leon had major financial incentives for reporting successful results.  He had recently received a 6.9 million dollar payment from Edward Lifesciences, the creators of the Sapien valve for purchase of his own transcatheter valve company.   He also received 1.5 million dollar bonus if the Partner A trial reached specific milestones.  This fact alone, in my mind, calls into question the integrity of the entire study.

[Please note that this is just a tiny summary of the exhaustive report.]

Thank you, Dr. Lapeyre for offering your expertise for the benefit of our readers!

* Estimates on the implantation of TAVI in Germany vary widely due to a lack of consistent reporting.

** At the time of the report, TAVI was reimbursed at 36,000 euros (45,500 dollars) versus 17,500 euros (22,000 dollars) for aortic valve replacement.

For more posts on TAVI and aortic stenosis, see our TAVI archive.

References

Mattias, N., Van Brabandt, H., Van de Sande, S. & Deviese, S. (2011).  Transcatheter aortic valve implantation (TAVI): a health technology assessment .  Belgian Health Care Knowledge Centre.

Vasques, F., Messori, A., Lucenteforte, E. & Biancari, F. (2012).  Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies.  Am Heart J 2012; 163: 477-85.

well, we knew this would happen…Edward Lifesciences 2: patients: 0

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As reported by heartwire, and a savvy reader, Lapeyre here at Cartagena Surgery, the FDA has gone ahead and approved TAVI/ TAVR for patients that are eligible for open surgery.  [We must think alike, as I was drafting this post when I received the reader mail].

Despite the FDA’s previously cited concerns over the excessive stroke rate with the Sapien device (as discussed in the article re-posted below) – the FDA approved the use of this therapy as an alternative to surgery on June 13th.

Now we can sit back and watch as the up selling of this device to the public as news hits the US media and the television advertisements begin.  Soon this device will crowd out surgery as interventionalists cite “patient refused surgery” as the criteria for implantation, no matter what the best interest of the patient really is.  I wonder if they will even disclose the heightened stroke rate when they start implanting this into patients at a much higher rate.  Of the 12 members of the FDA panel, only one member voted against the expansion criteria.

As reported by Shelley Wood in a follow-up Heartwire article , only Dr Valluvan Jeevanandam spoke out against expanding the criteria for use, stating,   “I think this is a very good technology, and it gives us an alternative to AVR surgery, and I’m sure the device will continue to get better,” Jeevanandam, a cardiovascular surgeon, told heartwire after the meeting.

“However, at the current time, compared with standard AVR, this device has a higher stroke rate and a high rate of aortic insufficiency, did not meet the criteria for noninferiority* in males, and has a high incidence of vascular complications.”

These are all issues that need to be very clearly explained to patients as part of the informed-consent process, he stressed. Otherwise, patients who are “enamored at the idea of avoiding a sternotomy” may not fully understand these risks.”  

I fully concur with Dr. Valluvan Jeevanandam except that I might re-phase the term ‘enamored of.’  Actually, I think our so-called peers need to quit coercing patients by intentionally scaring them – in order to bill more procedures out of them.  [Don’t believe it?  Then check out Mark Midei and our overstenting archives.]

I will continue to champion well-established therapies with strong long term data.  I know this will get me labeled as ‘old-fashioned’ (or worse) but as we’ve seen in cardiology – numerous times; easy is not always the best answer..

The is no easy button

Yes, conventional surgery hurts – it’s not glamorous, it’s not pretty.  But it’s (statistically) darn safe these days, and most of the surgeons doing it have done it thousands of times.. Even the bioprosthetic valves have a long durability than previously thought – meaning not everyone has to take warfarin..

We shouldn’t exploit people’s fears of surgery to use quasi-experimental procedures, no matter how “cool” they sound..

* I hope readers remember that ‘noninferiority’ is a lesser standard that superior to, or even EQUAL to..

FDA flags strokes, trial conduct, as TAVI maker seeks expanded role for Sapien – from Heartwire.com (Shelley Wood).

Gaithersburg, MD – A higher risk of stroke and differences in how patients randomized to different procedures were actually treated and evaluated within the PARTNER A trial, which compared transcatheter aortic-valve implantation (TAVI) with surgery, are issues the US Food and Drug Administration (FDA) hopes its expert advisors can help clarify in weighing the pros and cons of expanding approval of the Sapien transcatheter valve (Edwards Lifesciences) [1,2]. Those issues and others are detailed in an FDA briefing document, posted online today, that the agency’s Circulatory System Devices Panel will consider in advance of Wednesday’s meeting.

As previously reported by heartwire, the FDA last year reviewed and subsequently approved the Sapien valve and transfemoral delivery system in patients not suited to open-valve replacement, based primarily on the PARTNER B results. Wednesday’s meeting, drawing heavily on the  PARTNER A results, will help the FDA decide whether to expand approval to high-risk patients who are surgery eligible and whether to approve the transapical approach also tested in PARTNER A.

In briefing documents posted online today, the FDA directed its advisors to pay special attention to a number of issues relating to trial conduct as well as patient outcomes.

In particular, the FDA review cites the “doubling” of neurological events seen in the Sapien-treated patients in the first 30 days postprocedure, with a higher stroke rate seen among transapical as compared with the transfemoral group.

The FDA documents also query “attempt-to-treat” decisions, including the higher number of patients randomized to surgery in whom no treatment was attempted; longer delays to treatment in surgical patients; and the higher number of concomitant operations seen in the surgical aortic-valve-replacement group—all factors that could have influenced adverse-event and survival rates in this group.

FDA is also asking its expert panel to weigh in on whether both the transfemoral and transapical approaches should be approved, given the numerically higher mortality in the transapically treated patients as compared with the transfemorally treated patients in the device arm.

General questions the FDA panel will be answering Wednesday include those related to the issues above, as well as to different outcomes seen in men and women, the importance of paravalvular regurgitation seen in patients treated with TAVI, valve durability, the required anticoagulation/antiplatelet regimen, and obtaining true informed consent.

Voting questions center on whether the evidence is sufficient to demonstrate safety and efficacy and whether the benefits of the new device outweigh the risks.

Industry analysts reading the tea leaves in the FDA’s review see the agency’s briefing document as largely promising, with Wells Fargo’s Larry Biegelsen predicting a “tough day, but positive panel outcome” and JP Morgan’s Michael Weinstein stating that the FDA synopsis contained “no major surprises; positive outcome expected.”

In other cardiology news, 

New guidelines recommend the discontinuation of prasugrel a full seven days before surgery to prevent catastrophic bleeding complications. (The cynical side of me expects to see a bigger push by the industry to use prasugrel now that clopidogrel is generic.)  Expect to see a couple more “Ask your doctor” ads..

Overseas Radio Follow-up

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As a follow-up for all the overseasradio.com radio listeners (and all my loyal readers) I have posted some additional information on the topics covered during the radio program with Ilene Little from Traveling for Health.com including contact information for several of the physicians mentioned.

in the Operating Room at New Bocagrande Hospital

Thoracic Surgery

Esophageal cancer – during the segment we highlighted the importance of seeking surgical treatment for esophageal cancer at a high-volume center.  One of the centers we mentioned was the University of Pennsylvania Medical Center in Pittsburgh, PA – and the work of Dr. Benny Weksler, MD.

Dr. Benny Weksler*, MD

Hillman Cancer Center

5115 Centre Avenue

Pittsburgh, PA 15232

Phone: (412) 648-6271

He is an Associate Professor in Cardiothoracic Surgery and Chief of Thoracic Surgery at UPMC and the UPMC Cancer Center.  (For more information on Dr. Weksler, esophageal cancer, and issues in thoracic surgery – see my sister site, Cirugia de Torax.org)

(To schedule an appointment via UPMC on-line click here).

We also briefly mentioned Dr. Daniela Molena*, MD at John Hopkins in Baltimore, Maryland.

The Johns Hopkins Hospital

600 N. Wolfe Street

Baltimore, MD 21287

Phone: 410-614-3891

Appointment Phone: 410-933-1233

(The link above will take readers to the John Hopkins site where they can also make an appointment.)

* I would like to note that I have not observed either of these physicians (Weksler or Molena) in the operating room.

We also talked about several of the thoracic surgeons that I have interviewed and observed numerous times, including both Dr. Rafael Beltran, MD & Dr. Ricardo Buitrago, MD at the National Cancer Institute in Bogotá, Colombia.  These guys are doing some pretty amazing work, on a daily basis – including surgery and research on the treatment of some very aggressive cancers.

in the operating room with Dr. Rafael Beltran

Dr. Rafael Beltran is the Director of the Thoracic Surgery division, and has published several papers on tracheal surgery.   He’s an amazing surgeon, but primarily speaks Spanish, but his colleague Dr. Buitrago (equally excellent) is fully fluent in English.

Now the National Institute website is in Spanish, but Dr. Buitrago is happy to help, and both he and Dr. Beltran welcome overseas patients.

Dr. Buitrago recently introduced RATS (robot assisted thoracic surgery) to the city of Bogotá.

Now, I’ve written about these two surgeons several times (including two books) after spending a lot of time with both of them during the months I lived and researched surgery in Bogotá, so I have included some links here to the on-line journal I kept while researching the Bogotá book.  It’s not as precise, detailed or as lengthy as the book content (more like a diary of my schedule while working on the book), but I thought readers might enjoy it.

In the Operating Room with Dr. Beltran

There are a lot of other great surgeons on the Bogotá website, and in the Bogotá book – even if they didn’t get mentioned on the show, so take a look around, if you are interested.

in the operating room with Dr. Ricardo Buitrago

Contact information:

Dr. Ricardo Buitrago, MD 

Email: buitago77us@yahoo.com

please put “medical tourist” or “overseas patient for thoracic surgery” in the subject line.

We talked about Dr. Carlos Ochoa, MD – the thoracic surgeon I am currently studying with here in Mexicali, MX.  I’ve posted all sorts of interviews and stories about working with him – here at Cartagena Surgery under the “Mexicali tab” and over at Cirugia de Torax.org as well.  (Full disclosure – I assisted Dr. Ochoa in writing some of the English content of his site.)

out from behind the camera with Dr. Ayala (left) and Dr. Carlos Ochoa

He is easily reached – either through the website, www.drcarlosochoa.com or by email at drcarlosochoa@yahoo.com.mx

HIPEC / Treatment for Advanced Abdominal Cancers

I don’t think I even got to mention Dr. Fernando Arias’ name on the program, but we did talk about HIPEC or intra-operative chemotherapy, so I have posted some links to give everyone a little more information about both.

HIPEC archives at Bogotá Surgery.org – listing of articles about HIPEC, and Dr. Arias.  (I recommend starting from oldest to most recent.)

Dr. Fernando Arias

Oncologic Surgeon at the Fundacion Santa Fe de Bogotá in Bogotá, Colombia.  You can either email him directly at farias00@hotmail.com or contact the International Patient Center at the hospital.  (The international patient center will help you arrange all of your appointments, travel, etc.)

Fundacion Santa Fe de Bogota

   www.fsfb.org.co

Ms. Ana Maria Gonzalez Rojas, RN

Chief of the International Services Department

Calle 119 No 7- 75

Bogota, Colombia

Tele: 603 0303 ext. 5895

ana.gonzalez@fsfb.org.co  or info@fsfb.org.co

Now – one thing I would like to caution people is that email communications are treated very differently in Mexico and Colombia, meaning that you may not get a response for a day or two.  (They treat it more like we treat regular postal mail.  If something is really important, people tend to use the phone/ text.)

Of course, I should probably include a link to the books over on Amazon.com – and remind readers that while the Mexicali ‘mini-book’ isn’t finished yet – when it is – I’ll have it available on-line for free pdf downloads.

Spending the weekend with Dr. Vasquez, and medical photography

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For internet searches for medical photography – all of my images are free for your use, but please give proper credit for my work, ie. “Photo by K. Eckland”.  For commercial uses, contact me, (so that I can contact the subjects of my work).

Please note that patient privacy is protected – and patient permission is obtained prior to photographs.  For the most part – I photograph surgeons – not patients, or surgery.

Spent much of the weekend in the operating room with Dr. C. Vasquez, cardiac surgeon at two different facilities, and the differences couldn’t be more apparent – and perhaps not what one might expect.  Much of it comes from perspective; as a person behind the lens, I see the scene differently than others might.

harvesting the radial artery

In fact, this prompted me to write an article on the subject of medical photography, complete with a slide show to illustrate the effects of color on surgical photographs. I’ve also re-posted much of the article here (see below).  Once you see the photos from today, you’ll understand the article.

the beige operating room

The case today went beautifully, with the patient extubated in the operating room.

Dr. Vasquez, and Lupita, scrub nurse

While we were there – had an unexpected surprise! Dr. Gutierrez ‘Lalo’ showed up.  I have been trying to get him into the cardiac OR since he confessed his interest in cardiac surgery.  It was great to see him – and I like encouraging him in his educational goals.   (I kind of miss being a mentor, and preceptor to students..)

Lalo peeks over the curtain..

Dr. Gutierrez (Lalo) in the cardiac OR

Medical Photography

Medical photography is many ways is more art, and luck that skill – at least for people like me who never set out to be medical photographers in the first place.  It was a natural development prompted by dire necessity during the early days of interviewing surgeons and medical writing.  I am still learning, and hopefully improving.

But as I said before, much of it is luck, and timing, particularly in this field, where the subjects are always in motion and a slight movement of the hand tying the suture knot can result in either a breath-taking shot or an utter failure to capture the moment.

The most dramatic and vivid photographs often come at mundane moments, or unexpected situations.  In medical photography, where the subject matter combines with a dramatic interplay of color, light and shadow to illustrate some of life’s most pivotal moments such as birth, death and life-saving operations – it is surprising how important the background elements are.

Here in Mexicali, I have been taking photographs of different surgeons for several weeks at different facilities across the city.  But, almost unanimously, all of the photographs, regardless of subject at Hospital Almater are lackluster and uninspiring.  Contrast this with the glorious photos from the public facilities such as Hospital General de Mexicali, and Issstecali.

The culprit is immediately apparent, and it demonstrates how such carefully planned such as aesthetics and interior design can have unintended consequences.  The very studied, casual beigeness used to communicate upscale living in the more public parts of the hospital are destroying the esthetics of the operating room services they are selling.  Whereas, the older facilities, which have continued the use of traditional colored drapes and materials do not have the problem.

Historically, surgical drapes were green for a very specific reason.  As the complementary color to red, it was believed to be a method of combating eye fatigue for surgeons looking at the red, bloody surgical fields for hours at a time.  Over the years, operating room apparel and drapes evolved away from this soft green to a more vivid blue, know as ‘ceil’.  The reasons for this change are probably more related to manufacturing that medicine, and since that evolution, surgical drapes now come in a variety of colors – hence the color matching here, of the paint, the tile, the patients, the operating room and the surgeons itself.  Somewhere, an interior decorator is filled with gleeful satisfaction – but I can only muster up a groan; knowing I will be here again and that most of my photos will be unusable.

While the consequences of poor medical photographs may seem trivial to anyone but myself (and my interviewees) at this junction – it runs far deeper than that.  With the advent of the internet, and the complicated legalities of getty and other corporate images, small, independent photographers such as myself are gaining wider exposure than ever before.   Alas! – much of it is uncredited, but several of my more popular images are downloaded thousands of times per week, to grace slideshows, powerpoint presentations and other illustrations for discussions of anything from medicine and surgery to travel, technology and even risk assessment.  In an era of branding, and logo recognition, places like Hospital Almater are certainly missing out.

In  other news/ happenings: Upcoming elections!**

Finally found someone to talk to and explain some of the issues in Mexican politics – but he hates Quadri, and doesn’t really explain any of it except to say ‘He’s corrupt..”  (From my understanding, ‘corrupt’ is an understatement, and that all of the parties are corrupt – and it’s pretty well understood by everyone involved – so of course, if I hear something like that – please explain.. explain..)  It’s not like I am capable of voting anyway, but I’d sure like to hear perspectives..

It looks like I’m not the only one who is a little leary of pretty boy pena’s party’s dubious history.  His numbers have fallen in recent polls in advance of tonight’s televised debates.  (Let’s hope these debates are better than the last.)

My personal “favorite”, Quadri is still trailing in the dust, but it looks like Lopez has a chance to take the election from Pena (much like it was ‘taken’ from him in 2006 with his narrow defeat..  Lopez is a socialist which is hard for Americans like me to understand – but then again, it’s not my country, and the levels of inequity here are certainly wider than at home – so maybe someone like Lopez can bring some much needed support to the lower classes.

I mean, a lot of what we take for granted in the USA doesn’t exist here, like a decent free public school education.   (Okay – I know critics will argue about the value of an inner city education – but we still provide a free elementary & secondary school education to all our citizens.)  So socialism for the purpose of providing basic services in all areas of Mexico seems pretty reasonable.  (It would help if I could read some primary source stuff – without using translation software, so I would have a better idea of the specifics of AMLO’s ideas.)

I did ask my friend about the student demonstrations for Yo Soy 132.  I guess as an American growing up after the 1960’s – we tend to not too make much of a big deal over student demonstrators – after all – we have the ‘Occupy’ movements going on right now in our own/ other countries – but he was telling me that this is pretty uncommon in Mexico.

** No, I’m not really into politics but I feel like it’s important to try and understand as much as possible about the places (countries) where I am residing.

This week in Mexicali Surgery

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No – I haven’t changed the name of the blog, just reflecting the nature of my current assignment.  Spending some time in Interventional Cardiology this week as part of a story I am writing about chest pain emergencies for Mexico on my mind.com.  Today, I checked out the cath lab at Hispano Americano Hospital.  It’s a bit crowded, but all the equipment is brand-spanking new, and practically sparkling.  (Don’t worry – I have photos to prove it!)

Nurses in the cath lab at Hospital Hispano Americano

Dr. Fernando Monge was kind of enough to give me a guided tour.  While we were there he (assisted by Dr. Raul Aguilera) placed a stent in a patient with recurrent angina.  A doctor from the ER also stopped by to have him review a couple EKGs..  I’ll post a link when the full story is done.

Also stopped in to talk to Dr. Jose Antonio Olivares Felix, MD, a general surgeon who reports to me that he is doing single port laparoscopy – so of course, that got me interested.  Hoping to set a date to go to the operating room.

I’ll be spending all of tomorrow in the company of Dr. Marnes Molina, MD to learn more about some of the other stuff he’s doing in urology (and hopefully grab a picture of that green laser!)

Dr. Gabriel Ramos, Oncology Surgeon

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Dr. Gabriel Ramos, Oncologic Surgeon

Been a busy week  – (Yea!) but now that it is the weekend, I have a chance to post some more pictures and talk about my day in the operating room with Dr. Gabriel Omar Ramos Orozco. 

Despite living in a neighboring apartment, interviewing Dr. Ramos proved to be more difficult than anticipated.  But after several weeks, I was able to catch up with the busy surgeon.

Outside of the operating room, he is a brash, young surgeon with an off-beat charm and quirky sense of humor.  But inside the operating room, as he removes a large tumor with several cancerous implants, Dr. Gabriel Ramos Orozco is all business.

It’s different for me, as the interviewer to have this perspective.  As much as I enjoy him as a friendly neighbor – it’s the serious surgeon that I prefer.  It’s a side of him that is unexpected, and what finally wins me over.

Originally from San Luis Rio Colorado in the neighboring state of Sonora, Dr. Ramos now calls Mexicali home.  Like most surgeons here, he has a staff position at a public hospital separate from his private practice.  It is here at IMSS (Instituto Mexicano del Seguro Social) where Dr. Ramos operates on several patients during part of the extended interview.

Operating room nurses at IMSS

During the cases, the patients received a combination of epidural analgesia and conscious sedation.  While the anesthesiologist was not particularly involved or attentive to the patients during the cases, there was no intra-operative hypotension/ alterations in hemodynamic status or prolonged hypoxia.

Dr. Ramos reviewed patient films and medical charts prior to the procedures.  Patients were prepped, positioned and draped appropriately.  Surgical sterility was maintained during the cases.  The first case is a fairly straight forward laparoscopic case – and everything proceeds rapidly, in an uncomplicated fashion.  45 minutes later, and the procedure is over – and Dr. Ramos is typing his operative note.

Dr. Gabriel Ramos in the operating room

But the second case is not – and Dr. Ramos knows it going in..

The case is an extensive tumor resection, where Dr. Ramos painstakingly removes several areas of implants (or tumor tissue that has spread throughout the abdomen, separate from the original tumor).

The difference between being able to surgical remove all of the sites and being unable to remove all of the gross disease is the difference between a possible surgical ‘cure’ and a ‘de-bulking’ procedure, Dr. Ramos explains.  As always, when entering these surgeries, Dr. Ramos and his team do everything possible to go for surgical eradication of disease.  The patient will still need adjunctive therapy (chemotherapy) to treat any microscopic cancer cells, but the prognosis is better than in cases where gross disease is left behind*.  During this surgery, after extended exploration – it looks like Dr. Ramos was able to get everything.

“It’s not pretty,” he admits, “but in these types of cases, aesthetics are the last priority,” [behind removing all the tumor].  Despite that – the aesthetics after this large surgery are not as worrisome as one might have imagined.

The patient will have a large abdominal scar – but nothing that differs from most surgical scars in the pre-laparoscopy era.  [I admit I may be jaded in this respect after seeing so many surgeries] – It is several inches long, but there are no obvious defects, the scar is straight and neatly aligned at the conclusion of the case – and the umbilicus “belly-button” was spared.

after the successful removal of a large tumor

As I walk out of the hospital into the 95 degree heat at 11 o’clock at night – I admit surprise and revise my opinion of Dr. Ramos – he is better than I expected, (he is more than just the kid next door), and he deserves credit for such.

*This may happen due to the location of metastatic lesions – not all lesions are surgically removable.  (Tumor tissue may attach to major blood vessels such as the abdominal aorta, or other tissue that cannot be removed without seriously compromising the patient.)  In those cases, surgeons try to remove as much disease as possible – called ‘de-bulking’ knowing that they will have to leave tumor behind.

Dr. Ramos, HIPEC and Radio Broadcasts

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Finally caught up with the busy Dr. Gabriel Ramos, MD, oncologic surgeon and spent several hours with him in the operating room at IMSS (the social security hospital) for a couple of cases on Wednesday..  I’ll be writing more about him soon.

Dr. Gabriel Ramos, Oncologic Surgeon

Yesterday was a full day with clinics here and San Luis.  Also – more homework, so I have to get some studying in before heading back in this afternoon.

On the radio with Cartagena Surgery:

Recorded my very first radio interview with Ilene Little at Traveling 4 Health..  I hope I don’t sound too bad (when I get nervous, I laugh..)  It’s not a pre-determined format, so I didn’t know the questions until she asked them – which makes it more interesting, but I sound less polished as I search my brain for names, dates, places etc.  Trying to remember the name of the researchers who published a paper in 1998, 2008, or 1978 is daunting when you worry about ‘dead air’.. I was so nervous I was even forgetting my abbreviations.  I hope it comes across better to listeners.

We talked about the books, what I do (and how I am surviving on savings to do it).  We also talked about some of the great doctors I’ve interviewed, treatments such as HIPEC as well as some of the quackery and false hope being peddled by people with a lot to gain.. I kind of wish HIPEC and quackery weren’t in the same segment.  Since it was off the cuff – I didn’t have all of my medical references and literature to talk about to distinguish the two (so if you are here looking for information on HIPEC – search around the site – I have links to on-going studies, and research going back over a decade, both here at BogotaSurgery.org .  Of course, the crucial difference between the two is:

HIPEC is a new treatment, but there is NO assurance of success – in fact, some patients die from the treatment itself.

– There is a body of scientific literature on HIPEC for advanced abdominal cancers (ovarian, uterine, etc)

Quakery or pseudo-science can be a bit trickery.  Maybe they take an existing or  promising treatment (like therapies for stroke, Parkinson’s etc.) and apply it to something else – like treatment of serious cancers.  (Yes – people will find papers written about the ‘treatment’, but these papers may not meet scientific rigor, or may not be about the condition or treatment that they are receiving.)  They also promise miracles and cures.

In medicine, even the very best doctors and surgeons can’t promise these things – because medicine itself isn’t an exact science, and different people respond to the same treatments differently – ie. one patient may have complications and another patient doesn’t.

Lastly  – we just touched on it – but I think it’s an important concept – is patient self-determination.  That no matter what I, or anyone writes, does or says – people always have the right to determine their own medical treatment.

The health benefits of a Sunday in Bogota

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A very nice article in BBC latin america talking about the health benefits of those great Sundays in Bogotá that I previously mentioned..  All that family togetherness, along with the street closures for pedestrians, and bicyclists equals a healthier, fitter city..

During my time in Bogotá, I found that the city lifestyle (close compact streets), along with the mild climate made it very easy to exercise and to replace driving/ taking a taxi/ bus with walking for all but the most lengthy journeys.  At one point, I was actually clocking in around eight to ten miles a day as I transversed the city..

It’s a whole different story at my current location (Mexico) where temperatures have been upwards of 40 degrees centigrade (100 degrees) already since early April – and are only projected to get hotter  (50 centigrade in July)..   It’s already hot by 7am and the heat is a living breathing wave that rises up from the pavement to meet you.  It involves a lot of advanced planning, and preparation to get any sort of real exercise here..

Introducing Trish Hutton, CRNFA

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Today we are talking to one of my colleagues – Ms. Trisha Hutton.

Ms. Trisha Hutton, CRNFA

Ms. Trisha Hutton, CRNFA, ACNP (student)

Trisha is a certified registered nurse first assistant (CRNFA) .   She performs procedures in the operating room such as endovascular saphenous vein harvesting (EVH) for bypass surgery, and assists in other aspects of surgery, such as suturing, retraction and tissue dissection.

  Years in the operating room:   16

  Years working in cardiac surgery:  8

We’re talking to Ms. Hutton today about her current career and her developing role as an acute care nurse practitioner in cardiothoracic surgery.   Ms. Hutton is currently pursuing her master’s degree for certification in acute care, and will be part of a small but growing sub-specialty of acute care nurse practitioners in surgical practices.

As we’ve discussed during past posts; in the midst of a primary care crisis, advanced practice nurses such as nurse practitioners have moved to the forefront of the health care arena.  While NPs have worked (successfully) in this role since the creation of the specialty in the late 1960’s – the efforts of NPs in this (and other) roles are just now being recognized.

However, for nurses like Trisha Hutton, the increasing recognition (by surgeons) of the utility of nurse practitioners IN and OUT of the operating room is equally important.  So it’s important that nurses like Ms. Hutton receive the exposure to the public that may not always be aware of their role behind the scenes in caring for patients undergoing surgery.

What prompted you to return to school to become a nurse practitioner?

 “I felt like something was missing.  It was like chapters were missing from a book,” Ms. Hutton states, explaining that while she loves her current role, assisting and caring for patients in surgery – she wants to expand her role to encompass the care of patients outside of the operating room; from admission to discharge.

Ms. Hutton (pictured on the right) in the operating room

What drew you to cardiothoracic surgery, specifically?

I have always been interested in vascular surgery, and had been trained by and a vascular surgeon (Dr. Mark Donnelly) who I have worked closely with for many years.  When Flagstaff Medical Center started talking about beginning a heart program, I was immediately interested, and Donnelly encouraged me to be involved in it.  Also, because of our elevation (7000 ft), there was controversy about the success of our program, and that challenge excited me.

How do you see your role evolving after graduation?

To have the ability to continue my care to patients outside of the operating room.  I am looking forward to the opportunity to meet patients pre-operatively, participate in their diagnosis, operate on them, then continue their care through discharge.

Where do you see yourself in five years?

I hope to continue practicing within the CT and vascular specialty, and be comfortable within my expanded role.

Who are your role models?

I began as nurse in the operating room 16 years ago, and was instantly attracted to the vascular specialty.  I developed a relationship with a surgeon named Mark Donnelly, a very respected and talented General/Vascular surgeon.  When I decided to become a RNFA, he supported me, acted as my preceptor, and taught me how to operate.  As mentioned earlier, when word of a heart program started, he encouraged me to join the heart team.  That was a bitter-sweet decision for me….learning CT surgery has been a fantastic choice for me and has opened many doors, but it meant leaving a surgeon that I truly enjoyed operating and spending my day with.  He has been such an important role model for me and “life” coach (advice ranging from career to parenting!!), and I still miss working with him. More recently, our current heart surgeon Dr. Steve Peterson has been an important role model to me.  I joined cardiac surgery with good assisting skills, but he has pushed and challenged me even more.  He continues to test me daily, teaching me the finesse of cardiac surgery.  Without him I would not be  successful within this specialty, and I would never have considered continuing my education.  He has given me endless opportunities, pushed me to grow, and I am very grateful for him.

How do you see the nurse practitioner role in comparison to other peri-operative roles?  Do you think NPs provide any unique perspectives or contributions to surgical care?

NP’s absolutely offer unique contributions to surgical care!  Especially if they have had perioperative experience prior to becoming an advanced practice nurse.  I believe continuity of care is an important factor in delivering high quality care to our patients, and if the NP can follow her patient into the operating room, that continuity of care can be achieved.  They see and experience first hand what occurs during surgery, which can aid in their post op management.

For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the NP will know that post op blood pressure management will be even  more critical. If a different practitioner had been operating, that concern may not be communicated adequately.  The surgeon who practices with a NP First Assistant can feel at ease knowing that both HIS needs and the patients’ needs will be met.  The NP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient (ie family practice MD or TechFA) cannot offer that unique service.

Nurse Practitioners in the operating room?  Current issues and controversies

While this seems like a natural and normal progression for many nurses and nurse practitioners within the field – it isn’t as obvious to people outside the profession.  Many people including human resources personnel, staffing companies and the surgeons themselves have pre-conceived notions that exclude nurse practitioners, even those with extensive operating room (peri-operative) experience from assisting in the operating room.  That role is often exclusively assigned to Physician Assistants, often to the detriment of our profession, our nursing colleagues and the patients.

In fact, in this recent statement and study on the role of surgical assistants (2011) only mentions nurses as assistants as a side note.  It fails to recognize the different levels of qualifications (ie. a certified registered nurse first assistant (RNFA) versus a surgical technician (with weeks to months of formalized training).

Now, with the adverse economy, and changes in medicare regulations, nurse practitioners face even more competition for the operating room; the disenfranchised primary care physician.  In several of the facilities where I have worked in the past; more and more of these physicians were taking an active role in assisting in surgery.  These doctors, often primary care doctors ‘moonlight’ in the operating room as a way to augment their salaries.  Conversely, while these physicians had the least amount of surgical training, they were afforded the most reimbursement for their intra-operative role.    This array of peri-operative assistants has led to a wide range of skill sets in this patient care role with little research or comparison of effectiveness of these positions.

Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both nurse practitioners and physician assistants.  But only nurse practitioners can bring a holistic, patient-centered approach to this

* The ‘surgical assistant’ title like surgical technician/ technologist has also been designated to another career entirely, with similar focus.  However, in this post, we are using the term generically to refer to any individual (NP, RNFA, PA , MD or technician) who acts as an assistant to the surgeon intra-operatively, and performs procedures under the supervision of the attending surgeon.

References/  Literature surrounding nurse practitioners in the Operating Room

Hodson D. M. (1998).  The evolving role of advanced practice nurses in surgery.  AORN J. 1998 May;67(5):998-1009. Erratum in: AORN J 1998 Jun;67(6):1102

Pear, S. M., & Williamson, T. H. (2009).  The RN first assistant: An expert resource for surgical site infection prevention.  AORN, 89(6); 1093 – 1097.  No free full text available.
Schroeder JL. (2008).  Acute care nurse practitioner: an advanced practice role for RN first assistants.  AORN J. 2008 Jun;87(6):1205-15.
Wadas T. M. (2008).  Expanding the scope of acute care nurse practitioners with a registered nurse first assist specialty.  AACN Adv Crit Care. 2008 Jul-Sep;19(3):261-3.

Wadlund D. L.  (2001).  Graduate education: the perioperative nurse practitioner.  Semin Perioper Nurs. 2001 Apr;10(2):77-9

Zarnitz P, Malone E.  (2006).    Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training.  Mil Med. 2006 Sep;171(9):875-8.   No free full text available.
More about the Registered Nurse First Assistant (RNFA) role from the Association of peri-Operative Nurses (AORN).

Mexico on my mind….and the city by the fence

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Actually, it is on my mind quite a bit these days, as you can imagine.  But that’s also the title of the new website where I will be contributing to articles about life, and health care in Mexicali.  It’s a website designed for Americans and other extranjeros living in Mexico, so I thought it was the perfect place for some of my articles on medical emergencies and medical services.

I think that if you are an ex-pat living in a different country/ culture/ etc. even if you’ve been here for a while – if you become ill, it’s a little more frightening and confusing than it might be in your old hometown.  So, hopefully the addition of a fellow gringa to help navigate the system, so to speak, is more comforting and helpful to readers..

Of course, many of the readers of the site are living in different areas of the country, so this is also a chance for me to speak up and promote Mexicali – and after being here for a couple of months – I really think that Mexicali is often judged harshly.

Sure, I don’t want it to become the next Cabo San Lucas – where Spanish is drowned out by drunken teenagers hollering, puking and carrying on in English, and Mexican culture has been submerged beneath a sea of tacky shops, Starbucks, and the homogenous effect of chain restaurants and fast food.  But I also think that when people skip over Mexicali, they are missing a chance to see an interesting side of Mexico – a side that is often downplayed to tourists unless you are heading to Mexico City.

But first – let’s be sure to say what Mexicali isn’t.  It isn’t a quaint seaside resort, or charming village.  It also isn’t a crime-infested border city, as we’ve talked about before.

If you are looking for cute, charming and rural – this isn’t the place for you.

But that’s not to say that Mexicali is without its own considerable charms.  It is first and foremost – a city of industry.  While this contributes to wide areas of industrial blight (factories and their by-products aren’t particularly attractive) – it also means that there is a significant sector of skilled labor and a higher overall standard of living.  Some of this industry is medical, but much of it is more traditional – factories and companies who came here to take advantage of NAFTA.  Frito-Lay is here, Modelo brewing is here, as well as several juice distributors and machineries.  But there is also Intuitive Surgical – the makers of the DaVinci Robot, a two million dollar piece of extremely sophisticated medical technology.

street art in Mexicali

It is also the capital of Baja California, so there is a large contingent of government offices here too,  along with the Universities and educational facilities of higher learning.

But most importantly, it is a city of people.  These people are the true heart of ‘Mexican culture’, in a very real sense.  I am fortunate that as a student, in my daily activities – I get to encounter these people on a day-to-day basis – and the people of Mexicali have proven to be as friendly and welcoming as any city I’ve ever lived.  Despite the close proximity to the border, this is the real Mexico – and it hasn’t been diluted.  Spanish remains predominant, and real working class citizens populate the streets and buildings as opposed to the more touristy destinations where everything has been ‘Americanized’ for our comfort.

Want to learn Spanish?  Then come here.  You will get to practice every day.  People will help you, correct your grammar, offer you the occasional missing word – and they do it with patience and a smile, but they will expect you to speak Spanish all the same.

The charm is here – on the quiet, upscale streets in the different barrios of the city, in the music emanating from well-kept homes, in the kitchens of mom and pop restaurants serving native dishes, and in the way that residents still welcome outsiders like myself.

They have pride in their city, their way of life and take pains to encourage me to sample it – pieces of their culture, whether as part of traditional festivities for a national holiday, or a bite of food from a street vendor or even just directions to the best [blank] in town.

an art museum in Mexicali

It also has its own identity, distinct from larger Mexico.  Some of this comes from dealing with the heat – 120 degree days in the summer are not uncommon – on these dry, sun-baked and parched streets.. Some of it comes from the unique make-up of this city – which boasts a shared heritage with a large Chinese community who fled the states after building the railroads.  So, yeah – they probably have the best Chinese food in Mexico too.

So hopefully, as I write about the doctors, and hospitals of Mexicali, visitors to the city will see the other charms that make me appreciate this place a little more every day.

The dangers of Medical Tourism

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A new press release from a law office in the United States – highlights the importance of what I do – and why I think it is a necessary and essential endeavor.  The author, James Goldberg has also written a book about the potential dangers of medical tourism due to a lack of regulation among brokers who are just looking for the cheapest providers (for higher profit margins).  As we all know – that’s not the right way to chose a surgeon (and it’s not fair to consumers who trust brokers to deliver high quality care.)

I just ordered it – so I’ll give a full ‘book report’ once it arrives.

Unfortunately, the more I continue on in my efforts to provide unbiased and object reviews, the more I become disheartened by the lack of interest on the part of the medical tourism industry itself.  For the most part, these travel agencies are just that – and hold themselves to no higher ethical or moral standards that the travel agencies of old – except now we are talking about more than missed flights or less than stellar hotel rooms.

The response from the surgeons themselves has been (for the most part) enthusiastic about being reviewed, but until consumers hold the vendors of these services to a higher standard – it will never happen on any sort of global scale.

For the time being – it looks like it’s just me – and my dwindling retirement fund.

In the operating room with Dr. Victor Ramirez, MD, plastic surgeon

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Frankly, I wasn’t sure what to expect when I returned to see Dr. Victor Ramirez.  I had enjoyed talking to him during the first interview back in November of 2011, but as most people know – a lot had happened since then.  It took me a couple of weeks to re-connect with the now somewhat wary and (media-weary) surgeon, but when I did – he didn’t hesitate to invite me to the operating room.  And then – after the first case, he immediately invited me back**.

Dr. Victor Ramirez, plastic surgeon

For readers unfamiliar with the concept of my work – let me tell you, this is usually an excellent prognostic indicator.  It’s certainly not fail-proof – but as a general rule; when a surgeon invites you to his operating room, he is generally confident because he is a good surgeon. 

You’ll notice a couple of things about the statement above – when the surgeon invites me, is important.  Often when I have to ask – it’s because the surgeons are hesitant to let me watch.  Most (but not all of the time) – there is a good reason that a surgeon doesn’t want an observer in their operating room.  (And there are a multitude of reasons – not just a poorly skilled surgeon.)

But there are certainly no absolutes.  I have met fantastic surgeons who initially were not crazy about the idea (but quickly warmed up to it) and I have met less than skilled surgeons who happily encouraged me to visit – and everything in-between.. I’ve visited great surgeons who were hampered by poor facilities, unskilled staff, or limited resources.  That’s why the on-site, operating room visit is so important.  Anything less, is well – less than the full picture.

But back to Dr. Victor Ramirez – in the quirofano (operating room) performing surgery.

Dr. Victor Ramirez, Dr. Perez and Ricardo (RN)

I observed Dr. Ramirez operating at two different facilities – Hospital Quirurgico del Valle, and the Bellus clinic.  Hospital Quirurogico is a private hospital – with excellent operating room facilities.  While there are only two operating rooms, both rooms are large, well-lit, new, and very well equipped.  There are three separate ‘big screen’ tv sized monitors for video-assisted procedures – so if you are looking for a facility for video-assisted procedures such as endoscopy, laparoscopy or thoracoscopy – this is the place.  All the equipment was modern, in new or ‘near-new’ condition.  As a facility specifically designed as a surgical hospital – with private rooms, patients are segregated from ‘medical patients’ with infectious conditions.  (The facility is not designed for pneumonia patients, and other medical type hospitalizations.)

Dr. Ramirez applied the sequential stockings himself (kendall pneumatic devices), and supervised all patient preparations.  Patients received a combination of conscious sedation, and epidural analgesia – so they were awake, but comfortable during the procedures.  (This eliminates many of the risks associated with general anesthesia – and reduces other risks.)  The anesthesiologist himself, Dr. Luis Perez Fernandez, MD was excellent – attentive and on top of the situation at all times.  There was no hypoxia or hemodynamic instability during either of the cases.  (I have been favorably impressed by several of the anesthesiologists here in Mexicali.)

Dr. Perez monitors his patient closely

As for the surgery itself – everything proceeded in textbook fashion – sterility was maintained, and Dr. Ramirez demonstrated excellent surgical techniques.

For example – One of the signs of ‘good’ liposuction (and good preparation) is the color of the fat removed.  Ideally, it should be golden or light pink in color.  Over-aggressive liposuction or poorly prepped liposuction results in more bleeding.  As I watched fat being removed – the fat remained golden-yellow in the suction tubing, and even at the conclusion of the procedure, the accumulated suction canister contents remained just slightly tinged pink.

Results were cosmetically pleasing in both cases with minimal trauma to the patients***- but there will be more details forthcoming in the free book (since the post is becoming pretty long, and may be more detail than casual readers would like.)  I’ll have more information about the doctors, including the anesthesiologists, the clinics and the procedures themselves..

I did want to post some specifics – especially in this case, as the patient told me that her/his parent is a retired physician and had concerns about surgical conditions.

Mom, Dad – you don’t have to worry – Dr. Ramirez runs an excellent OR. Even in the tiny Bellus clinic, there is a full crash cart, a defibrillator and an emergency intubation cart – just in case.

**Given what I know about Dr. Ramirez, I am pretty confident – that if I wanted – I’d be there right now, and every day for a month, or until I said, “stop”..  That’s the kind of person Dr. Ramirez is.

*** In some liposuction cases – the patients appear as if they have been beaten (extensive bruising) due to the amount of trauma and force used during the procedure.

Talking with Dr. Jose Juan Durazo Madrid, MD about GI endoscopy

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This post is long overdue since I interviewed Dr. Jose Juan Durazo Madrid, MD, FACS almost two weeks ago – but as readers know, things have gotten pretty busy lately.  I’ve seen Dr. Jose Juan Durazo a couple times since the initial interview – but alas! I still haven’t talked my way into his operating room.

Dr. Durazo, who is a fellow in the American College of Surgeons is a primarily Spanish-Speaking general surgeon specializing in gastroenterology (endoscopy, and capsule endoscopy) and general surgery procedures such as cholecystectomies, appendectomies, hemorrhoid surgery and Nissen fundaplication for GERD.  H also performs surgery for cancers of the GI tract.  He performs bariatric surgery but reports that this is only a small portion of his practice.

Dr. Durazo has been a surgeon for 22 years.  After attending UABC (Universidad Autonoma Baja California) here in Mexicali, he completed his general surgery residency in Hermosillo, Sonora.

He now serves as a professor of surgery for his alma mater, in addition to his private practice.  He primarily operates at Hispano – Americano, Hospital Almater, Hospital Quirugico de la Valle, and IMSS (government facility.)

Hopefully, I’ll be reporting back from the operating room one of these days.

You’ve come a long way, baby!

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Wow..  a long couple of days – but I am sure not complaining!  Still having a blast – and as they teased me in the operating room, “Cristina, Cristina, Cristina!” I felt more like I belonged – instead of as a student, often lost/ confused.  Even more so – when I found myself irritated on rounds – irritated when the answers were obvious!!  Obvious – that’s certainly making progress..  (Irritated is such an improvement over clueless, I must say..) But the interns are a good bunch, even if they don’t love surgery like I do!

Residents at Mexicali General

The good doc gave me some homework – as we work on a ‘mystery diagnosis’ which I am enjoying.  Of course, it won’t be a mystery as soon as the pathology comes back, but I am surely enjoying the intellectual challenge (and kind of hoping that my preliminary leaps aren’t completely off-base..)  Of course – the doc is so smart – he probably already has it all figured out, and is just checking on the faculties of his student.  (He is secretly brilliant, and just hides it behind his braces and freckles.. Kind of scares me sometimes..)

Deceptively normal looking..

Bumped into Dr. Ramirez and Dr. Perez (the anesthesiologist) this morning, which reminds me that I still need to write about my visits to his operating room last week.  So I haven’t forgotten – expect it in just a couple of days..

It’s nice too when we run into people I know as we round at different hospitals around the city..  But then – as I glance at the calendar and realize that time is passing – I get a little sad.  Just as I am starting to understand things (Spanish, the hospital systems etc..) and I am enjoying it here so much, learning so much, yet time is flying, and before you know it – I will be returning home again (wherever that is!)

Gabriel Quadri de la Torre, will you marry me?

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[I have used images obtained on the internet to illustrate this post – and have tried to give proper attribution to sources.]

Just kidding about the marriage proposal – but it seemed like a nice headline for today’s post, as I muse about Mexican politics.. I’m no political pundit, just a little gringa temporarily living in Mexico.

So I am spending today at home, trying to get a better understanding of Mexican politics in advance of the presidential elections this July but it’s a daunting task!

As I read and read, different articles about the candidates and the issues** – it becomes very clear that this is one of those things that makes you truly appreciate how complex a lot of the things we often take for granted are – such as a working knowledge of your ‘home’ political systems, and its domestic and foreign policy issues.

Of course, the basics are easy enough to understand – Presidents are elected for a one time only six-year term – (no re-elections here) and there are more than two major political parties.  But the intricacies of this process, the sentiments surrounding it – and the true impact, and importance of the issues facing this nation are certainly too deep for a short-time resident like myself to really understand and comprehend on a deeper level.

I know who the candidates are – I watched the televised debate a few weeks ago, (and understood much of it) but of course, I couldn’t catch the nuances, or comprehend much of the deeper meaning, the context or the history behind their statements.

At this point, as an outsider looking in – I think that Enrique Pena Nieto of the PRI party will win.  Probably not for the reasons that residents vote for him – but because even to a foreigner like myself, he presents a nice, polished picture of what we expect politicians to look like.  (Not always a good thing in my opinion – but people can look at him, his 1960’s gelled look and picture him as president – in a John Kennedy-esque way – he is young, well-groomed and certainly handsome.  He seems smooth enough in his speech the other night, though a recent article (in English) leaves me doubtful as to his actual capabilities to govern this troubled but beautiful country**.  I also have some misgivings about his party – they ran Mexico for a long time – (70 years) and I’m not convinced they did such a great job of it.

Despite being as ignorant as I am – I have my own favorite, Gabriel Quadri de la Torre of the New Alliance party  – which just goes to show that you don’t really have to understand anything to hold an opinion.  So, Mexicans take note, and be glad that they don’t let ignorant gringas like me vote..

But – as an outsider looking in, Gabriel Quadri de la Torre (from my very limited perceptions) seems a little less like a career politician and a little more like a college professor.  Many people would argue that this is a handicap since it means he would be less effective, and less knowledgeable about actually navigating the system so to speak, but to a ‘southerner’ like myself – who is quite disgusted with the Ted Kennedys, the Robert Byrds, and all these other dynasty senators – it’s refreshing.. (I know that both of those American politicians are now deceased – but the mold of being able to be in politics just because you’ve been there, getting re-elected over and over and over still exists – just ask California politician, Jerry Brown.)

Photo by NTX – obtained from Vertigo Politico website.

I like Gabriel Quadri de la Torre because he seems to be a man of science, a man of reason – not some oratory firecracker who just likes to stir people up – but then again – that’s probably why he’s trailing so badly in the polls.  His platforms on alternative energy are forward thinking (but then – I grew up on a windfarm outside of Tracy, California – so of course, I would think so.)   I was also interested in his position on Pemex, but frankly didn’t know enough about the situation to understand it – even after I asked several people here in Mexicali.. (I’m not sure they understood it either – they are in health care too – not analysts, not economists..) So I decided to ask one.

I asked an outside financial analyst & economist who specializes on oil and alternative energy resources for more input/ insight on the Pemex issue from both a national (Mexican) and international perspective.  I also specifically asked –Is privatization the best thing for Mexico or does it just benefit outside investors?  How does it impact the rest of the world? 

This was his response [edited for length only]:

“Pemex is an incredibly poorly run state-run oil company (think of the postal service but drilling for oil)
 
Privatizing it would be the best thing for Mexico.  It wouldn’t make a big difference to people in my field [economics/ finance] but Mexico would find more oil which would be good for the whole world (especially Mexico).“
The other reason I like Gabriel Quadri so much – is that he seems like someone who is smart enough to know that all of these issues are more complicated than they first appear – and he doesn’t offer any quick easy fixes.. I like that – even if other people have told me it makes him look indecisive.  He also took the time in the debates to explain his positions instead of wasting time attacking his fellow candidates..
We all heard about Pena’s ex-mistress whining on facebook – can we move on to the real issues that affect the 100+ million people who live here?  Mr. Quadri seemed to be the only one who was really able to do that..

But then, like I said – I’m not sure if someone like me can even really understand the issues..

Take crime for example -we all heard about the headless bodies on the side of the highway – and we all know that the escalating homicide rate, and rampant violence among drug gangs is a big issue in the coming election.  But can a foreigner like myself, (particularly one living in the relatively sheltered environment of Mexicali) really understand the impact of this runaway train of grisly murders that has gripped this nation during the course of President Calderon’s term? Of what it’s like to live in an area where people ‘go missing’?

Is it possible for me to grasp the intricacies of the candidates plans to address this issue – particularly in light of the history of corruption among Mexican police forces?  What about political corruption?

And that’s just the tip of the iceberg as far as issues are concerned.  Just the idea of trying to govern a place like Mexico City (D.F) would send me into a panic – and that’s not even getting into the Pemex investment issues, endemic poverty and social security issues, or trying to bring the rest of Mexico into a technological age to make it more competitive with the rest of Latin America, and the rest of the World. With so many foreign trade opportunities, Mexico can and should carve out a better place for itself in the world – but how?  (Maybe they will figure it out at the G-20 next month, who knows?)

My gringa criticisms of the other candidates are probably equally unfair, as they hinge on such limited (okay, absent) insight.

Josefina Vasquez Mota – National Action Party. I guess my main issue with her – is I find her a bit too Hilary Clinton and not enough Geraldine Ferraro.  Plus her views on some of the issues are a little too conservative for me – particularly if she’s using the ‘woman power’ platform..  I am an old-school type feminist, which means I want equality, not special preference – so you can’t get my support by saying, “I am a woman, so if you are a woman, you should support me.”  You can’t have it both ways – equality means an equal chance to fail.

If I want to be the best at something – I want to be the best person at it – not the best woman.. It’s kind of like all of those world records, and Amelia Earhart – she got a lot of ‘first woman’ but not a lot of first person..  That’s really second place.  I guess in the 1930’s it was a big deal for a woman to do any of it, and maybe that’s the case in Mexican politics today (and the USA, for that matter) – but I still don’t think she should trade on her ‘womanhood’ to try to win an election.

Just be the best candidate.  She certainly seems smart enough without all of that – but then again, maybe it’s inescapable.  After all – I don’t hear people speculating that the other candidates have an eating disorder..

As for Andrés Manuel López Obrador (party of the democratic revolution, or something like that) – well – I guess he’s my second choice.. Since it’s impossible for Quadri to win, I guess I’d feel a bit more comfortable if Lopez was at the helm, because he seems to really care about the Mexican people (from what I’ve read about his previous work but I guess he also has a bit of a shady past..The whole ‘Legitimate Presidency’ thing kind of reminds me of the hanging chads episode down in Florida.)

** Of course, another significant issue for English speakers like myself – is always the use of language, and translational biases.  It really hits home once you try to function in another culture and another language how strong semantics really are – and how easy it is to make a mistaken impression through incorrect word choice.  So when I read these English language articles, I have to question how much of the information was slanted simply by the words the writers chose to use – even when translating quotes and candidate statements.  Also some of the sources themselves for English language information  are a bit sketchy..Kind of like if you read this blog for your Mexican election info..

In the OR (and back again!)

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It sounds awful to say but it’s a good thing my husband has been out-of-town this week – after all, considering my week in the operating room, he wouldn’t have seen much of me anyway!  But it always drives him a little crazy to see me racing from interviews to operating rooms – stumbling home late, with aching legs and a rumbling tummy, only to climb out of bed and the crack of dawn just to do it again.. then worry that I somehow won’t have time to write it all down – and round and round..  (That being said – he is phenomenal about understanding this driving motivation I have to interview, and to write – even when I’m not quite sure I understand myself.)

So he wouldn’t have complained about my whirlwind tours of the operating rooms this week – or the long days of back-to-back surgery but I would have felt bad about not seeing him all the same..

Instead with my husband thousands of miles away, I hear him smiling in the phone, laughing at my exploits, though I sometimes picture the wrinkle he gets in his brow when he thinks I’m not eating right, or getting enough sleep.. He currently serves as my remote editor for my articles at Examiner.com – calling to give feedback before submission.  He’ll be home soon – and he’ll be patient with me, as always.

Dr. Victor Ramirez, plastic surgeon

Had some great interviews and operating visits this week – including Dr. Victor Ramirez, and most of the plastic surgery community here in Mexicali – but to be fair, I will break it all up into a couple of posts.

Demonstration of techniques for breast reconstruction at Mexicali General

Back in my ‘home’ OR in thoracic surgery – which felt good.  I love meeting and seeing all the different specialties like bariatrics, urology and plastics, but it sure does feel good to come back home again..

back in thoracics (and trying to hang from the rafters)

I could wax some eloquent nonsense about the beauty of a muscle-sparing thoracotomy but then again – the good doc does almost everything minimally invasive, so I never see any.. (and you’ve heard me crow about dual port thoracoscopy.)

with more to come..

Coffee as a superfood round-up

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Update:  New article published on MSNBC –  25 May –underscores health benefits of coffee –  and further proves premise of optimal coffee ingestion at five to six cups.  (Previous studies showed the majority of benefits at five cups/ day.)

Posting this for a friend, who wasn’t quite convinced by my arguments for coffee..  Added the video just for a light-hearted touch..and who doesn’t like David Bowie..

Happily,  the majority of people have gotten away from the incorrect notion that coffee is somehow harmful, the “I gave up cigarettes and coffee” mentality.. It always irks me a bit when coffee drinking is lumped into a group of unhealthy behaviors….Stay away from coffee… and crack cocaine, people… But seriously, this is one beverage that has been mislabeled over the years – undeservedly.

With so many honest – to-  goodness harmful food additives,  fast food and other ‘junk‘ we put in our bodies – misidentifying coffee is a tragedy (albeit, a small one.)  Admittedly, it is hard on my dental enamel – but otherwise, it is a welcome part of my daily routine.

So today, we are going to review some of our previous posts and the latest published information on coffee and it’s health effects..

For starters, we are going back to a post dated March 2011 – where I first reviewed my love of the hot, rich beverage, along with a summary of health benefits..

We talked about preliminary research suggesting coffee may be protective against strokes.. An additional study on this was actually just published last month, as reported in Medscape.com, Moderate coffee intake protects against stroke, (11 May, 2012) on a meta-analysis presented at the European Society of Hypertension (ESH) European Meeting on Hypertension 2012 by Dr Lanfranco D’Elia. 

Then – a year ago (May 2011) we brought you more information about coffee as a potent anti-oxidant, and potential implications for preventing cancer (and refuting claims that it caused cancer.)

Following that – in July of 2011 – we went as far as proclaiming ‘superfood status’ when preliminary research suggested coffee ingesters were less likely to have MRSA colonization.

We haven’t even touched on the diabetes, and pancreatic cancer angle today, but suffice to say that research shows that the pancreas has a definite affinity for coffee..

Now, on the heels of reports of the underdiagnosis and increasing incidence of fatty liver disease – comes a study in the Annals of Hepatology entitled, “High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.”  Translated for readers, this small study by Gutierrez – Grobe, et. al (2012) suggests that high coffee intake is actual beneficial and may have a protective effect on the liver.  Now – don’t get too excited – since it was just a very small study, of 130 subjects – coffee and noncoffee drinkers, 73 without liver disease and 57 with liver disease.  So clearly, we need to look at this more closely..

But in the meantime, you can keep drinking your coffee.

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons

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My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr.  Ham and Dr. Abril.  This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case.  Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add).  If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.)  As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed.   So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter.  Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday.  (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

In the operating room with Dr. Marnes Molina, MD

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with Dr. Marnes Molina, Urologist

Spent the day with Dr. Marnes Molina, MD, a urologist here in Mexicali.  I initially met Dr. Molina by happenstance – in the hallways of Mexicali General Hospital.  After a brief chat we arranged for a longer interview and operating room visit.

Today, I spent the entire day in Dr. Molina’s company – first in surgery at one of the private hospitals, then his office on Madero Avenue, and then at another facility for another surgery.

Talking to the fluent English-speaking physician was a delight and a treat.  Since I don’t usually spent much time in urology – I do admit that I spent yesterday as a cram session reading about J stents and the like  so I would even know what questions to ask.  (Urology has come a long way since your basic lithotripsy.)

Dr. Molina performs a wide range of procedures – from treatment of kidney stones and ureteral obstructions, BPH, prostate cancer as well as continence restoring surgeries such as vaginal tape, and treatment of varicocele that may be contributing to infertility issues in men.

Today, for both cases, patients received conscious sedation – and both patients looked comfortable during the procedures.  (This also means that the associated risks of general anesthesia are avoided.) Everything went well – and quickly!

Dr. Marnes Molina (left) and his nurse in the operating room

Dr. Marnes Molina also tells me that he is the only urologist in the Mexicali area utilizing the green laser for treatment of benign prostate hypertrophy as an option instead of traditional surgery.

Dr. Marnes Molina Torres

Urology/ endourology

www.urologiamexicali.com

Madero 1059

Col. Nueva

Mexicali, BC

Email: marnesm@urologiamexicali.com

Tele (686) 553 6989

Expect to hear more about Dr. Molina soon..

References on Lasers in Urology

Lasers in urology (Grasso & Schwartz), 2008 Medscape.com article

Another Medscape article courtesy of Reuters Health on Green Light laser technology entitled, “Latest green-light laser effective for large prostate volumes.”

the Weight of a Nation: the obesity epidemic

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There’s a new series on HBO that is a collaboration between the Institute of Medicine, the CDC and the National Institute of Health (NIH) that begins airing tomorrow night.  This is a huge undertaking that took over three years to bring to the screen.

As many of you know – Obesity, diabetes and bariatric surgery are some of the topics that have been covered fairly extensively here at Cartagena Surgery.  In fact – it’s the heart of Cartagena Surgery – since the very first surgeon interview I ever performed back in 2010 was Dr. Francisco Holguin Rueda, MD, FACS, the renown Colombia bariatric surgeon.  (Shortly after that first leap – came Drs. Barbosa and Gutierrez – which is how we ended up here today.)

I’ve also been spending time, both last week and this week in the company of several bariatric surgeons here in Mexicali. MX and plan to go to several surgeries this week – so it seemed only appropriate to publish a few articles on the topic.

Talking with Dr. Horacio Ham – Bariatric surgeon, part 1

Talking with Dr. Ham, part 2

(I’m still transcribing notes from another one of my recent interviews – with Dr. Jose Durazo Madrid, MD, FACS).

I’d also like to encourage readers to take a look at HBO’s new mini-series (four episodes over Monday and Tuesday).

In the OR with Los Doctores, Dr. Ham & Dr. Abril

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Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility.  Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia.  Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists.  That confirms my own impressions and observations and what several other surgeons have told me.

campa

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed.  It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham  and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

w/ Dr. Ham

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores.  They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?)  I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

Los Doctores

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected.  Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…)  It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice.  (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions.  After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true.  It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers.  I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so.  She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time..  This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure..  So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

Update: Medicare to cover TAVI/ TAVR

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In an update to a previous story here at Cartagena Surgery, in the attached article, “Medicare to pay for TAVI” from Medpage.com by Chris Kaiser, the guidelines for CMS payment for TAVI/ TAVR have been released.   These criterion include the restriction that only surgery ineligible patients be included and that implanting surgeons must participate in the TAVI registry.

More importantly, this criteria requires that TWO cardiac surgeons determine the patient’s suitability to withstand surgery versus TAVI.  This is a crucial requirement as we’ve discussed before, since only a surgeon can accurately decide/ predict how a patient might tolerate surgery.  (Multiple previous studies showed that primary care providers and cardiologists were poor judges of patient’s surgical risk. )  Also, the lack of this requirement in Europe has caused several ethical problems as interventional cardiologists began the widespread implantation of experimental technologies in lower risk patients (particularly in Germany.)

Dr. Horacio Ham, and Los Doctores

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Just finished interviewing Dr. Horacio Ham, a bariatric surgeon with the DOCS (Diabetes & Obesity Control Surgery) Center here in Mexicali.  Later this evening, we’ll be heading off to surgery, so I can see what he does first-hand.

Tomorrow sounds like a jam-packed day for the young doctor, he’s being interviewed for a University television series on Obesity in addition to his normal activities (surgery, patients) and of course, the radio show.  Turns out his guest doctor tomorrow evening is none other my professor, the ‘good doctor.’

Sounds like a great show – so if you are interested it’s on 104.9 FM (and has internet streaming) at 8 pm tomorrow night..

I’ll report back on the OR in my next post..

Mexicali book update

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The service is quiet so I am spending the day writing and working on the Mexicali book.  For new readers, I would like to explain that the Mexicali book is a little different from my previous offerings.  This is not an exhaustive compilation of surgeons and facilities in Mexicali, as frankly, I do not have the time or resources to accomplish such a task at this point in time.

Like all my books, it is a labor of love, but differs in that it highlights some of the best, and worst of Mexicali and medical tourism in this city.  So instead of interviewing and observing hundreds of surgeons, it highlights the limited number of physicians who agreed to participate in this project.

As such, no plans are being made to market this book commercially. Instead, I plan to offer it as a free pdf download for interested readers.  I will also be offering a full color soft-bound edition (at cost) for people interested in the many full color photographs of surgeons and surgery in Mexicali.  I will be placing the soft-bound edition on Amazon.com for interested persons.  Unfortunately, the cost of producing such a book (color photos) in limited runs is fairly expensive, so I apologize in advance to readers – but as I said – it’s a labor of love, and I won’t make a dime off of it.  I can only hope that if readers enjoy this book, they will consider purchasing one of my longer, more detailed books on medical tourism (such as the Bogotá book.)

More information will be forthcoming as I get further and further towards completion of this project.

New series of articles

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I’ll be writing a new series of articles for the Examiner.com based on my experiences, interviews and observations here in Mexicali, MX and Calexico, California.  While the focus will be on serving the needs of the Calexico community (particularly now that there is a fast pass lane for medical travelers), I hope that all of my loyal readers will continue to support my work.

I have already published my first three articles  – and have added a new navigation section (on the side of this blog) for interested readers.

As part of this, I wrote a story about the good doctor and all of the work he is doing – including one of our recent ‘house calls’ to San Luis, in Sonora, Mexico.   It was probably one of the more difficult articles to write; due to space limitations and trying to present information in an objective fashion.  (It’s hard to present all the evidence to support your conclusions in just a few hundred words;  ie. He’s a good doctor because he does X, Y, and Z and follows H protocol according the P.”  Makes for wordy reading and not really what the Examiner is looking for.

Too bad, since readers over at Examiner.com haven’t had the chance to know that if the opposite is true (a less than stellar physician or treatment – that I have absolutely no reservations about presenting the evidence  and stating the facts about that either..)

Don’t worry, though – I will continue to provide that level of detail here at Cartagena Surgery – where the only limitations are my ability to type, and the (sometimes) faulty keys of my aging laptop.

The ‘Art of Medicine’ with Dr. Jose Mayagoitia Witron, MD, FACS

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I should be finishing my readings in preparation for clinic this afternoon, but after reading most of the day yesterday (it was an international holiday for people living outside the USA), I guess I am entitled to spend some time writing.

Besides, I spent an illuminating morning with Dr. Jose Mayagoitia Witron, MD, FACS over at Mexicali General Hospital.  While he was telling me what he doesn’t do: (no uniport laparoscopic surgery, and not a huge amount of bariatric surgery), what I observed told a very different story.

Dr. Mayagoitia, MD, FACS

I didn’t follow Dr. Mayagoitia to the operating room.  Instead – I accompanied him to a teaching session with his medical students, who presented case studies – and I observed Dr. Mayagoitia instructing his students in the ‘Art of Medicine’.  This skill is fast becoming a lost one in today’s emphasis on the science of diagnostics, and laboratory testing.  But not here, not today – and not with Dr. Mayagoitia.

He believes strongly in the physical examination and all of the wealth of information that it provides.  He also believes it is an underutilized tool to connect doctors with their patients.  As he explains, too often doctors become too busy ordering tests – which separates the doctors from their patients – instead of listening to ‘the person in the bed’.  (My terminology not his).  So during his students case presentations – the emphasis is on the story (the clinical history), the patient’s life (background, social settings, diet, habits) and the clinical physical examination.  Students aren’t allowed to talk about, or ask questions about diagnostic results such as radiographs or serum analysis until the story and the physical findings have been throughly discussed and examined in detail.

Even then – he challenges them – to use more than their eyes – to engage their brains, and their other senses.. “What about the description of this surgical scar?  Does it seem a little large for an appendectomy?” he asks.. “What about it’s location?’ he challenges**..

“What about the differentials?  What other diagnoses should we consider? he asks.  “I know you think the diagnosis is obvious – but give me some alternatives,” he coaxes.  “What else could be going on?  Tell me why you don’t think that it’s X” he asks – making the students review and explore the other possible causes for this patient’s abdominal pain.  “Could it be Z?” he asks.. “Why not?  What else would we see?” he states in reply to a student’s mumbled answer..

Then, only then, do we review the labs, and the films – the more tangible aspects of the practice of medicine.  Those results that students can see easily, (maybe too easily) and tempt them into abandoning the ‘art’ of medicine and patient care.  But he doesn’t allow it – and quickly steers the conversation back to the displayed pathology to this pathophysiology and symptomatology of the patient in question.

As someone who still struggles with the physical skill of percussion – this entry into the art of medicine hits home.  It is an art, and a woefully underappreciated one.

** Please note – these quotes are my best approximation from my translations during the case presentation, and may miss nuances. 

About Dr. Jose Mayagoitia Witron

Dr. Mayagoitia is more than a clinical instructor – he is a respected professor of surgery at the Universidad Autonoma Baja California (UABC) and has been teaching medical students for over 20 years. He also teaches surgical residents and has been doing so for over fifteen years.  He gives lectures daily at the University, in addition to his busy schedule as the Supervising Surgeon for the Intensive Care Unit at Mexicali General, and private surgical practice (with evening clinic hours).

He speaks in clear, unaccented English (my southern accent is thicker than any accent he might possess) which may be as a result of his fellowship training in San Diego.   He completed his general surgery residency right here at Mexicali General after attending UABC).

He remains active in the research community as a supervisor for resident research projects including two ongoing projects worthy of note: a new study looking at the treatment of open abdomens, (from massive trauma, infection, etc.) and a study looking at the early initiation of enteral feedings versus delayed (72 hours or greater) in surgical intensive care patients.

He, along with his wife, Gisela Ponce y Ponce de León, MD, PhD (a family medicine physician and instructor at the UABC nursing school) recently presented a paper on obesity research in Barcelona, Spain.

He does all of this in addition to a steady diet of general surgery (cholecystectomies, appendectomies, bowel surgery (such as resections) and the occasional bariatric surgery.  As one of the lead surgeons at a major trauma hospital** – he also sees a considerable amount of emergency and trauma cases.

He reports that on the last – bariatric surgery, he has mixed feelings.  While it has become a popular staple for the treatment of obesity and obesity-related complications – he questions it’s role in a society that steadfastedly ignores the causes.  “I wonder if we will look back one day and realize that we [surgery] did a real disservice to our patients by doing so much of this.”  So, while he does perform some bariatric procedures, he is very selective in his patients.  “It’s not a quick -fix, and they are going to be dealing with this [changes from bariatric surgery] for the rest of their lives so they [patients] need to understand that it’s a lifelong endeavor.”  When he does perform bariatric procedures, he prefers the gastric sleeve, which he believes is more effective [than lap-band, and smaller procedures] but less devastating in terms of complications and dramatic life alterations.

Dr. Jose Mayagoitia Witron, MD, FACS

General surgeon, Fellow in the American College of Surgeons

Edificio Azahares

Av. Reforma 1061 – 6

Mexicali, B. C.

Tele: 686 552 2400

** He reports that Mexicali General, as a public facility, sees about 80% of all traumas in the area.

Blue Cross/ Blue Shield of Mexicali & Dr. Cuauhtemoc Vasquez Jimenez

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Note:  I owe Dr. Vasquez a much more detailed article – which I am currently writing – but after our intellectually stimulating talk the other day, my mind headed off in it’s own direction..

Had a great sit down lunch and a fascinating talk with Dr. Vasquez.  As per usual – our discussion was lively, (a bit more lively than usual) which really got my gears turning.  Dr. Vasquez is a talented surgeon – but he could be even better with just a little ‘help’.  No – I am not trying to sell him a nurse practitioner – instead I am trying to sell Mexicali, and a comprehensive cardiac surgery program to the communities on both sides of the border..  Mexicali really could be the ‘land of opportunity’ for medical care – if motivated people and corporations got involved.

During lunch, Dr. Vasquez was explaining that there is no real ‘heart hospital’ or cardiac surgery program, per se in Mexicali – he just operates where ever his patients prefer.  In the past that has included Mexicali General, Issstecali (the public hospitals) as well as the tiny but more upscale private facilities such as Hospital Alamater, and Hospital de la Familia..

Not such a big deal if you are a plastic surgeon doing a nip/tuck here and there, or some outpatient procedures – okay even for general surgeons – hernia repairs and such – but less than ideal for a cardiac surgeon – who is less of a ‘lone wolf’ due to the nature and scale of cardiac surgery procedures..

Cardiac surgery differs from other specialties in its reliance on a cohesive, well-trained and experienced group – not one surgeon – but a whole team of people to look out for the patients; Before, During & After surgery..  That team approach [which includes perfusionists, cardiac anesthesiologists (more specialized than regular anesthesia), operating room personnel, cardiology interventionalists and specialty training cardiac surgery intensive care nurses]  is not easily transported from facility to facility.

just a couple members of the cardiac surgery team

That’s just the people involved; it doesn’t even touch on all the specialty equipment; such as the bypass pump itself, echocardiogram equipment, Impella/ IABP (intra-aortic balloon pump), ECMO or other equipment for the critically ill – or even just the infrastructure needed to support a heart team – like a pharmacy division that knows that ‘right now’ in the cardiac OR means five minutes ago, or a blood bank with an adequate stock of platelets, FFP and a wide range of other blood products..

We haven’t even gotten into such things such as a hydrid operating rooms and 24/7 caths labs – all the things you need for urgent/ emergent cases, endovascular interventions – things a city the size of Mexicali should really have..

But all of those things take money – and commitment, and I’m just not sure that the city of Mexicali is ready to commit to supporting Dr. Vasquez (and the 20 – something cases he’s done this year..) It also takes vision..

This is where a company/ corporation could come in and really change things – not just for Dr. Vasquez – and Mexicali – but for California..

It came to me again while I was in the operating room with Dr. Vasquez – watching him do what he does best – which is sometimes when I do what I do best.. (I have some of my best ideas in the operating room – where I tend to be a bit quieter.. More thinking, less talking)..

Dr. Vasquez, doing what he does best..

As I am watching Dr. Vasquez – I starting thinking about all the different cardiac surgery programs I’ve been to: visited, worked in – trained in.. About half of these programs were small – several were tiny, single surgeon programs a lot like his.. (You only need one great surgeon.. It’s all the other niceties that make or break a program..)

All of the American programs had the advantages of all the equipment / specialty trained staff that money could buy***

[I know what you are thinking – “well – but isn’t it all of these ‘niceties’ that make everything cost so darn much?”  No – actually it’s not – which is how the Cardioinfantils, and Santa Fe de Bogotas can still make a profit offering world-class services at Colombian prices…]

The cost of American programs are inflated due to the cost of defensive medicine practices (and lawyers), and the costs of medications/ equipment in the United States****

the possibilities are endless – when I spend quality time in the operating room (thinking!)

Well – there is plenty of money in Calexico, California** and not a hospital in sight – just a one room ‘urgent care center’.  The closest facility is in El Centro, California – and while it boasts a daVinci robot, and a (part-time?) heart surgeon (based out of La Mesa, California – 100 + miles away)– patients usually end up being transferred to San Diego for surgery.

Of course, in addition to all of the distance – there is also all of the expense..  So what’s a hard-working, blue-collar guy from Calexico with severe CAD going to do?  It seems the easiest and most logical thing – would be to walk/ drive/ head across the street to Mexicali.. (If only Kaiser Permanente or Blue Cross California would step up and spearhead this project – we could have the best of both worlds – for residents of both cities.. 

 A fully staffed, well-funded, well-designed, cohesive heart program in ONE medium- sized Mexicali facility – without the exorbitant costs of an American program (from defensive medicine practices, and outlandish American salaries.)  Not only that – but as a side benefit, there are NO drug shortages here..

How many ‘cross-border’ cases would it take to bring a profit to the investors?  I don’t know – but I’m sure once word got out – people would come from all over Southern California and Arizona – as well as Mexicali, other parts of Baja, and even places in Sonora like San Luis – which is closer to Mexicali than Hermasillo..  Then Dr. Vasquez could continue to do what he does so well – operate – but on a larger scale, without worrying about resources, or having to bring a suitcase full of equipment to the OR.

The Mexican – American International Cardiac Health Initiative?

But then – this article isn’t really about the ‘Mexican- American cross-border cardiac health initiative’ –

It is about a young, kind cardiac surgeon – with a vision of his own.

That vision brought Dr. Vasquez from his home in Guadalajara (the second largest city in Mexico) to one of my favorite places, Mexicali after graduating from the Universidad Autonomica in Guadalajara, and completing much of his training in Mexico (D.F.).  After finishing his training – Dr. Vasquez was more than ready to take on the world – and Mexicali as it’s first full-time cardiac surgeon.

Mexicali’s finest: Dr. Vasquez, (cardiac surgeon) Dr. Campa(anesthesia) and Dr. Ochoa (thoracic surgeon

Since arriving here almost two years ago – that’s exactly what he’s done.. Little by little, and case by case – he has begun building his practice; doing a wide range of cardiovascular procedures including coronary bypass surgery (CABG), valve replacement procedures, repair of the great vessels (aneurysm/ dissections), congenital repairs, and pulmonary thrombolectomies..

Dr. Vasquez, Mexicali’s cardiac surgeon

Dr. Cuauhtemoc Vasquez Jimenez, MD

Cardiac Surgeon

Calle B No. 248 entre Obregon y Reforma

Col. Centro, Mexicali, B. C.

Email: drcvasquez@hotmail.com

Tele: (686) 553 – 4714 (appointments)

Notes:

*The Imperial Valley paper reports that Calexico makes 3 million dollars a day off of Mexicali residents who cross the border to shop.

***In all the programs I visited  – there are a couple of things that we (in the United States do well..  Heart surgery is one of those things..)

**** Yes – they charge us more in Calexico for the same exact equipment made in India and sold everywhere else in the world..

In the operating room with Dr. Cuauhtemoc Vasquez, Cardiac Surgeon

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Had a great day in the operating room with Dr. Cuauhtemoc Vasquez, MD the promising young heart surgeon I told you about several months ago.  I have some absolutely breathtaking photos of the case – but I want to double-check with the patient before posting anything potentially revealing in such a public forum.

Todays’ surgery was at one of the public hospitals in Mexicali – and while technology was sometimes in short supply – talent sure wasn’t.  I was frankly surprised at the level of skill and finesse Dr. Vasquez displayed given the fact that he is so early in his career.

Dr. Cuauhtemoc Vasquez, Cardiac surgeon

He’s also just an all-around pleasant and charming person.  I know from previous encounters that he’s well-spoken, interesting, engaging and an excellent conversationalist –  We didn’t talk at length on this occasion – because honestly, I really don’t like to be distracting during cases – especially since much of the discussion was in an English-heavy Spanglish.. (He is fluent in English but we both tend to slip in and out of Spanish.  I mainly slip out when I start thinking in English and come across a concept that I am not sure about explaining or asking about in Spanish.**

But don’t worry – I am planning on seeing him next week – where I can hopefully lure him to lunch/ coffee or something so we have a more lengthy discussion – so I can give you all the details in a more formal fashion in a future post.

As a crazy side note – finally got that ‘great’ picture of the good doctor.. Oh, the irony – not during a thoracic case but while he was assisting Dr. Vasquez – (the good doctor is board-certified cardiothoracic surgeon, after all..) I didn’t post it here because there are some ‘patient bits’ in the photo..

**I know this can be frustrating from my experiences with my professor – but it’s also frustrating when: a. a question gets misinterpreted as a statement (because of my poor grammar) or b. misconstrued completely – which still happens pretty frequently.  Luckily, people around here are awfully nice, and tend to give me the benefit of a doubt.

Also – I need to post this photo of one of my favorite operating room nurses – Lupita.  (Lupita along with Carmen and Marisol) have been an absolute delight to be around even of those very first anxious days..

Lupita, operating room nurse.. Doesn’t hurt that she’s as cute as a button, eh?