Tag Archives: medical tourism in Mexicali

Mexicali and Medical Tourism

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As I mentioned in a post earlier this week, the New York Times article  by Jennifer Medina has really gotten Mexicali officials to sit up and take notice.  The NYT article was just one part of a ‘medical tourism plan’ outlined by the mayor of Mexicali and other government officials.

turismo medico

city of Mexicali

Right now the outline consists of several points:

1. Guide to medical services – they have published a book with the names and addresses of surgeons interested in participating in medical tourism.

2. Transportation – mainly by automobile and buses.  The medical tourism lane at the border was part of this.

3. A plan for a 32 block medical tourism zone.

A good start, and it shows forethought – but as I listened to their outline it prompted my own (humble) suggestions:

1. Medical guide – make this a ‘real’ guide not a phone book of surgeons and providers offering their services.  It should be comprehensive, and offer more than just names and addresses, ideally written as an independent review.. But then take the risk that maybe everything, and every service won’t come out shining..   (Admittedly, this is something I understand the best).

2. Transportation – consider approaching Volaris or another carrier to offer direct flights once or twice a week from Las Vegas, Dallas and Los Angeles.  Right now there are no direct flights from Mexicali to the United States.  By offering direct flights – Mexicali could be much more competitive with both Tijuana and Las Vegas (which is pursuing its own medical tourism strategy to make Las Vegas a medical tourism destination.)  This would play to Mexicali’s two biggest strengths:

1.  It’s proximity to the United States

2.  It’s reputation as a ‘safe’ destination in comparison to Tijuana and other border cities which have their own medical tourism ideas..

It would also open up Mexicali to a much wider market since both Dallas and Los Angeles is a hub for several American carriers serving Canada and the USA.

2. Consider changing the 32 block ‘medical tourism zone’ into one large facility offering dedicated service lines.  While all the small private hospitals in Mexicali will hate this idea – instead of fighting over patients, they would have the advantage of having one large facility with pooled resources.

This would also address the weaknesses of medical tourism in Mexicali: Right now each facility has five (or two) ICU beds, and just 10 or so post-operative beds.  It would also eliminate some of the waste caused by the costly duplication of services – since each hospital currently struggles to offer CT scans, cath facilities and other costly equipment.  As part of a long-range plan – this would better enable the providers and facilities in Mexicali to seek outside accreditation/ and certification of programs and service lines, which in turn would attract more patients.

In the meantime, participating hospitals could convert to specialty facilities (ie. an orthopedic hospital, and plastic surgery center etc.) while the new facility is being built.  This would also reduce the stress on doctors traveling all over town to see just one or two patients at each facility.. If medical tourism really gets going here – these doctors are going to need as much time as they can get; caring for patients..

The centralized large hospital would also enable people like Dr. Vasquez to really get his cardiac surgery program off the ground.  More specialized ancillary services like physical and rehabilitative services would also be pooled and would improve the quality of services in the city, for everyone, including the people of Mexicali who also suffer from the lack of large, comprehensive facilities.   This also brings me to my next point –

3.  Since the city and government of Mexicali is involved in the project – there needs to be a clear and comprehensive plan about how the revenue from this project is going to serve the people of Mexicali.  After all – their tax dollars are helping to fund this ingress into medical tourism, so they need to get something out of it.. Like a PET scanner or some other service that doesn’t currently exist in Mexicali.

4. Don’t forget the rest of Baja – there are an awful lot of retirees and such living in southern Baja – so make sure they know about what your city has to offer.  These people need hip replacements, heart surgery and a whole spectrum of services that are very limited in their geographic area.  Give them a reason to come to Mexicali instead of Ensenada or Tijuana by courting their business.

If anyone from Mexicali reads this post – I hope they can see my suggestions, in the spirit that they are given.  Mexicali has a lot of opportunity here, and the potential to be a great place for a wide range of medical tourism – not just bariatrics and plastic surgery, but they need more comprehensive, and long-range strategies to put their plans into action.

Today was a great example of how much the city has accomplished by working together – with a little more work, and a lot of vision – Mexicali could really go far, and provide great services to more than just a bunch of gringos..

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..

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..

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.

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?

Crime and Violence in Mexicali, Mexico

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Update:  May 15, 2012:  Newest estimates place the 6 year murder total at 55,000 for Mexico.  This latest incident in Monterrey is just heart-breaking – Monterrey used to have the reputation of being the safest of ALL Latin American cities.

As I’ve said before, Mexico border towns have a nasty reputation – and have had this reputation for decades.  Recently, it’s gotten worse, and the state department has issued multiple warnings to American travelers.

In fact, if you scan the headlines of American newspapers – you get the impression that it’s spiralled into open warfare in the streets..  and maybe it has in other cities, (notably Juarez).  But Mexicali – well I am just not sure.

The feeling of fear is notably absent here.  That wasn’t the case during my visits to Bogotá and Medellin, which were terrorized by Pablo Escabar and his minions in the 80’s and 90’s.  Despite dramatic decreases in crime in Bogotá (where I spent the majority of my time in 2011) the populace remained afraid – and acted accordingly.  It wasn’t unusual to see security guards armed with machine guns outside private businesses and on street corners in more affluent neighborhoods.   Hospitals were another secured environment – as someone who toured multiple institutions in that city – I endured countless scrutiny from security officials who searched all bags, and parcels and demanded documentation before allowing entry.

Security on a street corner in an upscale Bogota neighborhood

Admittedly, all of that seemed excessive to outsiders like me – who never had to deal with the violence (bombings and killings) that native Bogotanos endured.  But still, many Bogotá residents remained afraid – including my friends and neighbors who were often horrified by my adventures into the southern parts of the city.

But it doesn’t feel that way here – my friends never caution me about my travels; women don’t travel in packs – gripping their belongings tightly to their chests, taxis aren’t viewed as potential vehicles for kidnapping, rape or extortion.

I live just a few streets from the main trauma hospital, and while I occasionally hear sirens, it isn’t incessant (I heard more living next to the trauma hospital in Flagstaff, Arizona), and I have no way of knowing whether it’s police, fire or ambulances.

But I also study at that same hospital, and while I see ambulances bringing in patients strapped to gurneys, they haven’t been gunshot victims, or blood-splattered people who I’ve seen wheeled inside.  I’ve wandered around the ER with my instructor on several instances, and see a lot of the usual – people having heart attacks, strokes, respiratory problems..  Certainly none of the blood and guts from a typical episode of Gray’s Anatomy..

In fact, during my entire month here so far – we’ve only had one patient that had been stabbed on our service – about the same frequency as I saw in my native Danville, Virginia, which is a sleepy southern town.

But then again – maybe that’s the lure; as this 2009 LA Times article suggests that this apparent ‘tranquility’ is part of a larger plot orchestrated by drug cartels..  I kind of have a harder time believing that – I just don’t think that organized crime is so effective yet scattered – that they can prevent bank robberies, etc.. in one city – and have gun battles in the streets with police in neighboring cities..  The local Calexico paper also carried a similar story in 2010- but it’s not well written and makes some pretty larger leaps..  ( I have a much easier time believing the statistics presented by Professor Torres – which show Mexicali to have fewer homicides than Tijuana (somewhat lower than expected but no astronomical deviations from norms.). In his report, he concedes that Mexican homicide rates overall exceed that of the US, but that Mexicali itself compares with Savannah, Georgia (which has only about 1/3rd of Mexicali’s population.)

Does that mean I’ve been lulled into a false sense of security, or that I think Mexicali is crime free?  Of course not – as a city (any city) with almost a million residents, there is certainly crime, and drugs.. and with this – usually comes violence..   But how much?  I suspect some of  the hoopla is politically motivated and carefully crafted rhetoric, like suggested in this 2011 USAToday article..

So, in order to find out more about the realities of the situation – I am planning on asking the director of the emergency room (who I met on a previous visit), if I can come hang out this Saturday night – and get a better feel for the situation..

We knew it would happen…

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well, I guess we all knew what was coming next.. There was no way I could really stay still – and not interview some more surgeons while I was down here. So I thought I would start with two more specialities that are near and dear to my heart – and those of my readers; cardiac surgery and bariatric surgery.

I will be talking to Dr. Vasquez – who you may remember from a previous post (during an earlier visit to Mexicali) and Dr. Horatio Ham, a bariatric surgeon who also hosts the radio show, Los Doctores on 104.9 FM.

In the operating room with Dr. Carlos Ochoa, thoracic surgeon

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Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8

[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

Thoracic Surgery in Mexicali, Baja California

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As most readers know, Thoracic surgery is my absolute passion – and it’s a big part of my day-to-day life, too.. So, it was a great pleasure to spend this morning talking to Dr. Carlos Cesar Ochoa Gaxiola, here in Mexicali.

Dr. Ochoa is one of those surgeons that make this project so worthwhile.  He is enthusiastic, and enjoys what he does.  Talking with young surgeons like Dr. Ochoa seems to restore my faith in the future – which is desperately needed sometimes after reading (and reporting) all of the negative headlines regarding the health care crisis; shortages of vital medications (and surgeons!), escalating and out-of-control costs, fraudulent practices and patient mistreatment.

For more on this morning’s interview, see my sister site, www.cirugiadetorax.org

He kindly extended an invitation to visit the operating room, and see more about his practice – so I’ll give a full report on my next visit to this city.

In the meantime, I am enjoying the mild (and sunny) winter weather.