Gluteal implants

In the operating room with Dr. Gustavo Gaspar Blanco


Dr. Gustavo Gaspar, plastic surgeon

Dr. Gustavo Gaspar, plastic surgeon

In the operating room with Dr. Gustavo Gaspar Blanco

Hospital de la Familia,

Mexicali, B.C.

Mexico

After interviewing Dr. Gaspar, he graciously invited me to join him in the operating room as an observer for several cases during the week.

Hospital de la Familia

As reviewed in the Mexicali! mini-guide to medical tourism, Hospital de la Familia is widely acknowledged as “the second best hospital in Mexicali.”  Much like the Hertz automobile rental campaign “We try harder,” the directors of Hospital de la Familia have embarked on an aggressive publicity campaign to attract patients and physicians to their facility.  This includes medical tourism – as Hospital de la Familia has partnerships with multiple brokers including PlacidWay and Planet Hospital.

Dr. Gaspar exclusively operates at Hospital de la Familia.

In the ORs at Hospital de la Familia

OR #3 is the plastic surgery suite.  It is spacious and well-lit with modern and functional equipment.  Along with a designated OR, Dr. Gaspar has an operating room team consisting of an anesthesiologist, an assistant surgeon, scrub nurse and circulating nurse.

Dr. Gaspar and his OR team

Dr. Gaspar and his OR team

Anesthesia is managed by Dr. Armando Gonzalez Alvarez.  He monitors the patient with due diligence and remains in attendance at all times.  He avoids distractions during surgery (like texting or excessive cell phone use) and remains patient-focused.

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Binicio Leon Cruz, is a general surgeon who serves as Dr. Gaspar’s assistant surgeon during the case.  Monica Petrix Bustamante is the instrumentadora (scrub nurse), and she is excellent, as always*. She knows the surgeries, easily anticipates the doctors’ needs while maintaining surgical sterility and ensuring patient safety.

Monica prepares a prosthesis for implantation

Monica prepares a prosthesis for implantation

Adherence to international protocols

The majority of procedures are under an hour in length, which means that patients do not need deep vein prophylaxis during surgery.  The procedure (including site) and patient identity are confirmed prior to surgery with active patient participation before the patient receives anesthesia with both surgeons, nursing staff and the anesthesiologist in attendance.  Patients are then prepped and draped in sterile fashion, with care taken to prevent patient injury.

As with many plastic surgeons, Dr. Gaspar does not administer IV antibiotics for infection prophylaxis prior to the first incision.  Instead, all patients receive a course of oral antibiotics after surgery***.

Surgical sterility is maintained throughout surgery.  For the first case, after receiving adequate tissue preparation, since only limited liposuction is needed (for very specific sculpting), the patient receives manual liposuction (without suction) to prevent overcorrection or excess fat removal.  Despite having significant adhesions due to previous liposuction procedures, there is very minimal bleeding during the procedure.

Following the procedure, the patient is awakened, extubated and transferred to the recovery room for hemodynamic monitoring and adequate recovery prior to discharge.

Throughout the case, (and during all subsequent checks in the PACU), the patient is hemodynamically stable, and maintains excellent oxygenation.

The second case, is a breast augmentation revision – in a patient with a previous breast reconstruction after mastectomy for breast cancer.  The patient developed a capsular contracture which required surgical revision**.

Abdominoplasty

On a separate occasion, Dr. Gustavo Gaspar performed an abdominoplasty with minor liposuction of the “saddle bag” area at the top of the thighs.  For the abdominoplasty case, the patient received conscious sedation with spinal anesthesia.

While an abdominoplasty, “tummy tuck” is a much larger procedure, the case proceeded quickly (1 hour 15 minutes), and uneventfully.  There was very minimal bleeding, and excellent cosmetic results.

skin, and adipose tissue removed during abdominoplasty.

skin, and adipose tissue removed during an abdominoplasty

Gluteal augmentation (Gluteoplasty)

However, it was the gluteal augmentation case that attracted the most interest.  As mentioned during a previous interview, Dr. Gaspar is well-known throughout Mexico for his gluteal implantation technique.

Pre-surgical planning

Pre-surgical planning

Due to the proximity to the anus, and potential for wound infection and contamination, the area is prepped in a multi-step process, in addition to the standard surgical scrub.  A Xoban (iodine impregnated dressing) is applied to the area to prevent bacterial migration to the area around the incision.

For this procedure, Dr. Gaspar uses gluteal prostheses for intramuscular implantation.  Using one, small 3 cm incision, Dr. Gaspar dissects through the gluteal tissue to the muscle plane.  He then inserts the prosthesis and adjusts it into its final position.  When he has finished placing the implant, it is buried deep in the tissue and invisible.

after the implant is placed within the muscle it is invisible to the eye

after the implant is placed within the muscle it is invisible to the eye

He explains that by placing the prostheses in the intramuscular layer, the implants remain in a stable position, and are invisible to the eye and imperceptible to the touch.  (Even with movement and manipulation – there is no edge or pocket seen or felt after the gluteal prosthesis is placed).

The procedure is repeated on the opposite side.  Two small drains are placed, and the incision is closed.  The entire procedure has taken just 18 minutes.

incision and drains at the conclusion of surgery

incision and drains at the conclusion of surgery

Despite the speed by which Dr. Gaspar operates, he is meticulous in his approach. He frequently re-assesses during the procedure (particularly during bilateral procedures) to ensure symmetry of results.

*I frequently encountered Ms. Petrix during previous visits to the operating rooms at Hospital de la Familia during research and writing of the Mexicali book).

** Capsular contraction is one of the most frequently occurring complications of breast augmentation using breast prosthesis (implants).

*** this practice is somewhat controversial but the most recent surgical guidelines and literature on antibiotic stewardship suggest that pre-operative antibiotics may be unnecessary for some surgical procedures.

Thank you to the kind patient who graciously gave permission for publication of pre-operative, intra-operative and post-operative photographs on this site.

Additional readings: Gluteoplasty

The majority of publications originate in Latin America and Latin American journals (and are written in Spanish and Portuguese.)  Here is a small selection of open-access, English language journals.

Bruner, T. W., Roberts, T. L. & Nguyen, K. (2006).  Complications of buttocks augmentation: Diagnosis, management and prevention.  Clin Plastic Surg 33: 449 – 466.

Cardenas – Camarena, L. (2005). Various surgical techniques for improving body contour.  Aesth. Plast. Surg. 29:446-455.

Cardenas- Camerena, L. & Palliet, J. C. (2007).  Combined gluteoplasty: Liposuction and gluteal implants.  PRS Journal, 119(3): 1067 – 1074.  Part of a series on gluteal augmentation.

Harrison, D. & Selvaggi, G. (2006). Gluteal augmentation surgery: indications and surgical management.  JPRAS 60:922-928.

Dr. Gustavo Gaspar

Talking with Dr. Gustavo Gaspar Blanco, plastic surgeon


Dr. Gustavo Gaspar Blanco, plastic surgeon

Gaspar 083

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

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

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

Gluteal Implants versus Fat Grafting

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

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

Breast Implants and attention to detail

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

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

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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.

performing fat grafting

In the operating room with Dr. Luis Botero, plastic surgeon


Please note that some of the images in this article have been edited to preserve patient privacy.  

Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin.  He is performing full-body liposuction and fat grafting of the buttocks.

Dr. Luis Botero, in the operating room

Dr. Luis Botero, in the operating room

The facility: IQ Interquirofanos

Interquirofanos is located on the second floor

Interquirofanos is located on the second floor

IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado).  The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.

The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.

The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications.  There are crash carts available for the operating rooms and the patient recovery areas.

There are fourteen monitored recovery room beds, while the facility currently plans for expansion.  Next door, an additional three floors are being built along with six more operating rooms.

Sterile processing is located within the facility with several large sterilization units.  There is also a pharmacy on-site.  The pharmacy dispenses prosthetics such as breast implants in addition to medications.

The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan).  In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.

In the past seven years, over 31,000 procedures have been performed at Interquirofanos.  The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.

Prior to heading to the Operating Room:

Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed).  Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days.  Patients should not resume these medications until approved by their surgeon.

Complication Insurance

All patients are required to purchase complication insurance.  This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy.   All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.

Today’s Procedures: Liposuction & Fat Grafting

Liposuction – Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures.   First the surgeon makes several very small slits in the skin.  Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding.  After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure.  For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.

During this procedure, the surgeon introduces different canulas (long hollow tubes).  These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister.  To break up the fat, the surgeon uses a back and forth motion.  During this process – one hand is on the canula.  The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.

fat being removed by liposuction

fat being removed by liposuction

Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal.  Swelling may last up to a month.  Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.

Types of liposuction:

In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.

Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.)  Some of these canulas have serrated bores for easier fat removal.

Ultrasound-assisted liposuction uses the canulas  to deliver sound waves to help break up fat tissue.  These canulas are designed for patients who have had repeated liposuction.  This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.

Laser liposuction is another type of liposuction aimed at specifically improving skin contraction.  This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy.  However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.

During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade).  The application of heat is believed to stimulate collagen production (for skin tightening).  Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects.  There is also a risk of burn trauma during this procedure.

There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.

Fat Grafting

Fat from liposuction procedure to be used for buttock augmentation

Fat from liposuction procedure to be used for buttock augmentation

Fat grafting is a procedure used in combination with liposuction.  With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.

In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance.  Injecting into the muscle tissue also helps to preserve the longevity of the procedure.  However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream.  To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.

Results are immediately appreciable.

fat being injected for buttock augmentation. (Photo edited for patient privacy).

fat being injected for buttock augmentation. (Photo edited for patient privacy).

The Surgery:

Patient was appropriately marked prior to the procedure.   The patient was correctly prepped, drapped and positioned to prevent injury or infection.  Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis.  Pre-operative procedures were performed according to internationally recognized standards.

Sterility was maintained during the case.  Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.

His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.

Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case.  Ms. Perez was readily available to obtain instruments and supplies as needed.

Overall – the team worked well together and communicated effectively before, during and after the case.

Anesthesia was managed by Dr. Julio Arango.   He was using an anesthesia technique called “controlled hypotension”.  (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)

Controlled Hypotension

However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range.  This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance.  This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.

With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60.  This reduces the incidence of bleeding.

However, this technique is not safe for everyone.  Only young healthy patients are good candidates for this anesthesia technique.  Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you.  People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke.  Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.

The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important.  Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.

Dr. Julio Arrango keeps a close eye on his patient

Dr. Julio Arango keeps a close eye on his patient

However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia.   After intubating the patient, he maintained a close eye on vital signs and oxygenation.  The patient is hemodynamically stable with no desaturations or hypoxia during the case.  Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery.  Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.

He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.

Surgical apgar score: 9  (however, there is a point lost due to MAP of 50 – 60 as discussed above).

Results of the surgery were cosmetically pleasing.

Post -operative care:

Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the  nurses.

The patient also receives prescriptions for several medications including:

1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.

2. Non-narcotic analgesia (pain medications).

3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.

The patient will wear a support garment for several weeks.  She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.

Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).

Follow-up appointments:

Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday).  He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)

* Fat embolism is a risk with any liposuction procedure.

**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.

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Is your ‘cosmetic surgeon’ really even a surgeon?


The answer is “NO” for several disfigured patients in Australia, who later found out that a loophole in Australian licensing laws allowed Dentists and other medical (nonsurgeons) professionals to claim use of the title of ‘cosmetic surgeon’ without any formalized training or certification in plastic and reconstructive surgery (or even any surgery specialty at all).

In this article from the Sydney Morning Herald, Melissa Davey explains how dentists and other nonsurgical personnel skirted around laws designed to protect patients from exactly this sort of deceptive practice, and how this resulted in harm to several patients.

As readers will recall – we previously discussed several high-profile cases of similar instances in the United States, including a doctor charged in the deaths of several patients from his medical negligence.  In that case, a ‘homeopathic’  and “self-proclaimed” plastic surgeon, Peter Normann was criminally indicted in the intra-operative deaths of several of his patients.  The patients died while he was performing liposuction due to improper intubation techniques.

But at least, in both of the cases above – the people performing the procedures, presumably, had at a minimum, some training in a medical/ quasi-medical field..

Surgeon or a handyman

More frightening, is the ‘handyman’ cases that have plagued Las Vegas and several other American cities – where untrained smooth operators have preyed primarily on the Latino community – injecting cement, construction grade materials and even floor wax into their victims.

How to protect yourself from shady characters?  In our post, “Liposuction in a Myrtle Beach Apartment” we discuss some of the ways to verify a surgeon’s credentials.  We also talk about how not to be fooled by fancy internet ads and the like.  (Even savvy consumers can be fooled by circular advertisements designed to look like legitimate research articles as well as bogus credentials/ or ‘for-hire’ credentials*. )

*We will talk about some of the sketchy credentials in another post – but the field is growing, by leaps and bounds..More and more fly-by-night agencies are offering ‘credentials’ for a hefty fee (and not much else.)

Beauty, at any price?

Miami plastic surgeon tied to multiple deaths


From the Miami Herald comes a terrifying story about a plastic surgery group tied to multiple patient deaths.  The surgical group which operated out of three different south Florida clinics are responsible for at least three deaths, including the recent death of a young woman from West Virginia, Heather Meadows, 29,  who had traveled to south Florida looking for cheap plastic surgery.

bandaid

In addition to this case, come reports that the group housed post-operative patients in a local horse stable.  The clinics; Encore Plastic Surgery in Hialeah, and two Miami clinics; Vanity Plastic Surgery and Spectrum Aesthetics have also been linked with multiple serious medical complications including the case of Nyosha Fowler who was comatose for 28 days after surgeons at the clinic accidentally perforated her intestine and then injected the fecally contaminated fluid into her sciatic nerve during a liposuction/ fat transfer procedure.  Ms. Fowler, who is lucky to be alive, is now permanently disabled and facing a two-million dollar medical bill for the life-saving care she received at an outside facility.

Now, Heather Meadow’s death has been ruled accidental, which is no comfort to her family or the numerous patients harmed by these surgeons. While the state of Florida has reprimanded two of the surgeons in the surgical group in the past, this hasn’t affected their practice, and the surgical clinics continue to accept new patients from across the United States and operate on unsuspecting clients.

money

Beauty, at any price?

While Florida state health officials issued an emergency restriction prohibiting one of the group’s surgeons, Dr. Osak Omulepu from operating, no charges have been made despite cell phone photographs documenting horrific conditions at the horse stables where patients were forced to stay while they recuperated from various procedures.  In fact, Dr. Osak Omulepu continues to have four star ratings on several online sites.  His license is listed as active on the Florida Medical Board, with no complaints listed under his profile page.  However, under the disciplinary actions page, there are eight separate listings that do not appear on his general profile.

One of these Complaints, (posted here) related to the death of a 31-year-old woman due to repeated liver perforation during liposuction.  The complaint also cites several other cases against the doctor and notes that Dr. Osak Omulepu is not a board certified plastic surgeon.  In fact, according to the complaints filed in March, the good doctor, holds no certification in any recognized medical specialty.

Related posts:

Plastic surgery safety & Buttloads of Pain

Patient satisfaction scores vs. clinical outcomes: The Yelp! approach to surgery

Is your ‘cosmetic surgeon’ really even a surgeon?

Patient Safety & Medical Tourism

Liposuction in a Myrtle Beach apartment

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Cano Cristales in La Macarena


Cano Cristales

Cano Cristales

Just got back from a four-day trip to Cano Cristales – and it was fantastic.  I went with a Colombian travel company – which I think made the trip all the better.  (I am getting ready to go on another adventure trip with a foreign company – so when I get back – I will compare the two.)

The company offers a couple different trip options – but I thought the trip on a chartered plane directly from Medellin sounded the most interesting, so that’s what I chose.  There were 19 of us on the trip out from the airport in central Medellin (Enrique Olaya Herrera airport) – all Paisas (Medellin residents) except myself.  Immediately, all our my fellow travelers embraced me – as they were entrusted by the travel agent to ‘take care of the gringa’.  It was very endearing, actually.

getting on the plane

getting on the plane

There were several nurses on the trip – so we bonded right away..

With my travel companions

With my travel companions

The Airport at La Macarena in Meta, Colombia

The Airport at La Macarena in Meta, Colombia

So it was at little sad – when arrived and they mixed and subdivided our group with another smaller group – except that they all turned all be awesome too!

So I ended up as part of a group of six – (including our guide, Sergio).. For someone who wanted to learn more about Colombia, I couldn’t have created a better group.  In our little band, there was a biologist, a microbiologist, an anthropologist and a meteorologist – and it was all random.  Everyone was from Medellin and they had all come to enjoy the park.

with a group of Colombian experts

with a group of Colombian experts

On the River

After arriving, we headed down to the Guayabero river for a boat trip to the first part of the hike.

From our daily jaunts down the river – we then proceeded to have all kinds of fun – from 4 X4ing to the next trail, to long hikes from the plains into the jungle..  Stopped at multiple points of the river, to enjoy the sights and to swim in the cool waters.  (It’s high 90’s with 95% humidity – so the water felt great!)

As I mentioned in a previous post – I left my trusty Nikon (and polarized lenses) back at home so these photos don’t even begin to capture how beautiful it really is.

best800

Swimming in the river – 

One of the best times was swimming near a waterfall in the middle of a torrential downpour.. Unfortunately, my camera had already taken a bit of a swim downriver so I don’t have any photos.. (But I did manage to salvage the photos and the camera – with help from a bag of rice).

Cowboys!

on the way back to the river from the trail we got to see the traditional Colombian way of life here on the plains as the cowboys were rounding up their herd.

Just as we were walking to the boats – we saw a group of people staring at something on the ground. As we got closer, I saw that it was some kind of furred animal.  Was it a goat – I couldn’t tell.  I was initially reluctant to get closer – it looked half dead laying on the ground in the blazing sun, eyes dull and glassy.  But as I got closer, it started to move – and it wasn’t a goat or barnyard animal at all.

What the heck was it? I didn't know but it looked sick to me..

What the heck was it? I didn’t know but it looked sick to me..

It was a perezoso (or Sloth in English), which had wandered out of the nearby forest and was now lost.

The biologist in our group immediately organized the group to entice the animal on to a tree branch, to carry across the field, out of the heat and the sun into the forest.  (It felt about 20 degrees cooler when we got there.)  The animal perked up and quickly climbed up into a tree.  Because it’s coat matched the branches, it blended in perfectly.

Within just a few minutes, it was greeted by another sloth high in the tree.

Heavy Military Presence in the area

DSCN2003

Readers will quickly notice from the photos that there is a heavily military presence in the area.  Despite a history of mixed relations with the Colombian military  – including the discovery of a mass grave in 2010 with over 2,000 unknown corpses (and a history of some atrocities towards Colombian citizens), I am happy to see them.  I know I am ignorant and naive, but their presence in La Macarena makes me feel safer.  This area, in a lot of ways is kind of like Colombia’s own Vietnam conflict (in their own territory).  I feel bad talking to these soldiers who are far from their homes; I’ve met soldiers here from Cali, Boyaca, Bogota and all other points outside of Meta.  This is nothing like Bogota (obviously!) and it makes me sad for them.

soldiers

Do I feel better knowing they are around??

Most people from outside Colombia worry about the FARC, but right now – with the FARC in peace negotiations, paramilitaries like ELN and AUC are the bigger problem.  These violent groups clash with everyone who gets in their way; townspeople, the army, and even the FARC.  So anyone (like the Army) that keeps them at bay – is well, awesome!

You bet ya!

You bet ya!

DSCN1911

While both the governmental tour agency and the military officers I spoke with report that there has been minimal paramilitary activity in the La Macarena area for the last several years (8 to 10 years is what I was told), the Colombian state of Meta has an active area for paramilitary activities for the duration of the 50+ year conflict.  I found only one fairly recent report (August 2014) of paramilitary activity in other parts of Meta.  The majority of reports date back to 2006 – 2010, so it’s been fairly quiet lately.  Even so, it’s good to know that there are 2500 active duty soldiers in the area surrounding La Macarena.

Miguel (forefront) from the Colombian military patrols La Macarena

Miguel (forefront) from the Colombian military patrols La Macarena

It’s quiet enough that some of the soldiers spend time performing community activities, like helping paint the town, which is one of the local projects to enhance the image of La Macarena for tourists.

a soldier helps a young girl with the community painting project

a soldier helps a young girl with the community painting project

La Macarena: the town

Aside from the large military population, La Macarena is a small little village – with just a few paved streets at the center of town.  Most of the buildings are squat and square with a few second story and one tall four-story hotel tower..

We spent the evenings watching local entertainment – singers and dancers or enjoying a cervecita while playing tejo and enjoying the cool evening breeze.

usaquen

In Capitol City


Long time readers know that I am addicted to the capital city of Colombia.  So there was no way that I wasn’t going to take a few days to head over to Bogotá the moment I had a chance.  I just got back – and before I head off on my adventure to La Macarena tomorrow, I thought I’d post an update.

Charlie’s Place

8D y 106-84

Usaquen

Since I was just stopping in for a few days, I decided to forgo renting my usual apartment.  It’s a good thing I did or I would have missed out on getting to know the folks over at Charlie’s Place, a boutique hotel and spa in Usaquen.

CharliesPlace

It’s probably not for everyone – people who want to be in the middle of the tourist areas of Bogotá should stick to La Candeleria.  Business travels on large expense accounts can head to the big-name chains.  But for people like me, who want to be in the north side of Bogotá, around Barrio Chico and Usaquen, Charlie’s Place is ideal.

With just 22 rooms, the hotel is very cozy and accommodating.  The manager, Wilson, is a Minnesota native and is delightfully charming and easy-going.  The rest of the staff including Daniela and Javier are equally polite, friendly and helpful.  (There’s a reason Charlie’s Place is consistently rated as excellent by Trip Advisor for the last several years.)  The best part is that the rates are fair and the service is excellent.

Once I was comfortably settled, it was time to get back out and enjoy the brisk weather.  (The weather is one of the reasons I love this city!)  My first stop was over at SaludCoop where the doctors and nurses were nice enough to answer some questions about the ongoing healthcare crisis.

The Colombian Public Health Care Crisis

Right now, the public health system, EPS and SaludCoop are going broke.  Basically, much of the money paid in by members of the health care cooperative has disappeared (been embezzled), leaving hospitals with bare cupboards.  Hospital staff are feeling the pinch as payroll arrives late, in diminished amounts, or in some cases, not at all.   (There are rumors that the money was funneled into the purchase of luxury apartments, fancy vacations and the like).  There have been some protests and work stoppages by health care workers, but unfortunately, the local unions have been unwilling to support their efforts.

Unfortunately, the government seems apathetic to the concerns of the healthcare workers and their patients. The Minister of Health, Alejandro Gaviria went so far as to say that the health care crisis was a “lie” in a recent press conference, following up on his previous twitter (June 2015) and blog comments (Feb 2015), even going so far as quoting Christopher Hitchens in his defense of the health care system.  Of course, no where in his statement does he talk about healthcare workers going without pay or operating rooms without suture.  But he’s not alone in his apathy.

Most of the local politicians  couldn’t even be bothered to show up to a legislative session on the issue.  Only 9 members of the House of representatives (out of 166) attended.

This financial travesty has wide-spread implications beyond just the public health sector (of hospitals and clinics throughout Colombia).  Many of the private facilities also rely on payments from the healthcare cooperative.  (Imagine if medicare went broke through criminal mismanagement – it would affect a lot more that general and county hospitals).  In many cases, these hospitals are forced to write off millions of dollars of nonpayment from the health cooperative.  In fact, one of the largest hospitals in Cali (a city of 2.5 million people) will be forced to shut it;s doors, mainly due to losses incurred from nonpayment by EPS and SaludCoop.  So it’s a huge mess that will probably only get worse without government intervention.

On the flip side of the Colombian Health Care Crisis and the declining peso (over 3200 pesos to the dollar this week) – Hospital Santa Fe de Bogotá  appears to be thriving.

Santa Fe de Bogota’s new emergency department

Yesterday evening I had the pleasure of a guided tour of the new Emergency department at Santa fe de Bogota with the current Chief of the Emergency Department (and trauma surgeon), Dr. Francisco Holguin.

Fans of the Bogota book know that I spent quite a bit of time at Santa Fe de Bogotá in the past – and that it is one the highest ranked facilities in all of Latin America, so it was fantastic to see all of the improvements.  (The ER was still under construction the last few times I was there).  The first thing I can say – It’s big! Big, spacious, brightly lit and airy (especially for an ER).  The is good work flow with several large workspaces for the doctors and nurses, instead of the typical traffic jams that occur in older facilities.  It’s on the same floor as diagnostics (CT scan, radiology), the operating rooms and the intensive care units which means that critically ill and injured patients can be rapidly transported to where ever the need to go.

The spacious department now has 56 beds with an overflow unit for critically ill patients.  Several specialists are on-call, in the ER and available 24 hours including orthopedics, trauma and internal medicine.  Downstairs from the main ER is the fast track – for all of the non-life-threatening general medicine problems.

After spending two days interviewing and talking to people about the SaludCoop problems and EPS – it was nice to leave Bogotá on such a nice note.

at UPB open air auditorium

Taking it easy in Medellin


at UPB open air auditorium

at Universidad Nacional – Medellin  open air auditorium (The medellin campus is famed for the lush greenery)

So I am back in Medellin, Colombia for several weeks – but this trip is different from all of my previous visits.  It’s the first time I have come here without a specific purpose.  I’m not here to interview surgeons, attend surgical conferences or even ColombiaModa.

No Colombia Moda this year for me. :-(

No Colombia Moda this year for me.😦

Medellin has become so familiar to me, that when I needed a nice tranquil space to work on a non-Colombia related project – I headed here to get away from the thousands of distractions of my stateside life.  While I am here, I am also determined to enjoy and explore more of Colombia since I have just seen the bare minimum of life and locales.  So next week, I heading off to one of Colombia’s best known natural wonders, Cano Cristales.

I’m going as part of a group (which is something I’ve never done before).  It’s sounds like it will be a great trip – flying to Meta, Colombia in a small plane – to a community with limited electricity and no cellphone or internet service.  That doesn’t sound like a big deal, but as I writer, I have gotten used to almost always having computer access – almost anywhere in the world.  So this will be a nice break from the ordinary for me.

I don’t have my trusty Nikon this time around, which is a shame since Cano Cristales is famed for its beauty but I will attempt to take some pictures with a tiny camera (that packs well).  It’s weird because I tend to lose my confidence when I don’t have my big, heavy camera.

Naked without my Nikon? Not a great visual, is it?

Naked without my Nikon? Not a great visual, is it?

La Tierra del Olvido (2015 version)

In the meantime, I will continue to work on my current projects, relax a bit and enjoy Colombia.  Carlos Vives, one of my favorite Colombian singers, along with Medellin natives Maluma and J. Balvin, have re-made one of Carlos Vives most popular songs as part of a Colombia tourism promotion. It’s lovely, lively and catching – and features several other well-known Colombian entertainers and Colombian landscapes – so I hope you enjoy.. (Thankfully, no Sofia Vergara!)

bandaid

Reason #6


Reason # 6

Now this Florida story has botched written all over it – from start to finish..  It starts with an insecure man seeking ‘underground’ penile injections from an unlicensed person for penis enlargement.. and from there, it only goes downhill..

scalpel

From bad to worse..

After being deformed and defrauded by a scam artist named Nery Gonzalez who offered illegal, and dangerous ‘penile enhancement treatments’, the bargain-seeking Florida resident stumbled into the offices of another incompetent provider,Dr. Mark Schreiber, a plastic surgeon who lost his license several years ago after several botched plastic surgeries following initial investigations in the deaths of two of his patients.

Dr. Mark Schreibermultiple patient deaths, license revoked, but had a nice website

After the death of the second patient (also a penis enlargement case) in 2002, Florida revoked Dr. Schreiber’s license.  In 2008, he went to prison for practicing medicine (and operating on patients) without a license.

In the most recent case, the victim is now deformed, and unable to perform sexually due to his disfigurement.

Source article:

Clary, Michael (2015).  Penis ‘mutilated’ after surgery; ex-Boynton doctor from Tamarac accused.   Sun Sentinel, August 2015.

Related posts:

Just another reason for Latin American Surgery.com

Reason #146 – a cautionary tale

Plastic surgery safety & Buttloads of pain

Cement, Fix-a-flat and Superglue are not beauty aids

Is your surgeon really a doctor?

See the plastic surgery archives for even more articles.

This is a photograph from a famous trainwreck in my home town in Virginia in 1903.  Somehow, it seemed appropriate for today's discussion.

Patient satisfaction scores vs. clinical outcomes: The Yelp! approach to surgery


Patient satisfaction and clinical outcomes

Like Kevin MD says, “Patient satisfaction can kill“.  I’ve now seen several dramatic examples of this up close and personal.  For readers who feel like they are in the dark – there is a new ‘trend’ in healthcare, which financially rewards hospitals and physicians based on patient satisfaction scores..  Politicos, lobbyists and professional “patient advocates” have heralded this approach as the second coming.  A lot of these advocates try to lump patient satisfaction in with patient autonomy and patient rights.

Patient satisfaction is not the same as patient rights.

But it isn’t the same – and it’s stupid to pretend it is.  People have the right to determine if they want treatment X or not.  But giving people a “line-item veto” power on associated activities is a lazy clinician’s practice and recipe for disaster. (Not only that – it victimizes the very population we are trying to protect.  Anyone who is a parent understands this concept, but any degree of ‘paternalism’ in medicine is now viewed in a very negative light).

Instead of a new enlightened period of patient empowerment, informed consent and respect for patient rights, we have lazy attitudes (clinicians) and temper tantrums (patients) driving our clinical practices.  Doctors would rather ‘give in’ on critically important items than spend time to repeatedly try to explain key concepts of care to increasingly demanding ‘consumers’.  Overburdened staff are happy to go along with anything that decreases a workload which has tripled with recent changes in documentation.

It’s been a clinical nightmare and an  unprecedented fiasco in patient mismanagement which has lead to a dramatic rise in medical complications, length of stay and patient suffering.  I know, from first-hand observation and it’s been difficult to watch.  Even worse, it’s like a runaway train.  No one seems willing to reach for the brakes as it careens out of control and off the cliff.   It doesn’t seem to matter that there is ample evidence that this practice actually harms patients – the idea remains popular with payors, public relations departments and patients alike.

I work in cardiothoracic surgery so I guess I’ve been sheltered from this mentality.  It took a while for this concept to trickle down from the more ‘concerge-friendly’ specialities which have a high rate of elective procedures.  (No one really has elective cardiac surgery – when we used the term, we mean it’s not an active emergency).    I was first confronted with this concept when I started writing about plastic surgery.  People sent me numerous emails to complain about some of my reviews.  They didn’t care if conditions were sanitary or even safe.  Poorly staffed facilities, office-based surgeries with improper anesthesia, or a high rate of infections and post-operative complications didn’t concern them.   “Doctors” with falsified credentials didn’t daunt their enthusiasm.  The people writing to me only cared about two things; the doctor’s “bedside manner” and the price.  (Price was an important factor because we were often talking about procedures not usually covered by health insurance).

What is more important: a great surgeon or a great-looking one?

What is more important: a great surgeon or a great-looking one?  Patient satisfaction scores are often based on relatively superficial factors such as attractiveness, charisma or even whether the hospital has catered meals or hardwood floors..

I thought it was disturbing at the time, but I chalked it up to a lack of knowledge on the part of the “consumers”.  They just assume that these problems won’t happen to them.  Complications happen to other people.

Consumer or patient?

But it is this concept as consumers versus patients that is so very damaging.  It’s okay to use Yelp! to choose a restaurant, to google a hair dresser or  use tripadvisor for a hotel.  It’s even okay to use Angie’s List to find someone to trim your hedges and mow the lawn.  That’s because in the worst case scenario  – consumers have an unpleasant experience – the wait staff is slow, the haircut is ackward, or the hotel is noisy.  Maybe the gardener is late or leaves cut grass all over the sidewalk.  But no one gets hurt, and certainly no one dies.. Not from a bad haircut..

This is a photograph from a famous trainwreck in my home town in Virginia in 1903.  Somehow, it seemed appropriate for today's discussion.

This is a photograph from a famous trainwreck in my home town in Virginia in 1903. Somehow, it seemed appropriate for today’s discussion.

The problem with the consumer concept is the idea that “the customer is always right” or that the customer always knows best.   This means that customers are not only choosing their doctors based on this type of superficial data but also dictating the care.

  This is where it gets dangerous.

Aortic Valve Replacement

Aortic Valve Replacement – photo by K. Eckland, 2012

In cardiac surgery, we’ve long had a saying, “Cardiac surgery is not a democracy.”  This means that the surgeon has the last word, and is the highest authority when it comes to the care of cardiac patients.  The surgeon’s wishes trump mine, the anesthesiologists, the nurses, and even the patients and the patients’ family.  That’s because most cardiac surgeons have decades of medical and surgical training in addition to their individual years of clinical practice.  Surgeons and their support staff (like myself) are expected to use evidence-based practice.  This means we prescribe, and perform treatments based on years of research, and based on published guidelines.  These guidelines and protocols are then personalized or altered to suit each patient’s individual needs.  (Needs, not wants).

One of the biggest examples of this principle is:  Ambulation after surgery

Nobody wants to get out of bed and walk after heart surgery.  We’d all love to nap all day, get limitless pain medication and wake up six weeks later, rested and restored to health.  But reality doesn’t work that way.  Patients who get up and move, and do so in the early periods after surgery – do dramatically better than patients that don’t.  They have less complications, and they actually feel better  than patients who are allowed to take a more leisurely approach to cardiac rehabilitation.  Even a day makes a difference so this is where most surgeons draw rank.  Walking is not an “optional” part of post-surgical care.

In the ten years that I have been working in cardiac surgery, in massive academic facilities, average size hospitals and even small community programs – the guiding principle has been up and out of bed – and most programs do this at a fairly rapid pace.  For uncomplicated patients (no major immediate surgical problems, or advanced heart failure), the gold standard is out of bed to the chair on the evening of surgery (for patients who return from the operating room by mid-afternoon) or by 6 am the next morning (patients that arrive later, or who take longer to awaken from anesthesia).   These patients then take their first walk on post-operative day one to the nursing station and back, (usually around 50 to 200 feet) before lunchtime as a prerequisite for being transferred out of the intensive care unit to the step-down unit that afternoon.    For these patients, walking is not up for discussion.  It is the clinical expectation and part of the ‘package’ that goes with the operation.  Patients walk.  Period.

The majority of these patients will be discharged home on post-operative day 4.  Some will go home on post-operative day 3.  Not only that – but they will feel relatively good and will be clinically/ physically and psychologically* ready to go home by that time.

*Families are another story – the stress and anxiety of heart surgery is often worse for loved ones than for the patient and often does not clinically correlate with the patient’s actual physical condition.

Clinical Scenario of patient care driven by patient satisfaction scores$$$

In comparison, at a private, up-scale facility where I recently visited, the desire to please and get good Yelp! scores trumps the principles of patient care.  To start with, all patients automatically receive heavy doses of narcotics immediately after extubation via pca (patient controlled analgesia).  In theory, the pca allows patients to receive medication without lengthy delays to control pain to a ‘reasonable’ level.  (It is not reasonable to expect to be pain-free after major surgery.)

Patient satisfaction promise #1: You will be pain-free after surgery

But this hospital promises pain-free and they do their darndest to deliver.  Patients get on average 6 to 8 milligrams of dilaudid (hydromorphone) every hour after surgery by pushing their pca.  (If you think, “hey, after sawing my chest apart – that sounds like a great idea” then you are at risk for what happens next..

Nurses at this facility love this policy because it means they don’t have to attend to the patient as often and can catch up on computer documentation, facebook or whatever since the patient will be medicating himself into a semi-comatose state over the next few hours.  Semi-comatose is not an exaggeration.

Neurologically, some of these patients will develop delirium and vivid hallucinations.  Others will become agitated and combative.   Others will simply become confused and sleepy.

Since narcotics cause respiratory depression, sometimes these patients become hypoxic after using the pca heavily despite the supposed safeguards (lockouts are usually set ridiculously high – and despite policies against it – visitors, family and staff will push the pca button, even when the patient isn’t asking for medication).    Sometimes, patients end up on bipap or even re-intubated.  More often, they are just asleep – which as I said, suits the staff fine because it’s a lot less work for them.

But for the patient, it’s lost time – and puts them at risk for even more complications.  These people should be getting up to the chair, or walking for the first time.  Walking promotes respiratory expansion, prevents blood pooling (in extremities) and helps restore gastric function.

Instead, they are sleeping.  They should be performing pulmonary toileting to clear out all the secretions that built up during their lengthy surgery and reduce the risk of a post-operative pneumonia.  Instead, their lungs are building up more secretions.

Soon, the patient will want some water, after the intense mouth drying effects of the ventilator and breathing tube.  But the powerful narcotics have completely shut down bowel function.  No bowel sounds, no activity.  Water means nausea and vomiting, and more medications.  In many patients, this can cause an ileus, which adds several more unpleasant days (with a nasogastric tube) to their hospital stay.  For a fraction of these patients – they may need an emergent operation for a bowel obstruction as fecal material forms into hard, unpassable blockages in the GI tract.  Either way, the gross overuse of narcotics in these patients negatively impacts two of the most basic principles of post-cardiac surgery rehabilitation: ambulation and pulmonary toileting, and leads to increased risks of major/ unnecessary complications.

Patients need pain control after surgery – without adequate pain control patients can’t do all the activities they need to as part of their rehabilitation.  Untreated pain can in itself lead to complications.  But this bazooka approach to pain management is inappropriate for the vast majority of patients – especially the narcotic-naive or frail elderly (that make up a large percentage of cardiac patients).

Chasing patient satisfaction scores and profits in American healthcare

Chasing patient satisfaction scores and profits in American healthcare

The bottom line for CEOs and Administrators – I’m not sure if fulfilling the promise of pain-free cardiac surgery results in increased patient satisfaction scores on post-hospital surveys.  Do patients who spent the first two days after their surgery in a narcotic haze but then spent four or five extra days in the hospital due to preventable complications rate the service as well as patients undergoing surgery in a traditional program (who go home on day #4)?  And even if it does result in high satisfaction scores, (like it apparently did at this facility) – Is it ethical or moral to sacrifice the patient’s actual health and well-being for a couple of gold stars on post-discharge questionnaires.

But this is just the first part of the sequelae created by hospital administrators in their intense desire to chase profits, business and customers.  (This facility has created a niche market for itself by promoting these customer satisfaction practices that appeal to people that would otherwise seek care at the internationally known large academic facilities in the nearby area).  We will talk about some of the other pitfalls of programs  and practices devoted to chasing patient satisfaction scores, instead of patient care.

Take home message:

The real kicker:  multiple studies like this one by Aiken et al., demonstrate that the best way to increase patient satisfaction is to give good care, as defined by our more traditional measures (good outcomes). Hospitals that were well organized, with high levels of nurse staffing, (low levels of burnout) and good work environments.  Patients are happier, safer and have less complications when the nurse: patient ratios are appropriate for the level of care**.   It was never really about the ‘perks’ but it’s easier / cheaper for administrators to add enhanced cable television and pay-per-view movies to patient rooms than to actually give a darn..

$$$ – At the facility that was dominated by concerns related to patient satisfaction scores (ie. Press Ganey scores), that had such a high rate of complications (and a higher than average mortality)?? All those doctors have excellent, yes, excellent Press Ganey scores.. because apparently giving unlimited narcotics makes up for unnecessary (and life-threatening) complications. [and because, as demonstrated by several of the references below, Press Ganey scores are far from a reliable indicator of care.

**CEOs take note: I said nurses, not “nursing staff”.  Contrary to popular belief, 2 or 3 nursing aids, patient care techs or other ‘ancillary’ staff does NOT equal one well-trained registered nurse.  While these ancillary positions are important for providing basic care like hygeine (bathing and toileting, repositioning) and recording vital signs, they can not substitute for a nursing assessment and physical examination.

That being said – if hospitals increased (doubled or tripled) the number of occupational and physical therapists on staff – patient length of stay, level of debility and hospital complications related to disability and immobility (pneumonias, deep vein thrombosis/ pulmonary embolism, falls, fractures and failure to thrive) would dramatically decrease.

Resources/ References and Additional Reading

The Eckland Effect – this isn’t the first time we touched on this discussion, though previous posts have been focused more on international medical tourism, rather than American hospitals.

Kevin MD blog – I don’t always agree with him, but it’s an excellent blog on American medicine from a physician’s perspective.  If you read only one article from this post, read the article cited above.

Why rating your doctor is bad for your health.  Forbes article, 2013.

Rice, 2015.  Bioethicists say patient-satisfaction surveys could lead to bad medicine. Modern Healthcare, June 4th, 2015.

Dr. Delucia & Dr. Sullivan (2012). “Seven things you may not know about Press Ganey statistics“. Emergency Physicians Monthly.  The pitfalls of Press Ganey.

Robbins, Alexandra (2015).  The problem with satisfied patients.  Atlantic Monthly, April 2015.  An excellent read.  Best quote of the article, “Patients can be very satisfied and dead in an hour.”  Authors noted that the most satisfied patients were most likely to die.

Aiken LH1, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, Bruyneel L, Rafferty AM, Griffiths P, Moreno-Casbas MT, Tishelman C, Scott A,Brzostek T, Kinnunen J, Schwendimann R, Heinen M, Zikos D, Sjetne IS, Smith HL, Kutney-Lee A.  (2012).  Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United StatesBMJ. 2012 Mar 20;344:e1717. doi: 10.1136/bmj.e1717.

Zgierska, Robago & Miller (2014).  Impact of patient satisfaction ratings on physicians and clinical care.  Patient Preference and Adherence.  Results from a 26 item survey on physician’s attitudes and behaviors regarding patient satisfaction ratings.

This article demonstrates equal analgesia with IV tramadol versus the much stronger opioid, morphine.  (For comparison, hydromorphone (dilaudid) is 10X stronger than morphine).

Grunkemeier, et. al. (2007).  The narcotic bowel syndrome: clinical features, pathophysiology and management.    Clinical gastroenterology and hepatology. 2007 Nov 11. 

airplane3

Heading South!


It’s been a long hiatus as I’ve replenished Latin American Surgery’s coffers on a couple assignments over the last several months, but I will be back in the Southern hemisphere later this summer, and I am sure we will have a lot to talk about..

It’s an unfortunate reality that travel and travel writing costs money.  That, coupled with the long hours required in my “day job” mean that I do less writing and researching for the blogs than I’d like.  I was able to keep pace initially, but there was a point where it became a question of getting some sleep so I could work and pay my mortgage (and buy groceries) or continuing to churn pages for the blog.

on the runway at Colombia Moda 2104

on the runway at Colombia Moda 2104

After spending a lot of my resources working on a thoracic project this Spring over at the sister site, thoracics.org and working – it’s nice to be back here at Latin American Surgery.com

I’m going back to Medellin soon – and I look forward to taking all my readers with me.  (I wanted to travel to a couple other areas, but frankly, couldn’t afford it).  I won’t be attending Colombia Moda this year – but there is always someone to interview, health topics to talk about, cultural events explore or people and places to photograph.

I have a couple if ideas for some interesting articles, but we’ll have to wait to see how these ideas come together..  I hope it will be worth the wait..