Tag Archives: Mexicali

Talking with Dr. Gustavo Gaspar Blanco, plastic surgeon

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Dr. Gustavo Gaspar Blanco, plastic surgeon

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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).

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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).

Lastly

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

Email: gustavo@drgaspar.com

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.

Spending the day with Dr. Gabriel Ramos, Oncology Surgeon

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Spent the day in the operating rooms with one of my favorite Mexican surgeons, Dr. Gabriel Ramos Orozco.  Dr. Ramos is an oncology surgeon with offices in Mexicali (Baja California) and his hometown of San Luis Rio del Colorado in Sonora, Mexico.

Dr. Gabriel Ramos Orozco, Oncology Surgeon

Dr. Gabriel Ramos Orozco, Oncology Surgeon

In the operating room with Dr. Gabriel Ramos

We spent the day in his hometown – first at the Hospital Santa Margarita, where he performed a laparoscopic cholecystectomy, and then in his offices seeing patients.

In the operating room

In the operating room – photos edited to preserve patient privacy

Hospital Santa Marta

The hospital itself was a small intimate clinic.  The operating rooms were small but well-equipped.  We were joined by Dr. Campa, an excellent anesthesiologist and another general surgeon.  While the anesthesia equipment was dated, all of the equipment was functional.  At one point, the sensors for cardiac monitoring and oxymetry readings malfunctioned but within seconds a backup monitor was attached.  (This is a frequent occurrence in most hospitals around the world and the USA because the sensors that connect to the patient with gel are cheap disposable and somewhat fragile.)

There were several monitors dedicated to laparoscopy with good display quality.  The operating rooms had ample light and functioned well. Overall the clinic was very clean.

ramos surgery

The surgery itself proceeded in classic fashion.  The patient was positioned appropriately and safely before being prepped and draped in sterile fashion.  Since the surgery itself was of short duration, anti-embolic / DVT prophylaxis was not required but was still applied.  (Note:  in Mexico, these stockings are of limited utility – and for more lengthy procedures, TEDS or electronic squeezing devices are usually applied.)

The surgery itself was under an hour, with no bleeding or other complications. The patient was then transferred to the post-operative care area for monitored recovery from general anesthesia.

Dr. Ramos performs laparoscopic surgery

Dr. Ramos performs laparoscopic surgery

In the clinic

It was an interesting day – because he sees a diverse mix of patients.  As a general surgeon, he also operates for many of the classic indications, so there were several patients who saw Dr. Ramos for post-operative visits after appendectomies, cholecystomies (gallbladder removal) and the like.  There was also a mix of patients with more serious conditions like colon, testicular and breast cancers.  His patients were a cross section of people, from the United States and Mexico alike.

International patients

Some of these patients came for the lower cost of treatment here in Mexico, but others came due to the dearth of specialty physicians like oncology surgeons in places like Yuma and Las Vegas.  Many of these international patients spoke Spanish, or brought translators with them since Dr. Ramos is primarily Spanish speaking.

Since D. Ramos is not well-known outside of Mexico, many of these patients were referred by word-of-mouth, by former patients, friends and family.

Then it was back to the hospital twice to visit his patient post-operative.  She was resting comfortably and doing well.  It is this level of service that draws patients to his clinic both here and in central Mexicali.

This winter, Dr. Ramos returns to school so to speak – as he will be spending several months in Barcelona, Spain and Colombia learning new techniques such as uni-port laparoscopy.  He will then be able to offer these state-of-the-art treatments to his patients back here at home; whether these patients come from northern Mexico or other parts of the globe.

Highly Recommended:  Excellent surgeon with well-coordinated team.  However, patients requiring more extensive surgery (large tumor surgeries/ cytoreductive surgery) should request Dr. Ramos perform surgery in the larger Mexicali facilities for better access to advanced and specialized support services like hemodialysis etc. for sicker/ higher risk patients. 

However, the level of care was appropriate at this facility for this procedure, which is rated as low-risk.  (i.e. generally healthy patient, with straight-forward procedure)

Kim Kardashian: Better call your lawyers..

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As I mentioned previously – the ‘unauthorized’ use of celebrity images is pretty common around here.  We talked about this before in conjunction to Kim Kardashian and Rhianna – and today, while driving around Mexicali taking pictures for a section of the book on architecture, we saw yet another example of this.  (Sorry, Kim – we were in traffic, and seeing it was unexpected, so the photo is blurry – and I know, my window is filthy) – but it’s undeniably you hawking clothing up on a sign outside a clothing store on Blvd Anahuac..  Just thought you should know..

Kim Kardashian hawking cheap clothing in Mexico

In other news – spent the day trying to find the elusive “casa de Louis Vuitton” which is a house of the outskirts of Mexicali painted brown with symbols to look like a Louis Vuitton bag.  I know the house is still there – yesterday one of the people who lived near the house was lamenting being a neighbor – but the address and directions were far from correct..

I did get some more great photos of Mexicali.. including one of the fancy car dealerships down here.. (I like to remind people that Mexicali has one of the highest standards of living, and income in all of Baja)..  There is a growing middle-class here (and just like most of us), they like nice things..  It’s another side of the road photos since I wasn’t planning on taking pictures of car dealerships..

Mercedes Benz dealership

A lot more photos but I haven’t gotten around to sorting of all them yet..More architectural adventures tomorrow..

 

 

 

Reasons to write about medical tourism: #146, a cautionary tale

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As  I mentioned in several previous posts, there are numerous reasons why I write about medical tourism, and protection of the consumer is first and foremost.

Several months ago, I was told an exceedingly disturbing tale of patient abuse at the hands of a plastic surgeon here in Mexicali, MX where I am writing my latest book.  I’ve internally debated publishing information about it – not because I think the patient isn’t credible (the patient is exceedingly credible) but due to the lack of verifiable documentation and evidence related to this story.  Then again, this is exactly the reason that this American patient was so hesitant to come forward.  Ultimately, I feel that by failing to publish this account, I would be further victimizing this patient, and failing to warn consumers of the potential dangers.  It is of the utmost regret that I do not have conclusive proof to bring to the authorities (and readers) to prevent this surgeon from ever operating again.  This patient isn’t being vindictive, or seeking a payout – it’s the furthest thing from her mind.  Her only motivation is the pain, disfigurement and indignities that she has suffered, and a hope of preventing this from happening to another medical tourist.

“I wanted to go to the police, to the medical board, to someone, but how can I prove it?” the patient asks, agonizing over the episode which occurred more than a year ago.

Yet, she is still haunted by it – and the story itself is a harrowing account of  abuse of patient trust – and so it should be presented here.  Given the lack of verifiable documentation, I have omitted the name of the surgeon involved, but suffice to say, he is a popular surgeon in Mexicali, and one that I have intentionally omitted from my latest book.

The patient, who happens to be a bilingual health care provider came to Mexicali for liposuction and rhinoplasty.  While telling the story, she is embarrassed by this – as if her supposed vanity is to blame for what occurred.  It is another reason she was reluctant to report it to the police – for fear that she would be told that she deserved it.

Her surgery was botched from the beginning and almost cost her life.   A simple cosmetic procedure has profoundly damaged her physically and psychologically.   She has scars; both physical and emotional that testify to much of the trauma that occurred.

She presented for surgery that fateful morning with no sense that anything was amiss; the surgeon has an excellent reputation and she had investigated his credentials; he is in fact, a licensed plastic surgeon.  Previous patient testimonials were glowing with no hint of any problems.

The first indication there was a problem came with the initiation of the procedure.  After being given a mild paralytic, she remained conscious and aware during the procedure.  She remembers vividly being intubated by the anesthesiologist who appeared not to notice her distress.  “I could hear the heart monitor going crazy but they all ignored it.”

“There were several flashes, and that’s when I realized that the surgeon was taking pictures of me, naked, intubated and helpless.” 

She continued, “I know that many plastic surgeons take pictures for before and after photos, but no one ever asked me about it.  Also, in most clinics – they take the pictures while the patient is still awake before going into the operating room.”

“I finally lost consciousness and woke up in the recovery room.  I sensed right away that something was wrong – I had horrible pain on the left side of my abdomen and chest, and bandages on the left side of my abdomen but nothing on the right, or my face.”  [the patient had been scheduled for bilateral liposuction of the abdomen and rhinoplasty.]

Then the PACU nurse delivered devastating news; the procedure had been abandoned mid-way – with the liposuction performed on the left only, because she had gone into respiratory arrest during the procedure.  The nurse also whispered confidentially, that she was “lucky” because the surgeon and one of his staff members had been noticeably intoxicated on their arrival to the operating room, and had left immediately before the procedure [presumably] to “do some more cocaine.”

Later, when the anesthesiologist arrived, the patient questioned him gently; about her intubation experience, the abrupt discontinuation of her surgery – and as to what had happened.  “Nothing happened”, she was told repeatedly.  “Everything went absolutely fine.”  When she insisted, asking why her surgery did not match what was initially planned – the anesthesiologist left.

When the surgeon finally arrived, he was equally uncommunicative.   In answer to her questions; “Did anything happen during my surgery?” he gave repeated denials and assurances that ‘everything was fine.’   He also denied taking any photographs.

When she asked why, then, did she only have half the procedure completed, he answered, angrily, “because I changed my mind,” before stalking out.

When her family came to help her dress and leave the surgical center, there were even more surprises, a series of rounded, purplish marks on her chest.  “My mom asked if they were hickeys, and when I looked in the mirror – that’s exactly what they looked like.”  Being familiar with surgery, and medicine, I interrupted to ask if they could be from the electrodes, CPR or anything else.  “I don’t know” she answered, “but they sure don’t look like any of the marks I’ve seen on other patients before.”

These marks along with a fateful encounter as she was leaving the clinic are what haunt her to this day.  As she was leaving with her family, a young man was chuckling and staring at her as she walked past.  She looked over at him, and he started laughing, saying, “I recognize your face, [and your body] from the photos passed around the hospital.”  The photos that no one will admit to taking.

Even now – she has evidence of the botched procedure – one side of her abdomen has is lumpy and uneven with furrowed tunnels (an attempt at liposculturing, she thinks).  When comparing it to the side that was untreated – she begins to lament the folly of her procedure – and yet again, to blame herself.

“I wish I had never done it.  Now I have to see this everyday.  I am afraid to ever have surgery again (to fix it).”

At the end of the interview, she is in tears, and she leans over and whispers in my ear: the surgeon’s name.

“I wish I could prove it,” she says.  “This should never happen to anyone else.”  She states that when she went back to talk to the original nurse (from the recovery room), the nurse was no longer there – so her only collaborating witness is gone.  While her family saw the results – they were told the same story she was, that the surgery preceded normally, and that the surgeon ‘changed his mind’ in the middle of surgery.  Repeated calls to the surgeon for more information have gone unanswered.

I wish she could prove it too – the ensure that everyone knew the name of this heartless surgeon – to prevent anyone else from becoming a victim.  But even without the name, it’s a strong reason for me to continue doing what I do now.

[Readers should note that while this occurred in Mexico – unfortunately events such as this have occurred around the world.  In the 1990’s there was a widespread scandal as a notable plastic surgeon attempted to sell photos to a tabloid of Michael Jackson, Liz Taylor (among others) that were taken without their knowledge during plastic surgery procedures.]

Update:  There is a new scandal at John Hopkins in the wake of the February suicide of one of their popular OB/GYNs who is believed to have taken pictures of his patients secretly, using a mini – camera hidden in a pen.

“Likely Suicide of Johns Hopkins Ob/Gyn Tied to Secret Photos” article by Robert Lowes, Medscape, February 2013.

How’s the book coming?

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I was in the United States most of last week (at my reunion) but I didn’t stop working.  While a reunion may not seem like the most ideal situation for a medical writer – it’s actually a great opportunity to talk to people and get their opinions about health care, medicine and surgery.  After the first few minutes of catching up – talk naturally turns to everyday life, and for many of us – ‘everyday life’ involves worrying about the health of our families.. Also, many of my classmates – and old friends have been some of my biggest supporters of the blog (and my other work) so it was good to get some critical feedback.

Bret Harte class reunion

The book is coming along – almost continuous writing at this point.  While I (always!) want more interviews with more surgeons, I am now at the point where I am filling in some gaps  – talking about the city of Mexicali itself.  So I am visiting museums, archives, and talking to residents about Mexicali so I can provide a more complete picture to readers.  Right now, I would really like some information about 1920’s -30’s Mexicali – I can find a lot of interesting stuff about Tijuana, but Mexicali is proving more elusive.

It’s a bit of a change from my usual research – finding out about decades old scandals (even local haunted houses), visiting restaurants and nightclubs, but it’s been a lot of fun., even if it seems frivolous or silly at times.  I hope readers enjoy this glimpse into Mexicali’s rich history as much as I have.

Finished the cover – which to me, is critical at this point.  (I use the cover to inspire me when it comes to the less than thrilling stage of copy editing) so I am posting an image here.

cover for the new book

Meeting with an architect later this week – to learn about, and write about some of the variety of styles here in Mexicali.  (There is such a surprising array – I thought it would be nice for readers to have a chance to know a bit more.)

Now there’s one house I’ve dubbed “Mexicali’s Graceland.”  I don’t know why Graceland comes to mind every time I go past this home (it looks nothing like Elvis’ home in Memphis) but the term has stuck.  I am hoping to get some of the history on this house because it just looks like a place where even the walls have stories to tell.

The pictures aren’t the most flattering – but I’ll post one so you can tell me what you think.  (It’s actually far more lovely in person – with the contrast between the pink walls and the white scrollwork, as well as some of the more classic design features.) I guess my imagination tends to run away with me – with images of grandeur and elegant ladies sipping champagne in the marbled halls of the past – but then – most of my usual writing is technical in nature, so I have few outlets for my creativity.

Mexicali’s Graceland

Meeting with my co-writer today to go back to the archives..

In the operating room with Dr. Enrique Davalos Ruiz, Neurosurgeon

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Dr. Enrique Davalos Ruiz, Neurosurgeon

Spent the morning in the operating room with Dr. Davalos.  As we discussed in a previous post, Dr. Davalos is one of just a few neurosurgeons here in Mexico to specialize in both adult and pediatric neurosurgery procedures.  He performs a wide range of procedures such surgery for cerebral tumors, spinal bifida, hydrocephalus, trauma, spinal surgery and epilepsy.  But one of the procedures he is best-known for here in Mexicali is the surgical repair of craniosynostosis.  However, if you’ve ever watched this intricate procedure – ‘repair’ really isn’t the word that comes to mind to describe the procedure.  ‘Rebuild’ is much more appropriate.

Craniosynostosis is a congenital cranial deformity caused by the premature fusion of the cranial sutures.  (These sutures allow for the babies head to be slightly compressed during natural childbirth).  Many new moms can attest that their neonate’s head was temporarily ‘squashed’ looking at birth, but normalize over the first few days as the bones relax into their natural position.  In normal development, these sutures (or ridges where the bones come together) are not yet fused  – and fuse over the first few months of life.

When the bones that comprise the skull fuse early, it can result in a significant cranial abnormality.  (Luckily, in most cases of [primary] craniosynostosis – the patient’s brain functions normally despite this.)

To treat this surgically, Dr. Davalos had to essentially rebuild part of the skull (the coronal sections of the parietal and frontal bones).   He did this by removing and reshaping the skull in separate sections and then rejoining the pieces to conform to a more natural shape.  (As a someone who sews, it reminded me of lacing a corset to get curved shaping).   In a child of this age – the bones should fuse/ heal within approximately six weeks – with no long term limitations for activities.

Sterility was maintained during the case, and everything proceeded in a rapid and appropriate fashion.  Anesthesia was proficient during the case, with excellent hemodynamic stability and oxygenation.

Dr. Davalos beveling a portion of the skull

Dr. Enrique Davalos Ruiz, MD

Pediatric and Adult Neurosurgery specialist

Calle B No 248

entre Av. Reforma and Obregon

Zona Centro

Mexicali, B. C.

Meet Lupita Dominguez, surgical nurse

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Had an amazing day yesterday – one of those days that reminds you how much we can do in medicine when we all work together.  I am hoping to write it up as a case study – if not – I will tell you more about it here.  (The patient was exceedingly gracious when I asked permission.)

But this morning, I was back in the operating room with Dr. Cuauhtemoc Vasquez.  (If he is tired of me – he sure doesn’t let on..)

I finally had the opportunity to get some of the pictures I’ve been trying to get on every visit to his OR – to show readers the heart, and the pulse of cardiac surgery..

There’s a running joke in Mexicali – if you need help in the operating room, any operating room, in any of the hospitals in the city; just holler for Lupita because she’s always there.

Introducing Lupita Dominguez, surgical nurse

All kidding aside on the popularity of the name “Lupita” among operating room personnel, there is just one Lupita that I would like to talk about today,  Lupita Dominguez, who is Dr. Vasquez’s surgical nurse.  In the months, and the numerous occasions that I have been a guest in Dr. Vasquez’s operating room, I’ve had the opportunity to observe and appreciate the hard-working Lupita.

Lupita Dominguez with Dr. Vasquez

Teacher, Coordinator and Mind-Reader

Most people don’t know it – but Lupita has the hardest job in the operating room, and probably (in Mexico) the most poorly paid.   They say a good scrub nurse has the instrument in the surgeon’s hand before he knows he needs it – and from what I’ve seen, that’s Lupita.  She’s here an hour earlier than the rest of the surgical team, getting everything ready, and she’ll be here after everyone else escorts the patient to the intensive care unit.

Here she is, a blur of motion as she takes care of everyone at the operating room table

As I watch again today, she is ‘running the table’ and anticipating the needs of not just one demanding cardiac surgeon, and an additional surgeon, but also one surgical intern, and another student.  With all of these people crowded at the table, she still has to follow the surgery, anticipate everyone’s needs and keep track of all the instruments and supplies in use.  In the midst of this maelström, the scrub nurse has to ensure that everyone else maintains sterility while preventing surgical instruments from being knocked to the floor, or otherwise misplaced (a difficult task at times).

Here she is demonstrating how to correctly load the needle, and pass sharp instruments

She’s forever in motion which has made taking the few photos of her a difficult endeavor; She’s shaving ice for cardioplegia, while listening to the circulator, adjusting the OR lights, and gently guiding the apprentices.  She’s so gentle in her teaching methods that the student doesn’t even realize she’s being led, and relaxes enough to learn.  This is no easy task, particularly since it’s just the beginning of the July, and while bright-eyed, pleasant and enthusiastic, the new surgical resident is inexperienced.  Her own student nurse, is two parts shy, but helpful enough that near the end of the case, (and the first time since I’ve known her), Lupita actually stops for a moment and flashes me a wave when she sees the camera faced in her direction.  I’m surprised, but I manage to capture it.

a very rare moment – Lupita takes a millisecond to say hello

She is endlessly busy, but ever uncomplaining – even when a scheduled surgery takes an unexpected turn and extends to twelve or even fourteen hours.  Bladder straining perhaps, baby-sitter calling, but Lupita never complains.  She’s not unique in that – scrub nurses around the world endure long hours, tired feet and legs, hungry bellies, full bladders, and aching backs as they complete their days in the operating room.  But she does it with good nature and grace.

Lupita assisting Dr. Vasquez during surgery

The surgical nurse

In the United States, this important job has been lost to nursing, a casualty of the ongoing shortage.  Positions such as scrub nurse and others like it have been frequently replaced with technicians who require less training and thus, less compensation that nurses.  Maybe the nursing profession doesn’t mourn the loss; but I do.

as you can see – here she is, ‘behind the scenes’ so to speak..

But in Mexico, and many other locations, this position remains the exclusive domain of the nurse.  Nurses such as Lupita, spend three years studying general nursing in college, before completing an (optional) additional year of training for a specialty such as the operating room.  After completing this training, these nurses spend yet another year in public service.

The idea of the public service requirement is honorable yet almost ironic (to me)  at times, since the majority of nurses in Mexico will spent their careers in public facilities, and by definition (in my mind at least), nursing is an occupation almost entirely devoted to the service and care of others.

Working conditions vary but some constants

Depending on the country, the culture, and the facility; conditions may vary; nurses may get short breaks, or be relieved during particularly long cases.   The only constant is the cold, and the hard floors, and rickety stepstools[1].  While the nurses here tell me that the workday is only seven hours long – I’ve been in the operating room with these ladies before, and watched a supposed ‘seven-hour’ day stretch to fifteen.   But it is just part of being a nurse.

[Usually I tell people when I am writing about them – but on this instance – there was never an opportunity.. but she (and all the nurses in the OR with Dr. Vasquez) certainly deserve mention.]

[1] Temperatures are set lower in cardiac surgery rooms.  Why the stepstools always seem rickety, I have no idea.

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..

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..

Saturday in Mexicali

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

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

Betty Diner

Av. Honduras #123

Esq. on Bogotá

Col. Cuauhtemoc Sur

Mexicali, B.C

(near the Plazita)

Open 8am to 9am – closed Mondays..

Betty Boop restaurant

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

with the requisite chips and salsa..

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

the smiling staff at the Betty diner

All and all – it was a nice lunch.

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

The Hello Kitty store

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

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

Spending the weekend with Dr. Vasquez, and medical photography

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

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

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

harvesting the radial artery

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

the beige operating room

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

Dr. Vasquez, and Lupita, scrub nurse

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

Lalo peeks over the curtain..

Dr. Gutierrez (Lalo) in the cardiac OR

Medical Photography

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

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

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

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

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

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

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

In  other news/ happenings: Upcoming elections!**

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

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

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

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

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

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

Dr. Gabriel Ramos, Oncology Surgeon

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Dr. Gabriel Ramos, Oncologic Surgeon

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

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

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

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

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

Operating room nurses at IMSS

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

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

Dr. Gabriel Ramos in the operating room

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

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

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

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

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

after the successful removal of a large tumor

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

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

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

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

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

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

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

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

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

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

Dr. Ham (left) and Dr. Abril

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

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

Dr. Ham

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

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

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