Narcotics and Analgesia in Latin America: Issues related to managing acute pain in chronic opioid patients

This article is part of a new series that explores issues in medical tourism.

The geopolitical landscape of drug trafficking?

As a writer who has written on both Colombia and Mexico, the most frequent questions I encounter from friends, colleagues and acquaintances are almost always related to drugs and drug-related violence.  As I’ve mentioned in previous posts, the real risks of crime and violence affecting medical tourists is actually quite small in many of these areas, despite media headlines*.   Questions related to the drug trade are for all intents and purposes outside of my area of expertise..   However, this does bring up some other related issues that are increasingly relevent for our on-going discussions about medical tourism.  But, first some background –


The Latin American Drug Problem?

Just ask a Mexican, Colombian or another person from Latin America and they will tell you, the United States is the place with the drug problem.

Not only that, but the majority of Latin American countries hold the USA as responsible for fueling much of the violence that has devastated these countries in recent years.  Erik Vance over at recently published an excellent essay on this topic which explores the role and collective responsibility of American citizens for drug related atrocities under the guise of a Friday night high.

This isn’t Colombia Reports, its Latin American

But talking about the politics and trade issues regarding the growth, harvesting, and distribution of illegal drugs isn’t really the focus of my work.   Healthcare is, so my interpretation of issues regarding drugs is very different – almost like another language.  If you could see inside my head, and watch my thought processes, it would look a little like this:

Drugs —> Narcotics —-> medications for pain —–> treating pain —–> international / cultural issues related to pain and treatment of pain —> who is most heavily affected by this?

When I hear “drugs”, I think “medications.”  When I think of medications, or more specifically, narcotics – I don’t think of tiny, little bags littering the street in Medellin, but the somewhat vague medical definitions for narcotics..


Narcotics, Narcotics, Narcotics…

The definition of narcotics depends on the discussion..

Legally, a narcotic is any medication or drug that is prohibited/ restricted / illegal.  Thus while the government classifies amphetamines, MDMA (ecstasy) or cocaine as narcotics, healthcare providers usually don’t.

Medically, narcotics usually refers to opioid compounds or other medications used to relieve physical pain.  More recently, the term analgesics has replaced narcotics in the everyday vernacular.  When we refer to narcotics, we are usually talking about using medications in a therapeutic fashion specifically to treat pain – like prescribing Percocet or Lortab for pain after surgery..


A kid in the candy store

Americans are the kings of narcotics. But unlike the common perception of drug abuse being isolated to crack pipes, cocaine and heroin junkies – the majority of drug abuse in the USA is derived from legal prescription medications, readily available at large chain pharmacies.

CVS and Walgreens versus the Colombian drug dealer

It’s usually a Colombian or Mexican drug dealer – at least on the latest episode of modern crime dramas.  I guess that’s because the truth is a lot more mundane.  In actuality, CVS, Walgreens and any number of local pharmacies are the real ‘drug dealers’ for many Americans.

We prescribe, we use, and we abuse at astronomical rates.  No other country comes close to being as heavily medicated as ours. Not only have overdoses and addiction rates skyrocked, but so have the cases of “Chronic non-cancer pain” treated with long-term narcotics.  Some of this use is legitimate, some of it isn’t but anyway you look at it – we have a problem.

The prescription drug problem: Overdoses, addiction and chronic pain

In  a recent Medscape article by one of the foremost experts on chronic pain,  chronic pain management and addiction medicine,  Laxmaiah Manchikanti in “Lessons Learned in the Abuse of Pain-Relief Medication_ A Focus on Health Care Costs” estimates that there are over 100 million chronic pain patients in the United States. 

That’s a lot of pills and prescriptions.

But even if we ignore issues of prescription abuse and misuse, there still remains a large segment of people with chronic pain and chronic opioid use.  These people aren’t abusing their medications, but they are using opioid medications over long periods of time, often in escalating doses.

Chronic pain and Chronic Pain treatment with opioids

The problem chronic pain patients face is one of tolerance.  When patients are treated with opioid medications, including long-term opioid medication regimens for problems like chronic back pain, tolerance to these drugs and their effects occurs.  This means that it takes more of the medication to produce analgesic (and other) effects.

For example, a dosage that would make an opioid naive patient comatose for example, may only serve to reduce pain from a “10 [unbearable agony]” to an “8 [excruciating] ” in a patient with tolerance.

While an isolated prescription for Percocet after major surgery or an injection of morphine in the emergency room for an acute fracture shouldn’t cause any long-term problems, many of people with chronic use have developed a significant tolerance to these medications.

Tolerance makes obtaining adequate analgesia in acute pain difficult

This means that the ‘standard’ doses of pain medications that are usually ordered after procedures may be inadequate to manage their pain.  Huxtable et al describe the problem of maintaining adequate analgesia in opioid tolerant individuals during episodes of acute pain in his 2011 review, which gives a comprehensive overview of the issues involved.

But, if you can imagine the scenario of an opioid tolerant patient awakening from major surgery, only to find out that the prescribed medications aren’t working  – then you have a pretty good idea of how potentially traumatic and devastating this could be.

If you are planning for surgery: 

– Pain management planning (baseline pain score, realistic pain management goals, multi-modal therapies, and thorough review of medication history)

But more critically, people with increased opioid tolerance need to talk – to their providers and their caregivers about realistic expectations of post-operative pain control.  Together, patients and providers should review their pain medication history, as well as baseline pain scores.

Also contributing factors like depression or other emotional distress should be addressed prior to surgery.  (Even if you don’t have a diagnosed depression – antidepressants can often help alleviate pain).

For example:

Patient P is scheduled for a knee replacement.  While P’s knee has been hurting for some time, P’s chronic arthritis pain is mainly centered in P’s low back.  P takes several medications for his back pain, including oxycodone and has done so for several years since a workplace injury landed him in the emergency room with a herniated disk.  Now P is concerned about his pain after surgery.  

What are some of the issues that P faces?

If prior to surgery, patient P reports a chronic (baseline) pain level of 6 in his back (on scheduled, long-term narcotics):

– obtaining pain relief (a score of 3 or less) might be impossible.  It is almost certainly impossible that the same medication regimen used for opioid naïve patients is going to be equally effective for patient P.

 After a frank discussion with his/her surgeon during pre-surgical evaluation, P’s doctor anticipates P’s increased needs for post-operative analgesia.  The doctor also orders a wide range of non-pharmacological interventions and adjuvant medications to help alleviate P’s acute pain needs.

However, neither P nor P’s surgeon anticipate that this regimen will treat or relieve P’s chronic pain.  Following adequate recovery from surgery, P is referred back to his/her pain management specialist for long-term needs.

Sounds good, right?  Well, it should since this is the textbook scenario for patient care that has been taught in universities all over the United States for the last decade.

But this is Latin American Surgery..  so we need to explore the regulations and attitudes regarding pain management and analgesia outside of the USA.

But the very first thing people should know is: 

1.  Pain is culturally defined.

Cultural beliefs affect everyone, not just the patient..  So it isn’t just about whether the patient displays stoicism or tears.  It’s much more complex than that.   Cultural beliefs affect everyone; including doctors and nurses, so this means that culture also plays a role in pain management too…

That’s not to imply that some cultures just tell their patients “to shut up and suffer” but that pain and appropriate pain management may be viewed very, very differently depending on where the person is being treated.

In general, some cultures are more openly expressive of pain – and in these cultures pain may be treated with stronger medications and more frequently.  But that is not always the case – because the cultural beliefs surrounding pain and suffering also reflect that individual society’s belief regarding the value of suffering, as well as beliefs/ fears/ concerns regarding addiction.


Many of the cultures that are frequently cited as “highly emotive” or as cultures where pain is readily expressed are some of the same cultures where narcotics are not heavily used in in-patient or outpatient settings.

For example, many classic sociology references cite latino culture as being very expressive and emotive (ie. not stoic regarding pain).  At the same time, the use of narcotic pain medications (in my observations) are quite limited in both in-patient or outpatient settings.  Numerous medications (tramadol, ketorolac and other NSAIDS) are used to manage post-operative pain in these patients – including formulations not available in the United States.  Patients certainly weren’t undertreated:  during interviews and visits with patients, the vast majority of these patients reported good to excellent pain relief.

However, in the three years that I have been working closely with physicians in Mexico, and Colombia – I have very rarely seen a doctor order narcotics (ie. morphine, dilaudid or similar medications) on the post-operative orders.  I have never  seen a written prescription for percocet, lortab or similar medications for a patient in the outpatient setting (or as part of discharge medications.)

Obviously that doesn’t mean that these medications aren’t prescribed.  But it does show that what would be considered a routine Rx in the USA (ie. Discharge prescriptions for Percocet after cardiac surgery or lung surgery) is not routine for the doctors in the various practices that I have observed in my numerous travels.

So patients with opioid tolerance or chronic opioid use would certainly want to discuss this with their surgeons prior to surgery.

Of course, “cultural traditions” aren’t the only reason narcotics may be used / dispensed differently in other countries.  Other reasons may include:

Legal constraints / Availability

Globally, pain management practices may also be influenced by that nation’s laws as issues of supply and scarcity.  This is less of an issue in parts of Latin America but may be more problematic in Asia or other countries where narcotics are more tightly controlled.

In Mexico, for instance, many of the legal constraints for the prescribing and use of narcotics mirrors the United States.  There is a centralized governmental agency, COFEPRIS, similar to the DEA which regulates and monitors prescription drugs.  Narcotics like morphine, hydromorphone and fentanyl require a specific type of prescription called “Type 2” (and prescriptive authority for the prescribing physician).  There are dosage limitations and restrictions.  Only certain types of doctors are authorized to write these prescriptions and frequent follow ups are required (monthly) for on-going prescriptions of Type 2 drugs (A. Ballesteros, 2014).

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Happy, safe, successful travels

None of the above is to suggest that medical travel is contraindicated for American patients.  But like any big occasion or event, advanced planning is critical for a successful medical trip.

It is also a reminder to have clear expectations, good lines of communications and thorough discussions with medical providers** prior to having surgery or other procedures, particularly if you have special needs (like chronic pain management) or other health conditions.

*Venezuela is a different story. Travelers are advised to be informed, and take precautions prior to visiting this area.

** Overseas, domestic or just down the street

Additional references and resources

Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999–2010.  A CDC report.

Cultural aspects of pain management.  Marcia Carteret.

Laxmaiah Manchikanti (2007).  National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician, 2007;10;399-424.

Hartrick, Craig (2007).  Long term opioid treatment.  Virtual Mentor (American Medical Association Journal of Ethics).

Huxtable et. al. (2011). Acute pain management in opioid tolerant patients: a growing challenge.  Anesthesia Intensive Care, 2011, 39: 804-823.

Brafman, B (2014). Advance for nurses: Addiction in the surgical patient.

For fellow Medscape subscribers – there is an excellent series of articles as well as video lectures addressing multiple facets of the American prescription (opioid) pill problem.  I’ve included links to just a few of them here.

Managing pain

Safe prescribing

The “lessons learned” article, previously cited above.

The “Pain TV” series.

Medical tourism on the heels of Obamacare

Happy Thanksgiving to all of my American readers!  I hope everyone has a wonderful and safe holiday.

I’m home for a while, sort of.

After returning from Mexico this October, I’ll be spending the rest of the Fall/ Winter here in the United States while I replenish my writer’s budget by completing some travel assignments.  (Coming soon – to a hospital near you!)

Now that I am home, I have been catching up on all of the local news – and it looks like Obamacare hasn’t really kicked off to a wonderful start.  Of course, it was naive to think that anything SO large/ SO involved / Affecting some many people could go off without (several) hitches, but as one of the people losing their coverage because of it – I certainly understand all of the anxiety and worry out there.

In the midst of continuing coverage of the current Obamacare fiasco, as millions of Americans lose their existing health care, several new articles on medical tourism have been making headlines across the country.  Here’s a look at some of the latest news and reports from this past month.globe ribbon

In the Bay Area, NBC news‘ Elyce Kirchner, Jeremy Carroll and Kevin Nious published “Medical tourism: the future of healthcare?” along with a televised report. It’s the usual patient narrative along with an overview of medical tourism.

Kevin Gray, at the Men’s Journal talks about the domestic and international options available in his narrative, “Medical Tourism: Overseas and under the knife.”  Gray takes a slightly different approach and discusses how consumers can comparison shop for health care services.

Among these publications, is “Medical tourism: Spanning the globe for health care,” by Kent McDill which includes information from one of my publications and a recent interview published right here at Latin American

The sky’s the limit?

Also, in counterpoint to the numerous press releases and newspaper articles talking about Iran, Bermuda, and various other medical tourism destinations seeking to “cash in” on the phenomena, British researchers (Lunt et al.) have published a report that contradicts the “if you build it, they will come” philosophy which has taken over the industry in many quarters.

Medical News Today published a summary of their findings early this month.  Researchers also point out that much of the credible data required to provide a full and accurate picture regarding medical tourism is absent.

On a related note: While I talked about the limitations in medical tourism, accuracy of reported statistics and public perceptions in-depth during my 90 minute NPR interview, you wouldn’t really know it from my 2 sentence quote.


USA Today also published a story on some of the pitfalls for destinations with thriving medical tourism.  Kate Shuttleworth takes a look at the strain that Eastern European medical tourists have placed on some Israeli facilities.

Is medical tourism on the rise?  or is it all a spin of the numbers?  I guess it all depends on who you ask.. But for now – Obamacare is not a viable alternative to medical travel.

Start here…

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

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

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

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

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

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

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

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

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

Reasons to write about medical tourism: a cautionary tale

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

What I do and what I write about

I interview doctors to learn more about them.

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

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

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

I talk about checklists – a lot..

The surgical apgar score

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

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

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

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

Cultural Content

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

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

How the site is organized

See the sidebar! Check the drop-down box.

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

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

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

Topics of particular interest like HIPEC have their own section.

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

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

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

Thank you for coming.

Talking with Dr. Gustavo Gaspar Blanco, plastic surgeon

Dr. Gustavo Gaspar Blanco, plastic surgeon

Gaspar 083

Dr. Gustavo Gaspar Blanco is a plastic surgeon in Mexicali (Baja California) Mexico.  He is well-known throughout Baja and Northern Mexico for his gluteal augmentation techniques using gluteal implants.  While this is one of the procedures he is most famous for, he also performs the complete range of body, facial plastic surgery procedures, and post-bariatric reconstructive surgery.

It was an engaging series of interviews as Dr. Gaspar is extremely knowledgeable and passionate about his craft.  “Plastic surgery is different from other specialties, it is an art.  The surgeon needs to have an eye for beauty and symmetry in addition to surgical skill.”

To read more about Dr. Gaspar in the operating room.

Gluteal Implants versus Fat Grafting

There are multiple methods of gluteal augmentation (or buttock enhancement).  Dr. Gaspar performs both fat grafting and gluteal implantation procedures.  He prefers gluteal implantation for patients who are very thin (and have limited fat tissue available for grafting) or for patients who want longer-lasting, more noticeable enhancements.   (With all fat injection procedures, a portion of the fat is re-absorbed).

He recommends fat grafting procedures to patients who want a more subtle shaping, particularly as part of a body sculpting plan in conjunction to liposuction.

Breast Implants and attention to detail

Like most plastic surgeons, breast augmentation is one of the more popular procedures among his patients.  The vast majority of his patients receive silicone implants (by patient request), and Dr. Gaspar reports improved patient satisfaction with appearance and feel with silicone versus saline implants.  He uses Mentor and Natrelle brand implants, and is very familiar with these products.  In fact, he reports that he has visited the factories that create breast implants in Ireland and Costa Rica.  He says he visited these factories due to his own curiosity and questions about breast implants**.

Once he arrived, he found that each implant is made by a time-consuming one at a time process versus a vast assembly line as he had envisioned.  He was able to see the quality of the different types of implants during the manufacturing process.  These implants, which range from $800.00 to $1200.00 a piece, go through several stages of preparation before being completed and processed for shipping.  He also watched much of the testing process which he found very interesting in light of the history of controversy and concern over previous silicone implant leakage in the United States (during the 1960’s – 1970’s).

Gaspar 061

Another aspect of breast augmentation that Dr. Gaspar discusses during my visits is the breast implantation technique itself.  While there are several techniques, in general, he uses the over-the-muscle technique for the majority of breast implantation procedures.  He explains why, and demonstrates with one of his patients (who had the under-the-muscle technique with another surgeon, and now presents for revision).

“While the under-the-muscle technique remains very popular with many surgeons, the results are often less than optimal.  Due to the position of the muscle itself, and normal body movements (of the shoulders/ arms), this technique can cause unattractive rippling and dimpling of the breast.  In active women, it can actually displace the implant downward from pressure caused by normal muscle movements during daily activities.  This may permanently damage, displace or even rupture the implant.”

Instead, he reserves the under-the-muscle implant for specific cases, like post-mastectomy reconstruction.  In these patients (particularly after radiation to the chest), the skin around the original mastectomy incision is permanently weakened, so these patients need the additional support of the underlying muscle to prevent further skin damage.

Not just about outcomes

While his clients, from all over North America, are familiar with his plastic surgery results, few of them are aware of his deep commitment to maintaining the highest ethical and medical standards while pursing excellence in surgery.

Commitment to ethical care of patients crosses language barriers

While Dr. Gaspar is primarily Spanish-speaking, his commitment to ethical practice is crystal clear in any language.  He explains these ethical principles while offering general guidelines for patients that I will share here (the principles are his, the writing style is my own).

Advice for patients seeking plastic surgery

Be appropriate:

– Patients need to be appropriate candidates for surgery: 

Around fifty percent all of the people who walk into the office are not appropriate candidates for plastic surgery, for a variety of reasons.  Dr. Gaspar feels very strongly about this saying, “Unnecessary or inappropriate surgery is abusive.”

– Plastic surgery is not a weight-loss procedure.  Liposuction/ Abdominoplasty is not a weight loss procedure.  Plastic surgery can refine, but not remake the physique.  Obese or overweight patients should lose weight prior to considering refining techniques like abdominoplasty which can be used to remove excess or sagging skin after large-scale weight loss.

fat removed during liposuction procedure

fat removed during liposuction procedure

  – Have surgery for appropriate reasons.  Plastic surgery will not make someone love you.  It won’t fix troubled relationships, serious depression or illness.  Plastic surgery, when approached with realistic expectations (#3) can improve self-esteem and self-confidence.

Realistic expectations – just as plastic surgery won’t result in a 25 pound weight loss, or bring back a wayward spouse, it can’t turn back the clock completely, or radically remake someone’s appearance.  There is a limit to what procedures can do; for the majority people, no amount of surgery is going to make them into supermodels.

Know the limitations

Not only are there limits to what surgery itself can do, there are limits to the amounts of procedures that people should have, particularly during one session.  “Marathon/ Extreme Makeovers” make for exciting television but are a dangerous practice.

Stay Safe:

Just as patients should avoid marathon or multi-hour, multiple procedure surgeries, patients should stay safe.

–          Avoid office procedures

As Dr. Gaspar says, “The safest place for patients is in the operating room.” With the exception of Botox, all plastic surgery procedures should be performing the operating room, not the doctor’s office.  This is because the operating room is a sterile, well-prepared environment with adequate supplies and support staff.  There are monitors to help surgeons detect the development of potential problems, life-saving drugs and resuscitation (rescue) equipment on hand. Should a patient stop breathing, start bleeding or develop a life-threatening allergic reaction (among other things), the operating room (and operating room staff) are well prepared to take care of the patient.

Communicate with your surgeon –

Give your surgeon all the details s/he needs to keep you safe, and have a successful surgery.  Talk about more than the surgeries you are interested in –

– bring a list of all of your medications

– know a detailed history including all past medical problems/ conditions and surgeries.

If you had heart surgery ten years ago – that’s relevant, even if you feel fine now.  Have a history of previous blood transfusions/ radiation therapy/ medication reactions?  Be sure to tell the doctor all about it.

Even if you aren’t sure if it matters, “My sister had a blood clot after liposuction” – go ahead and mention it.. It might just be a critical piece of information such as a family predisposition to thromboembolism (like the example above).


Surgical complications are a part of surgery.  All surgeons have them – and having a surgical complication in and of itself is no indication of the quality or skill of the surgeon.  Complications can occur for a variety of reasons.

However, how efficiently and effectively the surgeon treats that complication is a good indicator of skill, experience and expertise.

As part of this, Dr. Gaspar stresses that medical tourism patients need to prepare to stay until they have reached an adequate stage of recovery.  This prevents the development of complications and allows the surgeon to rapidly treat a problem if it develops; before it become more serious.

“There is no set time limit for my patients after surgery, everyone is different.  But none of my patients can go [return home] until I give my approval.”  This philosophy applies to more than just medical tourists from far off destinations. It also applies to any patients have large procedures and their hospitalizations.  While many surgeons race to discharge clients as same-day surgery patients, Dr. Gaspar has no hesitation in keeping a patient hospitalized if he has any concerns regarding their recovery. “Hospitals are the best places for my patients, if I am concerned about their recovery.”

About Dr. Gustavo Gaspar Blanco, MD

Plastic and reconstructive surgeon

Av. Madero 1290 y Calle E

Plaza de Espana, suite 17 (second floor)

Mexicali, B.C

Tele: (686) 552 – 9266

If calling from the USA: 1 (877) 268 4868


Dr. Gaspar attended medical school at the Universidad Autonoma de Guadalajara.  He completed both his general surgery residency and plastic surgery fellowship in Mexico City at the Hospital de Especialidades Centro Medico La Raza.

He is a board certified plastic surgeon by the Mexican Society of Plastic and Reconstructive Surgery, license number #601.  He has been performing plastic surgery for over 20 years.  Surgeons from areas all over Mexico train with Dr. Gaspar to learn his gluteal implantation techniques.

** He has also visited the facilities in Germany where the Botulism toxin is prepared for cosmetic/ and medical use.

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

Now that Colombia Moda is over – let’s get back to the stuff that really matters.. Let’s warm up but reviewing some older posts for our newer readers.

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

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

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

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

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure.  While we don’t know the circumstances behind this case – (and don’t really want to…

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Colombia ranked 11th in the world for plastic surgery: who says so??

No, not the World Health Organization (WHO), but another entity entirely, ISAPS.

Plastic surgeons in Mexico gather for a demonstration of techniques for breast reconstruction

Plastic surgeons in Mexico gather for a demonstration of techniques for breast reconstruction. Mexico is currently ranked #5 for number of plastic surgeries

 International Society of Aesthetic Plastic Surgery (ISAPS) recently published survey data ranking Colombia at 11th for volume according to the most recent statistics (2011) available.   211,879 total procedures were reported.  Colombia currently ranks #27th globally in population with a 2013 estimated population of 47 million.   Considering the modest population size of Colombia this statistic may reflect both Colombian cultural expectations and the growing trend of medical tourism.

Countries that perform the most cosmetic surgery procedures***:

1. United States: 1,094,146

2. Brazil: 905,124

3. China: 415,140

These top three nations also represent a total population of 1.86 billion people.  Brazil, in particular is also widely known as the medical tourism destination of choice for plastic surgery.

Plastic surgery in Colombia

Of the 211, 879 procedures, 65,075 or 30.7% were breast enhancement procedures.  Liposuction accounted for 23% of all cosmetic surgical procedures.

Dr. Reyes, a plastic surgeon in Bogota, Colombia operates on a patient

Dr. Reyes, a plastic surgeon in Bogota, Colombia operates on a patient

Questionable study results due to lack of participation

However, the accuracy of the data collected by a joint American – Brazilian team is questionable given the low percentage of participation by licensed member surgeons.  Out of 20,000 eligible ISAPS member surgeons, only 996 participated in the organization’s survey.  Additionally, of the .04 percent of surgeons reporting their surgical practices, 43% (431 surgeons) were based in the United States.  Of the remaining 565 surgeons represented the remainder of the worldwide plastic surgery community, 172 of these participants were from Brazil.  The final statistics provided for each country are based on estimates extrapolated from a representative sample from survey responses received.

Are the results any surprise, given the players?  But then again, maybe these results will encourage more Latin American surgeons (and surgeons in other countries) to participate more fully in the academic activities of their specialty societies.

*Mexico was also in the top five with 299,835 procedures.

***As an interesting aside, the island nation of Japan ranked fourth.

Medellin, my beautiful friend..

I don’t know how it always happens.. I set out on one kind of expedition and (frequently) it turns into something else.  So we have it.. I was planning to write extensively on Panama City, but looky, looky – here I am again, living in the fantastic, tragic beauty of Medellin.

As I wrote once before, Medellin is a city of great loveliness, but somehow Bogotá always blinded me to Medellin’s charms.. But it’s time to give Medellin a fair shake, so here I am..

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The Department of Orthopedics at Clinica San Rafael

Dr. Victor Lizcano, Chief of Orthopedics

Spent the day with several surgeons from the Department of Orthopedics at Clinica San Rafael – which has a city-wide reputation for excellence.

Dr. Victor Lizcano, MD is the charming Chief of Orthopedics who opened his busy, 11 surgeon department to me. I watched surgeries, talked to patients, reviewed films, and interviewed the surgeons in his department, with free rein.

Orthopedics surgical team; two instrumentadors and 4th year resident (center)

Dr. Maria Angela Gomez, MD, a busy surgeon who nevertheless took the time to talk to me; manages dual practices; both as a plastic surgeon (at Clinica de Marly) and an orthopedic (hand) surgeon. She’s currently involved in a very interesting research project – tell you more about it later… A very fascinating lady.

Dr. Martha Pincon, MD an orthopedic surgeon specializing in foot and ankle surgery, also a very interesting and enjoyable surgeon.

Dr. Martha Pincon, during a complex case at Clinica San Rafael

There’s a lot more to tell – but I have another interview in a few minutes..

In the OR with Dr. Mauricio Largacha, Orthopedic Surgeon

The rest of Bogota may be quiet for the Easter holidays (la semana santa) but the operating rooms were busy at Unidad Medica Cecimin.

Dr. Mauricio Largacha, Shoulder and Elbow surgeon

I spent an interesting and enjoyable morning in the operating room with Dr. Mauricio Largacha, MD for an arthroscopic Rotator Cuff Repair. Dr. Largacha is a natural teacher, and did an excellent job at explaining different aspects of the procedure, expected post operative outcomes, and specialized equipment – since I am less familiar with shoulder and elbow surgery than other surgical procedures. (Unsurprising since as I mentioned previously, he is an expert in this area, and the author of several chapters in multiple orthopedic surgery textbooks on elbow, shoulder and ankle surgery).

Dr. Mauricio Largacha (left) and author

Surgery went beautifully, and surprisingly quick.. No intraoperative complications.

Dr. Celso Bohorquez, plastic surgeon

When we first met Dr. Celso Bohorquez, he was donating his time and surgical skills for the repair of congenital facial malformations in Chia, Colombia as part of Operacion Sonrisa.

I went back, yesterday, to Clinica Shaio, to learn more about the man, and the surgeon that so generously contributes to improving the lives of the less fortunate.

Dr. Celso Bohorquez, plastic surgeon

We spent the day in the operating room, watching Dr. Bohorquez perform several techniques including a case with facial endoscopy as part of a face-lift. The results of the cases were striking.


In other news, we are discussing pre-operative and intraoperative risk reduction for peri-operative/ post operative MI (along with the high incidence of missed diagnosis) over at our sister site.

Dr. Ernesto Andrade, plastic surgeon

Dr. Ernesto Andrade is another one of Bogota’s celebrity plastic surgeons, of “Cambrio Extremo” fame.  (A latin television version of ‘Extreme Makeover’ that was popular here several years ago.)  Unfortunately, he was delayed today so I was unable to meet with him, but I did speak with a young doctor in his office, Dr. Eliana Garces.  She filled in a bit of Dr. Andrade’s biography.

I’m hoping to meet with Dr. Andrade himself  tomorrow after I get out of the operating room with Dr. Celso Bohorquez.  If you remember, I met Dr. Bohorquez out in Chia while he was volunteering his surgical skills as part of Operacion Sonrisa (Operation Smile.)

Dr. Mauricio Largacha, orthopedic surgeon

Dr. Mauricio Largacha is an orthopedic surgeon specializing in shoulder and elbow surgery including arthroscopy, rotator cuff repair and joint replacement.  I’ll be following him to the operating room this weekend – so check back in for more details..

For readers unfamiliar with orthopedic surgery – ankle and shoulder joint surgeries are a particular sub-specialty only practiced by a few orthopedic surgeons.  Luckily for readers here – Dr. Largacha is the author of several of the most heavily used textbooks (and chapters in American medical textbooks) on both ankle and shoulder surgery.

Dr. Fabian Emura, of the EmuraCenter

Dr. Fabian Emura, of the EmuraCenter

is a gastroenterologist and general surgeon here in Bogota, who specializes in the detection and treatment of digestive cancers.  Along with his clinic, he has also created two separate divisions; a foundation for promote the prevention and detection of digestive cancers, and a medical education division – which supports training physicians world-wide in the endoscopy techniques he currently uses.

Currently, Dr. Emura is the only physician outside of China, Korea and Japan (where gastric cancer is endemic, and accounts for 20% of all cancers) who is treating early stage (stage I) cancers with endoscopic surgery versus a more radical gastrectomy.  This procedure has already been well validated in Asia, where it has been used for over a decade.

Dr. Emura has also created and implemented a classification system for the grading and staging of digestive lesions.

By using chromography endoscopy (or chromoendoscopy) and a wax dye,  doctors such as Dr. Emura are better able to visualize lesions that might otherwise be missed.

His research has also focused on differentiating colon lesions endoscopically, (to prevent unnecessary surgery for benign lesions).

He is currently working on screening guidelines (particularly for populations with higher incidence of gastric cancers such as in Colombia) because one of the main problems that still exists – is that the majority of patients with stomach cancer – are diagnosed late – when treatment options are limited and noncurative.