Kristin in Colombia again.

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Readers know that I am just not that cool – or up-to-date with social media etc.. As much as I hate to admit it, it’s a little bit after my demographic.. I am a bit too much Gen Z, and not enough today to be entirely natural with all of the online mediums. I still remember dating a informational systems major (see, even the name of the degree gives me away!) in college, and having him show me email for the first time. Of course, it was kind of a nerd messaging system then because it only worked on campus, and it only worked for people who had their own desktop computers, (which wasn’t very many of us.) Of course, less than two years later – everyone had a desktop and the internet was becoming “a thing” but it has quickly left me in the dust. It’s embarrassing since my mom (who is in her mid-80’s is more computer literate than I am.) Now, my dad – he refuses to use anything but a flip phone (he gets super irritated trying to learn the features of smart phones)- so we have a bit more in common there. It’s hard to realize that you have become dated, despite your best efforts. It comes along with no longer listening to the pop stations (as you find yourself twisting the dial to salsa channels, throw-back stations or even the dreaded talk news..)

So I am still working on my next podcast – but it’s a bit of a challenge – to avoid background noise – get past the fact that my voice sounds like That! and to avoid the same old trite soundbites. There are plenty of cooler, hipper IG perfect podcasters talking about Colombia. In fact, most of them have Gringa in their name. It’s one of the things I still argue about with my friends here.. They want me to be commercially successful – which is another thing I don’t quite understand about podcasts. I just want to be genuine. Not another bleach blonde bimbo “La Gringa………..” talking about the most instagram worthy photo locations, and such. I don’t want to show visitors to Colombia how to fake like they have experienced Colombian culture. In fact, I find that trite, annoying and a little bit offensive that all these little cuties (because they are all very cute versus my middle aged self) post pictures of a couple of famous Colombian destinations, a meal or two – and then declare that they have had the “Colombian experience.” I have becoming here since 2010, finally moved here permanently in 2019 – and I can tell you that I still haven’t finished my Colombian “experience.”

It’s not a hashmark to be checked – it’s a rich and vibrant country with a wealth of things to do, see and experience. Not everyone needs to move to Colombia to enjoy this beautiful country – but it would be wonderful if tourists could take more time to actually enjoy Colombia, instead of just finding the best photogenic angles of themselves in front of monuments that they haven’t even bothered to learn about. That’s kind of hard for even the most earnest tourists to do anything more profound when most of the “Gringa” podcasts out there are promoting exactly that sort of superficial garbage along with a “what happens in Colombia,” type attitude..

And I suppose I am supposed to say that that’s okay because vacations aren’t supposed to be educational lessons, etc.. etc.. But, I just can’t.

I am not the kind of person that would enjoy flying half-way around the world to fight over towel space on a crowded beach, or loungers at an expensive hotel. There’s no need too spend thousands of dollars to do that – especially if you are going to do it to the detriment of an actual opportunity to see something new – and learn something. Not only that – I think this trend of superficial tourism is so darn destructive. Travel is supposed to build bridges and be a cultural exchange – between the visitors and the inhabitants. The visitors learn about a new culture (and gain respect for it) and the inhabitants learn a bit about the people who come to visit. But that’s not happening anymore – or at least not in a way that builds bridges..

All over the globe, hordes of tourists are descending like locusts on social media featured hotspots.. And then they proceed to show their asses (literally and figuratively, in many cases) in a game of online one-upmanship before heading off to the next destination. And it’s making the inhabitants of these lovely places – places that people are racing to see – hate us. Luckily, the majority of people who come to Colombia aren’t going on narco tourism tours, or vandalizing national monuments. But they do litter in our national parks – and flout carefully constructed rules designed to protect the environment (like wearing lots of lotions, creams etc.) and going into the famous river of five colors. They also fail to respect locals – and continuous bring up sensitive topics. It’s not cute to probe or make jokes about a national wound, even if you see locals selling items related to it. Individuals who sell confederate flags do so to make a living – and that doesn’t make it collectively okay.

I know that as a person born in the United States that there are certain topics that are painful to me. Topics that are too large and complex to explain to a total stranger in a social setting. It hurts me to think about how the nation of my birth has failed us, in the past and continues to fight (and often fail) on issues that shouldn’t be so difficult. These things that are shameful to me, even though I have nothing to do with it. Many people from the United States, like myself don’t really want visitors asking about our civil rights legacy (George Floyd, Black Lives Matter, Slavery or racism in general) so why do we feel that it’s okay to throw other peoples’ hurts in their faces?

This has changed the way I look at a lot of people, people that I consider friends – as I watch them do this – even after I’ve asked them not too.. And they smile and grin while doing it – all the while thinking they are cute, funny or somehow original. Maybe this sounds trivial to some of my readers, but it has permanently changed the way I look / feel about these people.

So – maybe this so-call ‘gringa’ can be a bit of downer – because I don’t want to always talk about the shiny and superficial (sometimes, sure). But I also feel that I have an obligation – as a permanent resident here – to learn about my new home, expand my perspective, and learn to see things without that unique stain of ‘American superiority.” If you want to come on that journey with me – and I haven’t offended you too much with my opinions – please continue to join me on Kristin in Colombia..

The other apartment in North Bogota

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Last week, I wrote about my first interior design project and my love for the music of Carlos Vives. If that seems like a weird association – then you might need to read last week’s post.

After finishing the first apartment with Daniel Valderrama – who is the head of V & E design (where I am a partner), we started our next project, a few blocks away. While the first project was inspired by Colombian singer, Carlos Vives – the second apartment has a decidedly more North American feel..

Part of that is because of the unique way that V & E Design operates. It’s less of a “let us help you chose a new wallpaper,” then – “tell us what sorts of things you like – and then we will design something unique for you.”

So for our second apartment – we designed around the ideas of Elvis Presley and his Memphis estate, Graceland. The project is called, the We love Elvis! penthouse or the Elvis Apartment.

Here’s the kitchen door with a custom stained glass insert – if you want more of an idea of what we are talking about..

It’s a bigger apartment – with four bedrooms and three bathrooms – including an amazing gold bathroom. There is a fantastic open terrace and a smaller more private enclosed terrace too.

My niece in the golden bathroom – showing off the large jacuzzi tub.

Of course – if you want to see more pictures of the Elvis Apartment – you can see a wide variety on AirBNB.

We strayed a bit from my usual topics on Colombian culture and such – but we will pick back up on our usual topics soon. (Like the cuisine at El Chato – which is consistently rated at one of the best restaurants in Latin America and the world!)

I haven’t been there, yet.. I have included a link to the restaurant menu – if any of you want to give it a try and report back..

We Love Carlos Vives! The King of Colombian music..

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It’s been a while since I’ve had an opportunity to sit down and write but that doesn’t mean my adventures have stopped.. In fact, it was a little hectic for about six months. I have been working with an Interior Design firm doing specialty apartments.

The first apartment is the We Love Carlos Vives penthouse apartment. It’s an adorable apartment in the family friendly neighborhood of Cedritos in North Bogota. If you want all the hustle and bustle of downtown Bogota, then this isn’t the place for you. But if you are staying in Bogota, or working here – and want a nice, safe but lively (not noisy) neighborhood with restaurants, bars, grocery stores, banks, parks and shopping in close walking distance – this apartment may be ideal for you.

It has 3 bedrooms, 2 bathrooms and two large balconies with views of the city. It’s comfortably outfitted with modern amenities and decorated in rural Colombian style. It pays homage to one of Colombia’s greatest musical artists, Carlos Vives.

(If you’d like to rent the apartment – click here!

If you don’t know who Carlos Vives is – don’t worry! I have included some videos for your enjoyment!

https://player.pbs.org/viralplayer/3071811576/

He’s an amazing performer – and he (and artist Diomedes Diaz) popularized Colombian music around the world.

This link below plays his 20 most popular songs.. So click, relax and enjoy.. You can come back and read more about Carlos Vives, and the We Love Carlos Vives Apartment once you’ve immersed yourself in his music.

For many people outside of Colombia, he is best known for some of his collaborations – and for his song in the Disney movie, “Encanto”

Of course, if you really want to know about Carlos Vives, best to hear it from the man himself.. Here’s a brief interview.

Now that you love Carlos Vives’ music as much as I do – you might just enjoy the We Love Carlos Vives penthouse apartment.

I also made a little video.. It’s total amateur hour (because – yeah – I am a total amateur) and the music is nowhere as good as Carlos Vives, but here it is. I think the apartment is as colorful, charming and Colombian as the man himself..

I am going to try and get back to posting regularly – I’ve been traveling around Colombia recently – to the lovely coastal city of San Antero, to the pueblos of Cundinamarca, like Pacho and areas in between so I will post some pictures and descriptions soon.

A day in Boyaca

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in the colorful tourist town of Raquira

Big news dear readers.. It doesn’t entirely excuse my long absence but great news all the same.. After during a myriad of things during the last two years (like everyone else during this pandemic), I have finally received my Colombian visa. This allows me to stay in country for longer stretches. I am currently still back and forth quite a bit, while I supplement my income working in the USA, until my company can one day be self-supporting (if ever!) Right now, it’s still basically on pause – but hopefully that will change soon.

The pandemic has turned our lives upside down, but it’s also reminded us of what’s important. To me, it’s important for me to be here – and to continue to build my life here. Part of that is enjoying all the wonderful and beautiful things here – animals, flowers, nature, history.. and of course, FOOD. I’m not sophisticated enough to be a ‘foodie’ but I sure do like to try new flavors, tastes, fruits and vegetables.

I’d been feeling a bit hemmed in, with all the changes due to the pandemic, previous restrictions and missing my Sunday routine. So, I went on the internet and called a friend. Within a few minutes, we had booked a one day tour through several towns in Boyaca.

The tour we chose was through a group called Travel Experience VIP. Our tour guides were Nathalia and Alexandra and they were delightful and sweet. The trip cost 65,000 COP and included transport, snacks and a full day tour through several sites in the neighboring Colombian state of Boyaca. We had to pay for our lunch, a 5 mil trip insurance (for accidents etc.) and an optional nature hike (12 mil each). It was still a great deal – bus transport to Boyaca alone when we first looked at going on a trip to Villa de Leiva was 40,000 each way.

After we stopped for breakfast (included), we continued on to a dairy company. Boyaca is the home to the majority of Colombia’s dairy industry, so there were numerous dairy companies selling cheese, ice cream, milk and other dairy products. We stopped at this large well-known factory, to get some of the well-known cheese filled arapas. They were warm, and golden colored, and SO delicious that I was unable to get any pictures.

But I do have some more pictures of some of the cheeses and other products they sell. My favorite is a corn husk wrapped tamale style cheese filled delight called, “envueltos chavitos.” I like it because it’s not some greasy melted cheese mess. It’s made with a very dry crumbly style cheese that is so well mixed into the corn muffin tasting roll that you don’t see the cheese but it adds just a touch of sweet to what would otherwise be a plain corn muffin.

many of the dairy products made right on site -through the open door ,in the room behind the case.
this is the dessert case full of sweets..Bocadilla, araquipe, and my envueltos chavitos
a closer look at all the sweets you could ever want..

After we stopped to enjoy a delicious treat – back to the bus.. Now Colombian roads outside of major cities are really just rural lanes. Which is a nightmare if it’s a heavily travelled road – or a delight, if it’s a relaxing and sunny Sunday cruising in lovely rural farmland like our trip in Boyaca.. Green grass, farms, a small town here and there..

Then we were at our next stop, which was a sizable town, known mainly for it’s church.. Chiquinquira, I believe.. I am not a particularly churchy person, so I was happy to wander thru the small town square, and then get back on the bus. I later read about the poisoned bread incident back in the 1960’s, and well, that adds a bit more mystery to an otherwise kind of boring looking town..

The next stops were more fun..

ceramics!

As a middle-aged woman who likes to sew, crochet and take pictures, Raquira was definitely up my alley. (Did I mention that I have a cat, too?) Raquira is a totally cheesy tourist town, with cutesy little boutique hotels, coffee shops and romantic restaurants..

tourists shopping in Raquira

Now none of that particularly excites me.. But Raquira is also famous for artesanal crafts, particularly ceramics. And that does excite the craft loving part of me – the part that really really appreciates the effort involved in handmade goods – and Hecho en Colombia.. It’s also the me that is still trying to decorate my home – and doesn’t like that whole Ikea/ 2001 spaceship / antiseptic look. Ah, but limited space on the bus, so I mostly did take pictures, even though a lovely vase did follow me home.

yes, made in Colombia and painted by hand..

The streets were lined with shops, so there was plenty of different things to look at, admire or buy. We passed the ceramics factory, where large stacks of unpainted ceramic items just waited to be decorated.

a shopper’s delight

Unlike many tourist places, the prices were very reasonable – and much less than what you would pay for the same items in Bogota. Maybe I’ll go back one day – with folks with a car.. so I can pick up a couple more pieces.. maybe one of the handmade pieces of furniture I saw… Or a planter for my growing garden. My friend had the same dilemma.

in Sutamarchan – home of Longaniza sausage

After the shopping excursion, it was time for lunch – and it turns out that Sutamarchan, Boyaca is also famous for a specific type of chorizo-type sausage called Longaniza. Now long time readers know that I just love, love, love picada – or that delicious mix of potatoes, sausages and other meats. (It has the morcilla or blood sausage that I love!). I wasn’t a big sausage eater before I came to Colombia, but it’s definitely something that I enjoy now.

yes, I love picada.. and it’s part of my own Sunday tradition.

That huge plate is a portion for one – but it was more than plenty for my friend and I. After our bellies were stuffed – it was time to go for the nature hike.. and believe me, I was ready for a nice long walk about after all that food.

on a nature hike to see the “blue” lakes

The next big stop was the historical city of Villa de Leiva (Leyva). It’s famous for being a preserved Colonial town, with cobbled streets etc. and stringent building codes against modern construction.

Villa de Leiva plaza

The main plaza in the town is the largest cobbled plaza in Colombia. The city is full of restaurants and charming boutique hotels. For a tourist town, the locals remained surprisingly friendly and welcoming. (Which is pretty amazing when you think about all the tourists that pass thru Villa de Leiva, especially in December, which is peak tourist season.)

Then it was time to start the drive home. On the way – now that night had fallen, we drove by an amazing holiday lights display that just went on and on.. It was charming.

Then we stopped at one last place so we could stock up on arapas with cheese so they would be fresh for breakfast (which they were). On the way back, the bus stopped close to our place, so we wouldn’t have to travel very far to get home. I’ve even posted the link for the coupon we used for our trip with Travel Experience VIP. Now enjoy!

I added lots of links to make it easy to find more information about the places and things mentioned in my post.

**I have a whole series of posts on my Sundays here:

Sundays in Cartagena

Sundays at Parque Arvi

Sundays in la Candaleria

Sundays in Antioquia

Sundays in Usaquen

Sundays for your health

Sundays in Bogota

Readers may notice that this blog has changed over the years – to be more culture and life and less surgery. I still love surgery and I am still committed to everything I’ve always talked about here; patient safety, quality, and excellent care – I’ve just decided not to talk about it here anymore. It’s at a different site., dedicated to all things medical so I am changing the name – but slowly, so people will have time to get used to the idea..

Sightseeing in the age of Covid-19

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While my headline in a little tongue- in -cheek In the spirit of the famous Colombian writer, Gabriel Garcia Marquez, our topic today is a bit more serious. I decided to spent yesterday downtown at some historic sites. As I may have mentioned in a previous post, Colombia has quite a few public holidays. Over 20 in fact, so at least once a month (and sometimes twice) there is a festival Monday, where offices and businesses are closed.

Yesterday was the Feast of the Sacred Heart. It was a lovely day, the ciclovias are open, and people are out. But this post is a little different than my usual posts on fantastic restaurants, delicious fruits, amazing natural beauty, indigenous cultures, artisanal crafts and life in Bogota. This is a post for people who want to know more about the hearts of Colombians.

A friend and I decided to go on a history tour with Descubre Bogota. Our guide was Jose Ayala, and our tour was about the some of the famous and ultimately tragic figures in Bogota’s history. I knew it would be sad, and I knew it would be hard to hear. I know because I come from a country that has it’s own painful past – and we often struggle to reconcile with it. We also struggle to change course, from “that’s the way it’s always been (no matter how ugly or unfair” to trying to do better, and move forward. Like Colombia, my country has faced a lot of upheaval that has only been exacerbated by the pandemic.

I’ve read quite a bit about Colombia in the past 12 years, but I still take every opportunity to learn more. I will never been an expert – I don’t have a poli-science bone anywhere in my body. But it doesn’t mean I can’t try and learn. It’s especially important for people from the United States, because many of us never step out of our bubble, yet would be mortally offended if a visitor from another country didn’t know who Abraham Lincoln, John Kennedy or George Washington was.

I don’t expect casual visitors to delve deep into Colombia’s past, but I do feel that they should try and get past all the narco stereotypes. They should know at least a little something about some of the people who represent what Colombia is/ was and can and will be. They should know that Colombians have many of the same ideals that we purport to represent. That seems like an easy concept, but after more than a decade of working / writing/ traveling here, I know that to many people it’s not.

But today we are going downtown to scratch the surface, just a little bit.

(I didn’t have my camera, just my phone so the pictures are not very good).

The first stop on our tour was the Museo National, where Jose talked about the 1000 days war, which occurred just at the beginning of the 20th century. At that time, the Museo Nacional was a fortress and prison.

Then we proceeded up to the former home of Jaime Garzon, who is a more recent entry in Colombia’s history. I’m adding several links about him for readers to learn more about him, if you are interested. He was journalist and political critic who specialized in political satire. He also played an important part as a political activist and peace negotiator who worked to free many of the FARCs hostages. It was this work that was believed to have led to his assignation. According to our guide (and several other sources), Garzon knew an attempt was to be made on his life, and (possibly) knew that he was going to be murdered in his car that day. (The possibly, is due to a couple of Spanish words I was unsure of during the tour). They say that he carried on with his scheduled activities to keep the assassins’ away from his home and family. The outpouring of grief among Colombians was immense, and overwhelming.

An homage to Jaime Garzon:

Jaime Garzon memorial webpage

Archives in national center

The next stop on our somber tour was to view some of the architecture of the area and to talk about how this particular style of architecture was developed to incorporate nature into the design. It was a pretty amazing building, built in a series of semi-circles (just above the stadium del Toros) but hard to get a photo that real demonstrated the effect up close. (I had noticed the building on the drive to the door, it’s pretty striking).

Much of the rest of the tour was devoted to Gaitan and the more traditional figures in Colombian figures. Jorge Eliecer Gaitan (not to be confused with the later politician of the 1980’s Luis Carlos Galan) was a polarizing figure in Colombian politics. A populist leader of the left, he was active in politics from the 1920’s until his assignation in 1948 outside his office building. He was a very skilled public speaker and drew extremely large crowds due to his fiery nature. Many believed he would be the next President of Colombia. His murder on April 9th, 1948 like that of John Kennedy in 1963, where the suspected assassin next made it to trial. Like John Kennedy’s murderer, Lee Harvey Oswald, the complete motivations of Juan Roa Sierra were never known, and there are multiple theories that link the murder to outside entities including Fidel Castro and the Soviet Union were behind the assignation. Others claim US involvement which is not such a far-fetched idea, given the now known history of US interference in Latin American affairs.

I’ve been looking for some English language information to link to, but please note, much of what I have found, particularly historical footage, shows a pretty obvious bias. Others are equally biased in other ways. I chose the one here because, because it’s one of the few in English that show Gaitan and let modern day views see his dynamic appeal.

His death set off a series of protests and riots called the Bogotazo that left between 500 to 3,000 people dead (figures vary) and parts of Bogota destroyed.

It also directly led to a ten year civil war called, “La Violencia.”

Obviously not a small topic – and covered by many many scholars, journalists and political analysts far better than I could.

There were several more stops – one being the Palace of Justice. This is a story that has been widely covered, pretty much everywhere, including the series ‘Narcos” that I personally detest. (I recommend watching Pablo: el Patron de Mal, if you want to watch that stuff.)

The last stop, outside the Palace of Justice in the Plaza Bolivar is the most pertinent for many people. It’s fairly quiet today, with a intermittent heavy rain. But it’s been witness to almost everything Jose talked about on the tour – and visible in most of the film footage – from the 1940s to last week. (Look thru the next several pictures and then click on some of the links and videos).

“Those who don’t remember the past, are condemned to repeat it.” We hear this quote endlessly recycled but we don’t talk about what it really means. It’s not about ONLY remembering the past, it’s about learning and moving away from the actions of the past. Yes, this requires knowing about our most painful chapters, whether it be a nation, a family or an individual. But it also requires changing course. Knowing is not enough – action is required.

That is what Colombia, the USA and so many nations have struggled with this last year – the realization that we need to change course, and then trying to find the path to do so.

Now I don’t have a strong opinion on the current Colombian protests – I don’t feel like I have a deep enough understanding of all of the issues to do so. But I do understand what’s we’ve been seeing.. It’s the same as what we saw last year at home.. We are watching a nation – and it’s citizens try and find their path forward – and I respect that.

For readers who would like to know more about the current protests in Colombia, I highly recommend the Colombia Calling podcast along with Colombia Reports.com

A long time gone..

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Hello, everyone! It’s been a long time since I’ve even logged in here – and I won’t blame the pandemic. Well, it wasn’t entirely the pandemic.

As my previous subscribers know, I’ve been working and researching surgery, and medical travel options since 2010. It’s not just a passion, it’s something extremely serious to me (even though I am often very light-hearted over here!)

In late 2019, I finally took the leap to do what we all knew I needed to do. I always said, I’m just the researcher, I’m here to evaluate, I’m not here to run a medical travel company. But the longer I went around interviewing, observing and evaluating surgeons, hospitals and surgical practices, the more I realized that I was literally, the only person out there doing what I do. I was a one-woman Quality Assurance program; focused patient safety, and post-operative outcomes.

For everyone else, it’s just a job. It’s not that they were all heartless, hateful individuals – but they were not in a position to be able to care. They are travel agents, not medical providers (you’ve heard this part of the speech before) so they didn’t even know what they should be concerned about. You have to be aware of all the risks to understand them.

That’s not a dig at anyone, that’s a reality. If you aren’t trained and don’t have extensive experience in medicine and surgery, then you really aren’t qualified to be referring any potential patient/ client/ or even a friend to a surgeon. And even then – all that training doesn’t matter, if you don’t go thru the proper steps to fully evaluate someone.

A person can be a fantastic surgeon – maybe even your husband’s heart surgeon, but that doesn’t mean they know who the best surgeon is for your breast cancer. I might know some surgeons from around the hospital where I work – but if I don’t go into their operating room – and they are just a golfing partner, or a workplace acquaintance, then my recommendation really isn’t worth very much. A lot of medicine functions in exactly that. Referrals are made out of friendships, not merit.

It’s the same with a referral from a close friend. That isn’t because your friend isn’t a kind, caring person, but even if she had the exact same procedure that you want or need – her experience is not necessarily your experience. Great surgeons can have patients with terrible complications (often because they take care of sicker patients). Very mediocre, sloppy or unsafe surgeons can have good outcomes because if everyone they operated on died or had catastrophic complications, well, they (hopefully) wouldn’t be a surgeon for very long.

This is about training, techniques, protocols and odds rations. We have all run a red light, whether by accident,, because you were in a hurry or whatever. We don’t all get t-boned in the intersection, because sometimes we get lucky, and sometimes we get away with it.

But careful and safe drivers who pay attention, slow down when they seen the light turn yellow are much much less likely to run a red light, which in turn means that their risk of getting in that accident in the intersection is much less than someone else who routinely hits the gas when that light turns yellow.

What I do is look for the safe drivers. The people who do things the correct and proper way every single time. So that when you are unconscious, and powerless on that operating room, you don’t have to be lucky.

With that in mind, I started my own travel company in late 2019. I knew I would never get rich doing it – but I knew that I could really help some people. I set my personal goal at having a very small exclusive clientele – and having 5 to 10 clients per year for the first five years.

Now that doesn’t even cover overhead – so it means I’d be doing my “day job” for at least another decade. But that’s okay – not everything in life is about money. Sometimes it’s just about doing the job right and helping people, As a health care provider, that is something that I already do. This is just taking it to another level.

So – I opened the company, and our maiden voyage so to speak, I have four clients. (As part of quality control program to ensure that all the nonmedical aspects come together in a timely fashion, I had decided to do the first two years of operating as very small group travel. As a trial and error process to streamline the process (hotel, luggage, meals, sightseeing, all the things that go with traveling but are not related to patient safety). You can never make sure that all the logistics are perfect with out a couple trial runs. With that in mind, our first clients were offered our services as at fraction of the price. (My accountant was screaming and so was my wallet – but that’s just how it has to be sometimes.)

All that hard work paid off – not only did ALL of our clients get excellent care, they had a good time too! We saw off the last client just a week before Christmas 2019. It was exhausting, but I was exhilarated. I also realized that it was very unlikely that I’d ever make money doing this. To make money, I’d have to charge more, a lot more. So much of the money I collected went to enhance the client experience, that there was very little left over.

I wouldn’t make money the way other medical travel companies do – they make money two ways:

-sheer volume

-kickbacks on front/ and back end. They get paid by the hospitals, the providers and sometimes even by hotels, restaurants and such for steering the clients in a specific direction. A lot of times, they are actually a front for a hospital – b ut pretend to be an independent entity.

Obviously, my loyal readers know that this wouldn’t work for me. It violates everything I believe. In fact, it’s part of the mission statement on my “official” company page.

But in the meantime, Covid did happen. So I have had a year and a half to think about it. The company is closed, and I’,m at a decision point.. Carry on or shutter entirely.

Now this blog was undercover for about that long too – and that’s not a coincidence. That’s because I was worried that if people read this blog, and read about Colombian food, my various adventures and even just the random absurd little things that happen sometimes, that they wouldn’t think I was professional – and thus wouldn’t want to be a client.

But people are multi-faceted. You can be a nuclear physicist AND a mom. Electrical engineers play musical instruments. We all have the abilities, interests and talents to do more than one thing. So as I stayed inside, and watched the entire world stop, I had plenty of time to think, and make decisions about my own life and the life of my company.

My goals are the same. I want to come out of this pandemic and be able to help five to ten people each year.

My goals are the same, but my perceptions have changed. Now, I’m okay if it’s never more than five or ten people a year.

It’s okay that I won’t get wealthy doing this – and that I will never be able to surrender my day job. I don’t know if I could do that anyway – it’s too much a part of who I am. I just want to be able to help five or ten people every year without losing money. I’ll write off my time as being basically free – but I still need to make enough money to do all the nice things for the clients that I feel are important, and to be able to pay the people that help make it possible. That’s not an impossible goal, and I don’t feel it’s a foolish one. I’ve been fortunate in life, so I can decide to do something just because it makes me feel good. So that’s what I am doing.

And lastly, it’s okay if people seeing and reading this realize that I’m a person, a fully rounded person, who likes to take pictures, loves to travel, and to have new experiences. It’s okay if they know that I’m a cat lady, and I love to sew, especially dutch wax prints in bright colors. It’s even fine if they know I love to sing – but I’m always terribly off-key. It’s okay because I will be here to help the people who want my help. People who recognize my expertise and still see me as a professional (despite my singing) and not a servant. People who know me, friends, family and people who trust me, respect my abilities – and know that I will always put their health and safety first.

So, I’m back!

Miami plastic surgeon tied to multiple deaths

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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.

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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

Cano Cristales in La Macarena

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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.

Military partrolling for paramilitaries on the river
riverboats

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!)

Cano Cristales

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.

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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.

and then this “half-dead creature got up..
and walked to a nearby table..

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

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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..

Of course I checked out the hospital

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

Taking it easy in Medellin

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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!)

Reason #6

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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 Schreiber – multiple 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.

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

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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 States.  BMJ. 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. 

Heading South!

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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..

Life in the fast lane: my most recent assignment

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No medical tourism or Latin America this winter, but as my latest assignment finishes, it’s been an interesting journey!

New friends, new places, and new experiences!

Co-workers in the PACU

Co-workers in the PACU

I spent the last few months working in the intensive care unit on the trauma service at a large, busy trauma hospital outside of the nation’s capitol.  It wasn’t quite what I expected – for all of my world travels and travel nursing, I still tend to revert back to Chicago Hope in my mind sometimes.. This was a lot more like St. Elsewhere – meaning that as a person from a rural background, I always expect to be somewhat overwhelmed in larger facilities but by the first week, it was surprisingly familiar and kind of homey feeling.  Instead of a cast of thousands, and a sea of unknown faces, it become a daily chorus of ‘good mornings’ to a close-knit group of providers.  (I was there quite a bit, which probably helped).

the view from the call room

the view from the call room

But somethings were definitely different, and it was more than just monuments, politics and presidents, and the “newsworthy” aspect of some of our patients.

just outside the federal district - and a whole different world from cardiac surgery

the federal district – (and a whole different world from cardiac surgery!)

Crash course in major trauma

Running from the police seems to be a frequent requirement for some of our admissions.  Bad jokes aside, where cardiac surgery is planned, detailed and precise, the world of trauma is often chaos, tragedy and upheaval.  A split-second accident, or fall becomes a forever life altering event.  All of the ugly of the world; crime, abuse and assault comes to our door.  Innocence smashed, so often without any sense of rhyme, reason or fairness.  Working here makes me confront my mortality in a way I’ve never had to before.

Doctors in the ICU

Doctors in the ICU

Scheduled chaos

Sure, many people have unexpected heart attacks – even people we tend to think of being ‘low-risk” – and nonsmokers have no guarantee of avoiding a lung cancer diagnosis.  But, for the most part, that’s the beauty and elegance of cardiothoracic surgery – it’s a calculated, orderly world for those of us working in it.   Cardiac surgery feeds the math-loving, logistical and analytical side, while thoracic surgery with its cornucopia and ‘catch-all’ of chest pathophysiology is a never-ending journey of the Jules Verne variety.

As comforting as this can be, it can also become a hindrance if we stay in the familiar for too long.  Sure, it’s nice to have the experience, to know most of the answers, most of the time – but these brief glimpses outside cardiothoracic surgery are crucial for staying engaged, and involved in medicine.  Even if I feel silly or stupid at times, it’s important to continue to learn new things (and dredge up older knowledge that’s been unused for a while).

The good thing is that the essentials, and the principles of caring for people never really change even if the hospital, the staff, the city and the specialty service does.   I don’t know why that surprises me anymore, but it still does.

So now that the assignment is over – I am back home.  I am planning for my next big trip (Asia, this time for a big thoracic conference), catching up on medical journals, and  a bit of continuing education while awaiting my next assignment.

Until then – we’ll get back to our usual programming!

Obamacare, American medicine, medical tourism and what it means for me

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I haven’t written in a while because I have been looking for a way to describe what’s been going on in healthcare.

the American healthcare system

the American healthcare system

As a provider

There has been a weird unhappy vibe in the  American hospitals these days.. It’s like nothing I’ve ever felt before in the last 15 years.  There has always been a collective feeling of frustration among providers; but it’s usually sat somewhat untended, like a slow cooker slowly simmering away..  These frustrations were related to our inability to provide the best for all of our patients, our frustration with the broken-ness of a health care system so rife with waste, yet with so little help for our vulnerable populations, and those in dire need.

It was manifested by occasion individual grumbling; during case management meetings, during conversations with faceless insurance companies as we explained yet again, why our patient:

a. really needed XYX treatment and

b. how it was actually more cost-effective in the long run..

But it was isolated for the most part, and the majority of providers still felt like they were helping people – and enjoyed the job satisfaction that went along with that..

It seems like a lot of that has changed over the past year.. I don’t know if it’s fear of coming changes, and the uncertainty that goes along with that..  But most providers are actually in favor of the Affordable Care Act – or the concept, anyway.  It’s something else, maybe the forced implementation of governmental changes like clunky and poorly functioning EMRs, the continual threats of “pay-for-performance” or a cummulative effect of all of the above, but many providers seem to have reached the breaking point in frustration.

For the first time that I can recall, a lot of really excellent physicians and other providers I know are just burned out to the point of complete mental and physical exhaustion.  People I’ve know for a long time, people I consider my mentors, my inspiration are talking about retiring early or leaving the field to do something else entirely.

It’s also the first time that I’ve ever seen doctors, nurses, and others as a collective to seem so broken in spirit.

Patients are people, not check box diagnoses

I am feeling a bit of it myself – a kernel of hopelessness that sparks in my heart.. a sinking feeling when I order a standard medication (but individualized for a specific patient/ condition) and enter in the computer – and receive a message telling me that dosage is not permitted.  A follow-up phone call with the pharmacist continues the charade.. Since it doesn’t fall into a specific category between two mandatory dosing schedules (for diagnoses that differ from what my patient has) then – they don’t know how to categorize it on the computer – and thus my patient can’t have it..  This makes no sense to me, I am following best practices, the current literature and evidence-based practice, but somehow my patient’s condition hasn’t been coded somewhere down in the pharmacy, so they won’t release the medication.  Too scared of the consequences I guess – or too apathetic to care that the medicine is for a real, living, breathing person and not a statistical table somewhere.

– and I argue the realities of this individual scenario but the bureaucratic mentality on the other end of the phone doesn’t care..  How am I supposed to do my job; to care and protect my patient in a system like this?  It’s only going to get worse as the government gets more and more involved in patient care.

What?  My patient isn’t a peg, it’s a person – and if this person doesn’t fit the pre-specified check box doesn’t matter to me  (in this specific instance)- what matters is that my patient keeps his leg (which he may not, if he doesn’t get this medication at the dosage I ordered in consultation with his surgeon).

As the consumer – losing my current plan

At the same time that this brokenness is affecting providers nationwide – I have fallen into the dilemma of many of my readers. As a locum tenems provider, I am self-insured.  My current plan, which was flexible, affordable and provided coverage which suited our needs (low monthly fee, low deductible, reasonable co-pay, and two free wellness checks a year) is being discontinued.  It was also a flexible plan that allowed my family and I to see providers nationally.  So if I was working in Texas for six months, I could see a doctor in Dallas. Or Massachusetts, or California, even back in my home state of Virginia.

Now, I am spending most of my days off on the phone and the internet – looking for a policy that doesn’t limit my coverage by location.  Most of the time, I can’t even find the correct phone numbers to talk to the right people.  The numbers listed online at the marketplace are incorrect, or out of service.  The representatives that I do speak to after being on hold for thirty minutes and routed through a computer automated system are sometimes nice, (often completely indifferent) but can’t answer my questions.

I do know that at a minimum my monthly expenditure for even the bronze “no frills” plans will double, and may even triple.  My deductible will also double or even triple, so in January, I will be literally paying two or three times what I paid last month (December) for a fraction of the services.

Paying a lot, and getting almost nothing in return

All of the new government approved plans are based on my home state – and some even limit coverage to my county only.  Since my county is rural – and the nearest major medical center is actually in a neighboring state, having one of these local plans is like being uninsured.  (Some representatives said they would cover out-of-area “life-threatening emergencies*”, but others weren’t sure).

this should be a significant concern for anyone in rural or limited medical access areas**.  For someone with my geographical needs, it’s become a major nightmare.   Even with the increased costs – I may still not have coverage for the majority of my time (for 2013 for example, I was home for a total of 1 month. In 2014, I was home for four months).  Since I can’t predict where I will be sent – I can’t pick a plan for another state.  Not only that – but even if I knew I was going to be posted to Indiana or somewhere like that – I am not allowed to buy a plan outside of my registered address.

No one knows the answers – and what they do know doesn’t sound good:

After another full day on the phone with representatives for the Healthcare Marketplace and different insurance providers, it looks like the answers are pretty ugly when they even know them.  Most of the representatives had no answers.  One of them even asked me, “Well, do you vote?”  They won’t even give a call back number or extension so that when they “accidentally” disconnect you during another of the “let me transfer you to another representative” spiel, you have to go thru the whole rigmarole all over again.

1.  If you have a plan that does not have out-of-network coverage – consider yourself uninsured if you become injured or have a medical emergency outside of your area (which may be as small as your county.)  The cheapest plan for two people on Blue Cross/Anthem/Blue Shield (my existing company) that offers out of network coverage is 594.00 a month (we paid 213.00 a month before).

2.  None of the plans cover medical tourism – even from companies that previously provided these options.  So, if you live in a county like mine (with no trauma center, and a tiny rural hospital) – you aren’t covered for the neighboring hospital in another area in an emergency.

Not only that – you can’t receive coverage for a non-urgent (elective) procedure for something like a knee replacement at another facility.  My town has one orthopedic surgeon (and he isn’t someone I’d ever chose to go to.)  Now I can’t go to Duke, UVA or another nearby facility – and they won’t pay for me to have the same treatment (at a fraction of the cost somewhere else like Bogotá.)

Here’s a typical example of what I’ve learned after several days/ weeks of reading & talking to representatives –

I’ll pay $5,112 in premiums with a $13,200 deductible with NO coverage of any conditions (except an annual physical and a flu shot) until I’ve put out a total of $18,300 (every year – not a one time deal).   Then the insurance will start to pick up the tab.. This is supposed to be affordable?  For whom?

And while some people will pay less in premiums based on their income level – they still have to come up with the $13,200 deductible.  How the heck is that supposed to work for someone making $30,000 a year?

So now we are calling all the other companies and reading, reading, reading all the fine print.  For now – it looks like I will paying an exorbitant amount for minimal coverage, and will need to rely on medical tourism for any non-urgent but essential treatment that either falls below my high deductible or isn’t even available in my home area.  Luckily, I am pretty healthy (but I am currently working in a trauma unit so I know how quick that can change) – but isn’t the whole point of insurance to prepare for the unexpected?

So what does that mean?

I don’t have the answers for everyon1e.. In fact, I don’t even have them for myself. But it may mean that I am better served by paying my premium and using medical tourism for all of my other (non-emergency) health care needs.  After all, $13,199.99 buys a lot of care in Colombia, Mexico and many of the other places I’ve researched and written about.

*And, if you survive – you may have to argue with some bureaucrat whether your illness was actually life-threatening or not.. I mean, it can always be argued that “how serious was it, really, if you made it home alive?”

** Limited access areas may include major cities.  For example, the city of Las Vegas has a very limited number of specialists.

Ebola and medical tourism

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biohazard

There’s a new editorial over at the IMJT on Ebola, medical tourists and the medical travel industry.  In the article, “Ebola: a hot topic for the next medical tourism event?” by Ian Youngman, he explores the potential pitfalls from medical tourists who are seeking treatment overseas.  As an insurance expert, who makes his living by preparing for “What if?” scenarios, the author offers valuable insight on a topic that has provoked wide speculation and fear-mongering among the general media.

Mr. Youngman explores current medical screening at airports, the impact on current medical tourists as well as the potential impact of a global pandemic/panic on the medical tourism industry.  Mr. Youngman urges for a clear, reasoned and cohesive discussion and response from leaders in the medical tourism industry.

passport w money

Death of young patient raises questions of safety

IN other news, the BBC is reporting on the recent death of a 24 year old British medical tourist.  While the BBC article offers few details on the patient who died during a liposuction procedure in Thailand, a more in-depth report from the UK Mail reports that the woman stopped breathing after receiving anesthesia at the private medical clinic.  The article reports that this was a repeat visit for the patient, who had previously undergone another plastic surgery procedure at the clinic.

Now questions are being raised about the doctor’s qualifications to perform the procedure, as well as the lack of availability of life-saving medical equipment at the medical clinic.  The doctor at the clinic, Dr. Sombob Saensiri has been arrested while this case is being investigated.

Note: There are conflicting reports regarding the exact circumstances of this patient’s death.  An Asian story reports that the patient had returned after a recent surgery with complaints of a developing infection.

Related posts:  Plastic surgery safety archives

Plastic surgery safety: Know before you go radio interview

Is your cosmetic surgeon really even a surgeon?

Liposuction in a Myrtle Beach apartment

 

Story updates: Be care my friends, and Mexicali

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It may have been a while since my last post, but I haven’t been idle.  In the last few weeks, I’ve traveled to Mexicali to check in, have some dental work done as well as attending professional conferences and working on my next locum tenens assignment.

Mexicali sign

First – some updates on Mexicali:

I don’t have photos to accompany these updates, but the new emergency department at Hospital General de Mexicali is big, beautiful and open for business.

I also met with both Carlo Bonfante and Dr. Carlos Ochoa to talk about some of the upcoming improvements to the Hospital de la Familia.  Nothing has been completed yet, but they have some big plans to improve services for local residents and medical tourists alike.  I’ll write more when I have the rest of the details.

I also had a chance to catch up with Dr. Horatio Ham (Bariatric surgeon) and Alejandro Ballestereos (Anesthesia).  Dr. Ham reports that Dr. Abril’s radio show has been revived as an internet radio program.

Sadly, Dr. Alberto Aceves, a well-known Mexicali bariatric surgeon died in a private plane crash back in June.

 

My Mexicali dentist: Dr. Luis Israel Quintana

 

Dr. Israel Quintana with one of his American patients

I don’t have dental insurance but I have a history of bruxism (grinding my teeth) so I am pretty fanatical about taking care of my teeth.  I’ve written before about the difficulties in reporting on dental tourism, as well as my previous experiences with Dr. Quintana, so when my dentist at my last locum assignment gave me a work estimate for almost eight thousand dollars!*,  I knew I needed to plan a trip to Mexicali before my next assignment.

photo (12)

I ended up having 12 fillings (no cavities but plenty of damage from grinding), as well as a root canal and a partial crown.  He also made me a new night guard since my old one obviously wasn’t preventing ongoing damage.  While several days in the dentist’s chair was no picnic, I had minimal discomfort and little damage to my wallet.  All told, the bill was less than 1300.  I still need some additional work, but the majority of my teeth are now taken care of.  I don’t have to worry about having a dental emergency while I am working a contract.

Dr. Quintana also reminded me that his office accepts most American insurance plans – with no co-pays or other payment required.

* My initial estimate in Dallas only covered work on four teeth.  The additional surface fillings were not included.

 

Story Update: Please be careful my friends!

baby

Baby making and Planet Hospital: Lots of money and no baby

Some readers may remember the sad story that I received from a childless couple last year.  The couple had contracted with Planet Hospital for surrogacy services after receiving devastating news on the birth of their only child.  The child had been born with a terminal disease (the child later died).  The couple also learned that due to a rare (and previously undetected) genetic condition, it was likely that any future children would also contract this disease.   The couple had started a blog to document their journey into surrogacy, but after several months, it devolved into a story of deception, with the couple being defrauded of thousands and thousands of dollars by one of Planet Hospital’s contracted facilities.

Recently, Planet Hospital and their surrogacy scams made the front page of the print edition of The New York Times.  The story by Tamar Lewin rips the mask off of Rudy Rupak, the shyster I told you about previously.  (I also wrote about his shady transplant tourism practices at the Examiner.com back in 2012).

Surprisingly, the “Medical Travel Quality Alliance,” a branch of the MTA that advocates for “self-regulation” of the medical tourism industry only seems to partially condemn the practice of tourism surrogacy and Rudy Rupak in their latest publications and newsletter.  Of course, anyone with even a few years experience covering medical tourism remembers that Rudy Rupak was the poster child for the medical tourism industry for many years, even after the first rumors of shady business practices emerged in 2010.  Mr. Rupak has since filed for bankrupcy, but knowing of some of the deals Planet Hospital was involved in, I think he should be in prison.

The second time is the charm!

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My apologies to my dear readers for this late post.  I usually write about surgery and surgeons, but occasionally drift into other things..   I visited the new Clinica de Medellin facility in late July, but didn’t have time to write about it before now.

Dermatology

Just before travelling to Medellin to cover Colombia Moda and the ALAT conference, I developed a dermatology problem.  As my American readers know, getting an appointment with a specialist in the USA can often take several months.  In fact, I was given an appointment in early July for later this fall.

However, during my stay in Medellin, my dermatology condition continued, so I decided to give the Clinica de Medellin another try.  I had heard rumors about some re-organization of the medical travel division so I decided to use this as an opportunity to verify those rumors.  I am very pleased to report that after sending my initial email to the Clinica de Medellin requesting a consultation with a dermatologist that I received a reply that same day (from Adriana Henao – email: ahenao@correo.clinicamedellin.com.co).

The coördinator called me back to confirm my availability and to ask if I would be willing to go to a clinic at one of the other Clinica de Medellin campuses.   (She also asked about my level of Spanish fluency so she could direct me to the appropriate physician.)

By the next day, an appointment had been scheduled for the end of the week.

New clinic

The clinic was so new that when I gave the address to the cab driver, he merely raised an eyebrow before starting the car.  On arrival, he expressed surprise – and said, “This wasn’t there before.”  The Clinica de Medellin Sede Occidental is divided into a hospital and an outpatient clinic area.  The smell of fresh paint was still evident in the immaculate, and sparkling facility.

The officer at the information desk had me personally escorted to the correct clinic when he heard my American accent (and hesitant Spanish).  I waited about fifteen minutes before being escorted into the private office of Dra. Sara Gonzalez Trujillo.  She was very friendly and pleasant.  We reviewed my past medical history and current treatments before she examined me.  She explained the condition in-depth before writing several prescriptions and requesting a lab test.

She provided me with a full copy of my medical records to take to my upcoming appointment and gave me her contact information.

Total cost of consultation: less than $50.00

 

Lab:

The labs cost about 25.00.  After a quick lab draw, I was given a lab slip with my record number on it.  I later received an email with my login to access my results.  Since I was headed back to the states, I emailed my results to Dr. Gonzalez, who called me with additional treatment recommendations and an explanation of the results.

Since seeing Dr. Gonzalez, I have been using the medications as prescribed – and my condition has improved dramatically.

Follow-up:

I have been taking the medications as prescribed and it is getting better.  I will email Dr. Gonzalez after seeing the dermatologist here to give her an update.

 

To make an appointment with Clinica Medellin, click here.

Crazy days!

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It’s been a couple crazy, busy days here in Medellin.  I have a bit of a backlog of posts – from a day learning to finger crochet in a group crochet class, the festival of flowers, a visit to Clinica Medellin Occidente and the ALAT conference.  It will take me a little while to post everything before heading home in just a few short days.

DSC_0001

The ALAT conference was fantastic.  In addition to numerous wonderful, learned speakers from all over Latin America, it was a great chance to connect with innovative thoracic surgeons from practices all around the world.  We also re-connected with surgeons we’ve interviewed in the past – to hear what they have been doing since my last visit.

One of these surgeons was Dr. Andres Jimenez at Fundacion Santa Fe de Bogotá (SFdeB).  As astute readers of the Bogotá books may remember, our encounters haven’t always been as collegial as they could have been.   However, he did grant me an interview, and permit my ingress into the operating room.  To my surprise, I found that while he was a hesitant interviewee, he was also a promising young surgeon.

With that in mind, I re-connected with Dr. Jimenez briefly to ask about the program.  Dr. Jimenez reports that they have started a lung transplant program and recently performed his first lung transplant at SFdeB.

Dr. Carlos Carvajal (right)

Dr. Carlos Carvajal (right)

Dr. Carlos Carvajal, who was a thoracic surgery fellow when we first interviewed him – is now a practicing thoracic surgeon at Hospital Santa Clara in downtown Bogotá.

Dr. Ricardo Buitrago continues his work in robotic surgery at Clinica de Marly.  Caught up with Dr. Luis Torres, the young and charming thoracic surgeon from Clinica Palermo.

But the biggest surprise at all – was the twinkling brown eyes of Dr. Cristian Anuz Martinez.  (The twinkling brown eyes above a surgical mask are all I remembered from my 2012 trip to the operating room with Dr. Frnando Bello in Santa Cruz, Bolivia).

with Dr. Cristian Anuz Martinez

with Dr. Cristian Anuz Martinez

We spent some time over coffee talking about the current state of cardiothoracic surgery in Bolivia, his private practice and his colleagues.

The conference itself was phenomenal – the amount and range of topics covered – from sleep medicine, tuberculosis, critical care medicine and pulmonology in addition to thoracic surgery.

The Festival of Flowers

The festival of flowers, one of the largest events in Medellin also started August 1st.  The event which is expected to draw 19,000 visitors to Medellin this year – celebrates the floral industry of Antioquia with ten days of events.  The events are staggered through out the city and include musical concerts, singing contests, parades, flora displays, children’s events and arts.

 

 

Festival of Flowers displays in Plaza Mayor

Festival of Flowers displays in Plaza Mayor

Tomorrow: Clinica de Medellin – Second time is the charm!

Street of Dreams – Calle 49

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el centro map with shopping districts outlined

el centro map with shopping districts outlined -high resolution

During Colombia Moda, I met several American business people looking for more information about fabric and textiles than the small booths could provide.  Many of them wanted to go out and see the fabrics, some of the shops and the factories but no one thought to take them to see any of these things.  All of the people I met were first-time visitors to Medellin (and some may never be back).  I can’t help with factory tours (I’d like to see those myself) but I do live nearby, so I thought maybe I could help provide some information for future visitors to this fair city. Since I thought wandering around El Centro as a first-time visitor without a guide might be a little daunting, this post might help people feel more comfortable. So I spent all day Saturday wandering around the district  – to take pictures and be able to provide more information to people interested in finding fabrics and materials while in Medellin.

A note about Fabric shopping in Medellin: If you are looking for super cheap – crazy bargains, you probably won’t find them here.  But you will find a huge array of all kinds of fabric – most of it made right here in the city.  For someone like myself who is sometimes (okay, frequently) frustrated by the lack of floor space given to apparel fabrics in the United States – (where it seems like 90% of fabric is for quilting and such), it’s still a bonanza.

Also, while it isn’t made in the USA (which is increasingly rare, I know) – I still feel a bit of loyalty towards buying locally sourced items – even if Medellin is that source. Still interested?  Good.

How to get here – the real Medellin

The best fabric and general shopping in  Medellin isn’t in the fancy malls of El Poblado and Enviagado.  It’s in the busy, teeming streets of El Centro.  El Centro is also where many of the most famous tourist attractions are, so if you are interested in seeing some of the famous architecture, the Botero collection (at the Museo de Antioquia) – you can do that too.  El Poblado and Enviagado are the rich, sanitized versions of Medellin – so if you have friends that aren’t interested in shopping but would like to see more of Medellin – this is a trip to take them on…

1.  Taxi – if you want to take a taxi, ask him to take you to the Plaza Botero.  It’s a few streets away from your destination, but it’s a nice central space – especially good if you are meeting friends or other visitors.

2.  Metro Train –  the metro train is cheap, clean and quite reliable.  It’s also a good way to see a bit of the city.  Take the (blue line) train to either Parque Berrio station or the San Antonio station.  San Antonio is closer to shopping, but Parque Berrio puts you right at the Plaza.  (For more information about the Metro, see this helpful article at Medellin Living).

Get a map –  Now, I know this is a digital age, but sometimes a paper map is just easier.. Safer too because it makes you less of a target for thieves who prey on upscale tourists for all of our fancy electronic devices.

tourist kiosk with maps

tourist kiosk with maps

There are several of these kiosks located in/ around Plaza Botero and around the Parque Berrio station.  Just ask for a map “Mapa, por favor” and they will be happy to provide you with a free map of Medellin.  I used this same map for reference for the shopping areas, to make it easy for visitors to recognize where to go.

Navigating the city Places like Medellin and Bogotá are particularly easy to navigate because streets use numbers, not names for the most part.  (Once you get used to the system – our system of street naming in the USA seems needlessly confusing.) Everything is basically on a grid – Calles run in one direction and are abbreviated as Cll.  Carreras run in a perpendicular direction and are often abbreviated as Cr. It makes locating a business very easy.  For example, my favorite fabric store in Medellin is Textiles El Faison – and their address is Calle 49 #53 – 101.  This means that they are located on Calle 49, about 101 meters from the cross-street, Carerra 53.

Now that you are here – with your map Walk south towards Calle 49.  (To orient yourself – remember that Medellin is set in the foothills.  If you start walking uphill, you are heading East (the wrong direction) – towards the financial center of Medellin (near where I usually stay). On Calle 49 – turn West (or downwards on a very slight grade)  The next several streets will be crammed with shops filled with all kinds of sewing related items – thread stores, fabric stores, sewing machine repair etc.

Sewing machine repair and sales

Sewing machine repair and sales

Many of the shops look tiny compared to JoAnn’s or the big craft stores you may be used to.  Sometimes they are tiny – but sometimes, it’s just the entrance to a larger indoor mall.

Entrance to one of the small fabric markets

Entrance to one of the small fabric markets

Fabric

Now, the fabric stores line Calle 49 and many of the cross-streets.. But sometimes notions can be a bit trickier to track down.  A lot of tiny shops sell just one product – like elastic or ribbon trims, buttons and the like.

small shop in an indoor fabric mini-mall selling thread

small shop in an indoor fabric mini-mall (Shanghai) off calle 49 selling thread

elastics and trims

elastics and trims

As I mentioned before, my favorite fabric store from my wandering on Saturday – is Textiles El Faison.  It’s a big store, and not quite as claustrophobic feeling as some of the smaller shops.  (When the shops are crowded, and the fabric piled to the ceilings, I get a bit closed in feeling in some of the smaller shops..) Not that this would prevent me – if I saw ‘the fabric’ there.

many shops are small but piled high with fabric

many shops are small but piled high with fabric

Lots of great stuff- but limited luggage space, so I move on to the next ones.

as you can see - the width of the store is pretty narrow, maybe 12 feet in total. Now add ten customers and I get a bit 'crowded' feeling

as you can see – the width of the store is pretty narrow, maybe 12 feet in total. Now add ten customers and I get a bit ‘crowded’ feeling

But for general browsing, or to see fabric in a shop more like what most of us are used to – Textiles El Faison is a well-lit two story shop.   Jaime Sosa is the manager there – and he is very nice and helpful.  My photos are a bit blurry because I was relying on my small phone (an older model) because I don’t like lugging my fancy Nikon down to El Centro).

Jaiime Sosa

Jaiime Sosa

Here’s the address for people who want to skip the adventures and go straight to his shop:

Textiles El Faison Calle 49 No 53 – 101 Medellin

displays piled high with fabric

displays piled high with fabric

But that’s not the only great place.. I really liked Portofino Textil too.. It’s located on the ground floor of a little textile mall.  (It’s a very interesting mall – about half the shops sell custom printed fabrics).

One of the malls for custom printed fabric

One of the malls for custom printed fabric

I was trying to cover a lot of ground, so I didn’t stop in and get all the details on custom printing – even though I saw little storefronts printing the fabric during my wandering.  (Maybe I will get a chance to go back and ask some questions.)  Custom may be the wrong word since most of it seems to be more like “Small lot pop prints” but at one shop, I did see a customer hand over a jump drive filled with images for printing).  But some of the other shops / kiosks didn’t look to have computers just their own style of pop prints (justin beiber, popular artists, other cool designs).

small storefront.. the lady in the blue tank is printing custom fabric

small storefront.. the lady in the blue tank is printing custom fabric

Portofino IMG_1881 Portofino has more of a warehouse feel  –  and a two meter minimum.  Fabric is priced by the kilogram.  I couldn’t resist one of the fabrics there – and my two meters of this lightweight lycra was 0.7kg in total.  For an example on prices – the tag on the bolt said 45,000 per kilogram but advertised a discount.. After the discount, my fabric total 27,156.  tax added a bit – for a total of 28,350 for my two meters of a 60 inch (or there about width).   According to today’s exchange rate – that’s about $15.35 (or around 7.50 a yard since a meter is a couple of inches more.)  So, like I said – not a crazy, amazing deal – except that I love the fabric, it was made right here, and it’s certainly not something I’d find at Hancocks or Joanns (if we even had one in my town). It’s actually located under another fabric store but I found it to have better selection, and salespeople that were very helpful and friendly. (Fabien was particularly nice – and patient with my limited Spanish).

I just couldn't resist..

I just couldn’t resist..

Portfino Textil #162  Carrera 53 No. 49 – 68 Medellin There were quite a few other shops – so you will just have to make you way down Calle 49 and find your own favorites. Patterns Pattern magazines can be especially hard to find – but when you do find them – they are a great deal.. Most pattern books contain anywhere from 20 to 200 patterns.  It depends on the magazine.  My favorites are Bianca, Quili and the more simply named Patrones.  Bianca has a lot of the patterns that are hard to find in the United States – like an extended variety of swimwear, lingerie and exercise apparel.  They also have a great assortment of patterns made for the new stretchy fabrics; lycra blends and modal.

Magazines containing 10 - 40 different patterns

Magazines containing 10 – 40 different patterns

Patrones is a grand brand because it has copies of a lot of the designs by major labels.  Want to wear your own Dolce & Gabbana? Then patrones is the magazine for you.  Sometimes you can find the magazines at larger newsstands or bookstores like Panoamericano.  Some of the patterns in Patrones are pretty intricate and instructions are limited (and in Spanish) but at 4,000 to 10,000 pesos (2.25 to about 6 dollars) a book – if you are an experienced sewer it is still quite the find.) patterns2 Now – for patterns on Calle 49 – the best place to go is – this little shop..

the place to buy patterns

the place to buy patterns Calle 49 #53 – 14

The place is tiny, so you have to ask to see the pattern books (or point, if necessary.)  They don’t have long aisles to browse like some of the bigger bookstores.  But the owner is very sweet – and they have a large array of titles available.

some of the patterns available at this small shop

some of the patterns available at this small shop

Yarns

Now, Medellin has that ‘perpetual spring’ climate we have been talking about, so I didn’t find as many places offering the bulky and superbulky yarns that I love.  Quite a few thread stores offered the smaller crochet threads and yarns similar to Lily’s Sugar N’ Cream but since I am on a superbulky yarn kick – I will keep looking..   I did see a couple, but shame on me because I didn’t write down exact addresses or take pictures (but since one of them is on a street close to home, I may venture out later this week – when I’ve exhausted my current supply and get some pics.)

yarns

yarns

Now before you head out for your shopping adventure  – review a few things to make your shopping more enjoyable and safe.  

In Medellin – alone or not quite ready to venture into El Centro by yourself?

I am always up and willing to lend a hand – if I am in the city.  (It’s a good guess if I am blogging about Medellin, then you can find me here.)  You can always call me/ text me at 301-706-3929 (If I am not in Colombia, I won’t answer) or email me at k.eckland@gmail.com I’d be happy to arrange to get together for a day tour of the shopping areas.  We can check out museums, eat some tasty street food, buy local produce, window shop – or hunt down that one special piece of fabric you’ve been waiting for..

If you don’t catch me on this trip – I’ll be back.. I’ll definitely be back for Colombia Moda 2015, so if you come a few days early (in July) we can have some fun.

Under Une Canal

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Now that it’s over, I can say it’s been another wonderful week at Colombia Moda:  I met Miss Colombia (she seems sweet) and took a picture of the President of the Republic..

santos

 

Didn’t get to meet President Santos, but maybe someday.  (I promise not to talk politics.)

Miss Colombia, Paula Vega of Atlantico region (Barranquilla)

Miss Colombia, Paula Vega of Atlantico region (Barranquilla)

Luis Martin

I even say hello to one of the models (since we were heading down the hallway) and we had a nice conversation.  It’s funny – I guess I always get intimidated by people taller than me, etc.. and I guess sometimes the expectation is just that models aren’t that nice.. But nothing could be farther from the truth.  Luis Martin – a local model from a neighborhood here in Medellin was very nice, sweet and pleasant.  It must be weird for him – I mean, his face is really familiar to me – after two years of seeing it thru my lens..

 

Luis Martin, model and a nice kid

Luis Martin, model and a nice kid

I wish we hadn’t be racing down a hallway – I would have liked to get a photo because he looks better in his own clothes..(Better sense of style).  Anyway, I thought it was nice of him to make conversation with a random gringa.. (We talked about Virginia of all things).  So – I wish him the best luck, and hope he makes the cover of Vogue one of these days.

Last day of Moda

Yesterday was the last day at Colombia Moda, and I don’t have enough nice things to say about all of the photographers and videographers there.  They are the reason I came back this year.  Instead of treating me as an outsider, they have always been welcoming and kind.

the orange backpack shows where I sit during the runways

the orange backpack shows where I sit during the runways

This year it was great to be back and see old friends like Stiven and Fredrico.  I didn’t see some of the wonderful people from last year, like Estaban who kept me in laughter and good humor even when every bone in my body ached from long hours in contorted positions.

Always great to see Stiven

Always great to see Stiven

This year, I have to give special thanks and words of gratitude to the videographers of Une Canal (Channel One) of Medellin.  Une Canal is the public television station for the city and during fashion week, they record live from the runway so it can be seen on big screens outside (so people without access to the runway itself can see it as it happens.)  That means they are at every single catwalk – always smiling, joking and being friendly even while setting up cameras, untangling cables etc…

The Videographers of Une Canal

That’s the handsome Juan Carlos, the charming Danilo Gallego and the ever kind Hernan.  For the entire fashion week, they allowed (and encouraged) me to take one of the plum floor positions beneath their cameras – in the dead center position of the runway.

Danilo Gallego of Une Canal

Danilo Gallego of Une Canal

People with better equipment than my starter Nikon can take sitting positions and even rise up on the press bleachers, but without this prime spot on the floor – I’d have been toast.  I never would have been able to capture 1/10th of the images that I’ve used in my recent articles.

I’d love to do a real (in-depth) articles on the videographers and photographers here at Moda, but it looks like I’ve already been scooped which I think it really cool.  Yesterday, the reporter from Une canal turned the tables of the videographers and interviewed them before one of the runways.

Danilo is interviewed for a segment on Une Canal

Danilo is interviewed for a segment on Une Canal

I am hoping to see Juan Carlos, Danilo and Stiven at some future events here in Medellin before I leave in August..  If not – I’ll see you next year!

Colombia Moda and Examiner.com

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Colombia Moda is over, and I am exhausted..  Sorting through several thousands of photos while writing articles about fashion collections has to be done in as timely a manner as possible, which doesn’t leave much time for sleep!

The good thing about writing for the Examiner.com is that they don’t give me any deadlines or article requirements.  I write about what I want – and submit it as fast as I can.  But there is no editor to nag me for specific lines so I feel free to focus on writing about the fashion that I like, or that I think is important.

I don’t write about Gef France because I think it’s boring.  I do cover Studio F if only because it is so immensely popular here – though I prefer the more daring and creative (and often smaller) lines.

But while I continue to gulp coffee and sort photos (even though my eyes are so tired I’m not sure if the photo is blurry or it’s just me, I wanted to give my readers links to my most recent articles (and photos) at Examiner.com

Lenonisa Runway

Agua Bandita and Onda de Mar – the Agua bandita photos are disappointing – the lighting was terrible.  (I thought that was me too – but then several photographers grumbled about substandard lighting and showed me their photos..)  They even called out during the runway to get better light..

Ipanema by Paradizia

Nonstop Runway: Faride Ramos

Nonstop Runway designer trio

Beverly Hills by Carmen Belissa

Studio F

I also talked to some Americans I met at the expo.  They seemed a little overwhelmed and lost – as they looked for textile manufacturers to produce fabric samples for use in their designs.  I bet they would have liked my textile/ fabric city tour idea.

I have a couple of articles I am still working on – and then it will be back to normal here at Latin American Surgery.  The ALAT conference (thoracic surgeons from all over Latin America) will be here in Medellin next week, so we will be back to some surgical topics soon.

Colombia Moda, Fashion and wearable art

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It may not look like it, but photographers like Steven have a philosophical side

It may not look like it, but photographers like Steven have a philosophical side

Because at the heart of it – isn’t that what fashion is really supposed to be?  Wearable art that allows us to express ourselves through the vision of talented designers?

That’s part of the discussion I had today with several of Colombia’s best photographers while waiting for the runways to begin here on the second day of Colombia Moda.  As we looked around at the many devotees to fashion – we saw a range of expression.  Some ridiculously shiny and spangled in the bright light of the sunny afternoon, others ill-fitting or overly tight.  Even the standard t-shirt and jeans of the working photographers were art.  Many of the photographers wore t-shirts expressing their political, philosophical or personal sentiments.

Juan Moore, another photographer explained it best when we were talking about the fashion collections, and why we loved the fantastical student lines versus the somewhat tepid, often mundane but super popular lines like Gef and Studio F.  It may be outlandish, impractical and extreme in nature, but..

As he explained, fashion is more than clothing – it’s an expression of the hopes and dreams of the artist, a view into the mind of the creator, and a vision for the future.  That may seem like a heavy burden for a t-shirt or dress but that’s what makes fashion such a challenging field.

the work of young designers offers us a glimpse inside

the work of young designers offers us a glimpse inside

So while I am writing (and publishing! articles and photos on the big houses like Leonisa, Studio F and Agua Bandita – it’s important to look at, and appreciate the work of the next generation of designers.  It’s their work that inspires me, and keeps me typing long after I’d like to go to bed.  It’s been a long day – cramped on the floor with strangers (and new friends) but they are the reason I do it – Los Jovenes Creatadores, Universidad Pontifica Boliviana and the rest of the young designers.

It may take me a few days – Colombia Moda ends tomorrow – to finish my writing commitments and sort through the thousands of pictures – but then let’s get back to the art of the next generation.

*For more photos and looks at the collections at Colombia Moda, I am in the process of publishing several articles over at Examiner.com – you can see the first articles here.

Crochet, crafts and traditional arts in Colombia

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One of my latest crochet projects – American flag scarf

Since learning some basic crochet (very basic) from my (very patient) roommate, Iris in Cartagena, I have continued to crochet.  I find it’s an excellent activity for all the waiting that goes along with travel.  I crochet in the car when we drive from assignment to assignment.

Hat and scarf

Hat and scarf

I need to learn some new stitches but I am getting a lot of practice with my basic stitch.   I have switched to a very large crochet hook (15mm or an “S” hook) and cuddly soft bulky yarns (types 5 and 6).  It makes it easier to see when I make errors and it works up quickly.  Plus, the yarn is so plush and soft feeling.

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I made a couple things for my friend’s new baby in Bogota.

My tiny model wearing the first hat I made

My tiny model wearing the first hat I made

 

So when I went to see her – I spent an afternoon in Chapinero checking out the yarn situation.  I was in a large bookstore in Chapinero when I met Ligia Morena Vega.  I was looking at some new sewing pattern magazines (since I am a sewer who crochets) and she was buying crochet magazines.

So I asked her if she knew where I could find some yarns in the neighborhood.. Not only did she know – she took me with her to meet the proprietors and learn more about the crafting classes offered.

That’s one of the things I’ve noticed in Colombia – pull out a crochet hook or start asking about crochet, and instantly you make friends.  I was on the bus to the airport in Rionegro when this happened the first time.  (It’s a long bus ride to Medellin, so I pulled out my crochet..)  Very quickly I made friends with several women  on the bus as we talked crochet.

 

with Ligia, shopping for yarn in Bogota

with Ligia, shopping for yarn in Bogota

Ligia crochets professionally.  She was buying magazines to use as catalogs for customers who want custom-made clothing, including formal style and elegant ankle length dresses.    Ligia’s husband runs a coffee and chocolate shop nearby on Calle 57 and Carrera 16 – so I will have to stop in and visit on my next trip to Bogotá (and get some pictures of her latest crochet creations too!)

We walked a few blocks to a short street, Calle 56 (with Carrera 13) where there are several stores selling a variety of yarns.  While there was a lot of Red Heart and Lion Brand (especially the Homespun USA – my favorite, at home), I was able to find some beautiful yarns that are made right in Bogotá.

I fell in love with some of the yarns from Lanas Arvi.

Lanas Arvi

One of the yarns is a beautiful tan and turquoise mix..

some of my new Colombian yarn.. with my gigantic crochet hook.

some of my new Colombian yarn.. with my gigantic crochet hook.

It’s destined to be a scarf.. This time I might even keep it.  So far, I have gifted away everything I’ve made with the exception of a camera lens bag..

Several of the shops offer crochet and knitting classes.  Todos Lanas and Almacen Mutifibras even print the class schedules on the back of their receipts.

The prices are about the same as Wal-mart (since JoAnn’s and some of the craft stores mark up the yarns quite a bit.)  I also bought two small skeins of a lovely dark purple to make a gift for a friend – and two small skeins of a variegated yarn with the bright yellow, blue and red of the Colombian flag..   All of the other yellow/ blue / red yarns were sold out just about everywhere we looked.  Several owners told us that between Colombian Independence Day (today) and the World Cup – they haven’t been able to keep any of the patriotic colors in stock for the last month.

Embajada de la Coca

During my visit to Bogotá – we sampled some delicious Andean style cuisine at the Embajada de la Coca.  (To read my article on the experience, click here.)

welcome to Embajada de la Coca

welcome to Embajada de la Coca

Meet the artist: Isabella Klein

The next day, I spent the afternoon visiting the Klein family.  If the name sounds familiar – it’s because one the sons, Albert Klein, PharmD is a close friend and my co-writer on several of the Hidden Gem titles.  (The Kleins are a talented family; the younger son, Alex plays piano with the Bogotá Philharmonic Orchestra and the daughter, A. J. is an occasional model.)

(For more about the Bogotá Philharmonic – read this post by a blogger from the University of Texas at Austin.)

His mother, Isabella works as a professional translator as well as teaching English.  But that’s just her job – art is her life.  She works in multiple platforms – mixed media, paintings, photography and artisan crafts.

On today’s visit – we talked about some of her craft work as well as the large craft fairs here in Colombia.  We discussed my ideas for ‘artisan craft style tours‘ where visitors could learn more about the crafting process and Indigenous cultures of Colombia.

She showed me some of her more recent projects – making decorative wooden boxes.  Instead of using the traditional Colombian patterns, she designs her own.

Some of the wooden boxes designed by Isabella Klein

Some of the wooden boxes designed by Isabella Klein

Her mixed media paints are arresting to look at.  Unfortunately, I was too busy admiring them to take any pictures..

But I do have a couple more pictures of the boxes.

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I think the next box is just fantastic.. It’s a design that just catches the eye.  I like the combination of blues.

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For a portfolio of some of Isabella Klein’s work – click here.

After too few days – it was time to say goodbye to my Bogota friends (new and old) and head back to Medellin to prepare for Colombia Moda..

with dear friends, Camila and Flavita.

with dear friends, Camila and Flavita.

Of course – it wasn’t all bad – these lovely ladies were at the airport in Rionegro to greet me..  The Aguardiente Girls!!

Welcome to Medellin!

Welcome to Medellin!

 

Calling all fashionistas!

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map Medellin

While many of you know that Medellin isn’t my favorite city in Colombia – it does have its own attractions.  I am not talking about the spectacularly breath-taking ride up to Parque Arvi on the metro cable or the Botero museum.

It’s the shopping – Medellin is the New York of Colombia and much of Latin America.  As home to Colombia Moda and the Colombian textile industry, the array of shopping opportunities are mind-boggling.  Most tourist guides will direct you to the upscale, brand name only shopping malls in the wealthier enclaves like El Poblado.  While these malls are worth seeing, I advise visitors to go in the guise of a museum-seeking tourist.

indoor flower garden at upscale mall in Medellin

indoor flower garden at upscale mall in Medellin (El Poblado district)

That is to say – go to look (at the sculptured gardens, majestic views and boutique brands) and maybe for a light lunch at one of the elegant eateries but save your cash for the real shopping mecca, in El Centro.  Wear comfortable shoes – and plan to finish shopping before 6 pm..

To get here:  Take the Metro (train) to Station San Antonio.  That will put you in the center of the shopping district.

Biggest Open Air Shopping District in Latin America

Don't worry, honey.. I stayed safely outside of this shop dedicated to crochet

Don’t worry, honey.. I stayed safely outside of this shop dedicated to crochet

At least, according to the banner hanging over one of the cobbled pedestrian streets.  But it seems pretty accurate as I wander street after street of an amazing array of goods.. If it isn’t here – than you won’t find it in Colombia.

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Since it’s not Buenos Aires (Argentina), yes – they have sizes larger than SIX.

 

There are streets filled with row after row of sidewalk vendors selling a multitude of items.  A whole street devoted to shoes.. Sidewalk vendors selling ornamental sandals with adjacent stores sell every kind of shoe ever made..

sandals

Just one of the many, many displays of sandals in the shopping district of El Centro

Street after street with store after store of Shoes.. Appliances.. Clothing.. Cosmetics.. Electronics.. DVDs.. Porn…  Lingerie.. Hats.  Costume Jewelry.  Fabric. Ribbons.  Yarn..  Several stores filled to the brim with beads.  Pastry and cake shops.  Any kind of soccer (futbol) jersey you could ever want (and not because it’s the world cup – these stores are always here.)

Whole malls (centro commercials) for bridal wear.. Others filled with row after row of beauty salons.

Dollar stores for all the items you forgot to pack.. Luggage stores for extra space to bring back your fabulous finds..

About the only thing I didn’t see was a street devoted to mascotas (pets) but that’s probably just because I didn’t wander far enough.

You can find almost anything here!

You can find almost anything here!

 

Calling all Colombian travel agencies!   Fashion and textile guided tours

Add this to my wish list for Colombian tourism businesses –  or other ways to make Colombia accessible to tourists on a whole new level.  For people who are familiar with Colombia, the tours would just be a nice, relaxing way to have someone else take care of the details…  Not everyone lives in El Centro and has the ability to walk a few streets right into the commercial heart of the city.

But for first-time visitors; wives of travelling businessmen or people unfamiliar with this part of the city – a guided tour to the heart of Medellin’s fashion district would be absolutely essential, particularly as the area gets kind of sketchy after 6 pm.  Tours for fashion sewers, crafters and knitters along with general shopping and factory tours just sounds like a fun way to spend a day.  Throw in a typical Colombian lunch (not the enormous banda paisa but something featuring all of the great local fruits and vegetables) and a mixed group of tourists (Colombians, and foreigners from several nations) as well as a knowledgeable, bilingual guide  – and I think there would be a line of people ready to sign up..

I think it would go along with my dream trip to Bucaramanga for a weekend guided factory tour and shoe-shopping adventure.

Alas!  I am not a marketing genius – just a lover of fashion, sewing and crochet.  But just for fun – I am going to add a survey here where readers can let me know what they think of this idea..  If I get enough interested responses – I’ll pass it along to someone in the tourism industry.

Proexport advertises Shopping Tours but they are short on details..

If you are interested in a personal beauty consultant – and shopping.. a bit pricey but here’s the link.  (link is a bit short on details too..)

Fashion Tourism Survey

 Tips for Shopping in El Centro:

– Wear comfortable shoes

– Don’t bring extras: jewelry, cameras, smart phones.  (This is a high crime area).

– Bring mainly small bills: 2ooo, 5000 and 10,000 peso bills.  It’s problematic to pay for a 3,000 peso purchase with a 50 mil bill for shopkeepers and may be impossible for outside vendors.

– keep your belongings secure – I recommend a zippered purse.  Backpacks should be worn on the front.  Messenger bags work for me – so I can keep the strap across my chest, and the bag close to my body.

– Try not to be too loud and (gringo-ey) in El Centro.. While most Colombians like Americans, in this instance, you don’t want to attract too much attention.

– Be prepared to leave by 6 pm – and don’t stay in El Centro after dark unless you are with a native paisa (person from Medellin).  It is easy to get lost – and dangerous at night.

In general, use commonsense – have fun and good luck on your shopping adventures!

It’s not vanity and it’s not easy: NHS agrees

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As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.

vanity

Not a vanity procedure

Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate,  life-saving intervention which has been scientifically proven to have multiple major health benefits.

For years, patients have had to jump numerous hurdles to be considered for this procedure.  One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure.  The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss.  This was in addition to several months of therapy with nutritionists and counselors.

hoops

A punitive process

While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help.  No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.

No, not this kind of scale

New guidelines – perform surgery earlier (2012)

But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians.  Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries).  But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs.  Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.

Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement.  Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’  and thus it was considered a ‘vanity’ procedure.  Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.

Adding stigma and shame to a medical condition

Patients who were overweight  and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance.  They were also told to return only if they continued to fail (or gain weight).

The Diabetes Pandemic

But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.

New guidelines were passed for eligibility criteria for gastric bypass procedures.  These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes.  But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.

But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.

The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.

* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.

Surge of patients but few surgeries

But can supply keep up with demand?  Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.

**Diabetics of Asian and East Indian  heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

The Eckland Effect

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It’s been a while since I’ve written – but sometimes between maintaining two blogs, a series on health for Examiner.com, answering emails from potential medical tourists, traveling and working long hours on assignment – I sometimes feel a bit like a candle burning at both ends.

But I am happy to report – that I recently completed my latest assignment and am back home in my native Virginia (for a few days) before heading back to Colombia.

I’ll spend the next couple days getting ready; contacting potential interviewees, researching articles,

Colombia flag

The downside of frequent extended travel is the piling up of all the inevitable errands and hassles.  Sometimes its just stuff like sorting through a couple of months of mail, but other times it’s paying property taxes (in person because I live in a small town) or renewing my driver’s license (now good until 2022!)

But now that we’re all caught up – we can get back to work (and writing!)

The Profiteer Model

Several interesting articles and posts have been written about medical tourism lately. We will talk about some of the other issues in future posts but today, I wanted to share this article by Stacy Hsu from the Tampai Times.  This article takes issue with the “Profiteer’ model of many so-called “Medical Tourism” hospitals and clinics.

VIP Medicine

As we’ve mentioned in previous posts, the idea of exclusive hospitals designed solely for the wealthy foreigner is both a noxious and popular one.  To many people, the idea of a resort-like or decadent atmosphere that caters to the every whim of the monied tourist or “Club Medicine” is a charmed one. VIP/ Executive health programs thrive around the world – from the hallowed halls of academic medicine like  John Hopkins, the Cleveland Clinic to the Planet Hospital branded facilities around the world.

Much of the medical tourism industry has been based on this context.  Programs are advertised on the basis of desirable location, gourmet cuisine menus, luxurious accommodations and nightly turn down service; not surgical skill or publishable clinical outcomes.  No one hypes a short-length of stay or low re-admission rate when catered meals, high-speed internet and cable television are part of the selling points.

money pills

VIP versus Concierge: Not entirely the same

Don’t want to travel?  But want your health care needs catered to?  There are whole branches of primary care practices (ie. the “Royal Pains” practices) that are now based on this principle.  On the surface, it doesn’t sound like much – patients pay extra money to have their doctor actually give them the time and attention they deserve* (during visits, phone calls and emails) but in reality, it can very quickly turn into something else as this ‘bonus’ pay approach changes the patient – provider relationship.

But “concierge medicine” as it is called in primary care medicine is a far cry from the VIP and Executive programs offered as part of medical tourism programs.  In concierge medicine, patients still have a long-term and established relationship with their physician – and it is this relationship that can actually improve health care outcomes along with patient satisfaction.  That’s because having more time with your family doctor means that s/he will spend more time answering questions and explaining care to patients. In turn, the patient is more likely to fill their prescriptions, take their medications and otherwise follow this doctor’s instructions.

*Instead of delegating more personalized care to people like me; the nurse practitioner (NP) or physician assistant (PA) which is more commonly done in standard medical offices.

But is ego-tickling medicine good for your health? 

According to the scant amount of existing research, the answer is often no, when we are talking about short-term patient-provider relationships like the one-day executive physical or the spa style surgery service.  In fact, patients often receive unnecessary and even potentially harmful, expensive tests and procedures (like the famed “Full body CT”).

I liken it to “The emperor’s new clothes” syndrome, where the patient is seen more as a consumer / purchaser of goods than a person seeking health services.  In this scenario, the healthcare provider is more concerned with keeping the customer satisfied than explaining why many of these tests and procedures are not necessary or may even be harmful.

Remember: First do no harm!

The customer is always right!

These contradictory objectives may become a conflict when the needed health advice isn’t what the patient wants to hear*.

Not even the humble fools dare tell the emperor the truth.

Not even the humble fools dare tell the emperor the truth.

The ‘Eckland Effect’

But it looks like this may be changing.  Several new research projects as well as recent articles are showing a move towards data collection and measurement of objective outcomes in regards to medical tourism.  Instead of patient satisfaction surveys, researchers are asking about the incidence of complications.

Other organizations are talking about implementing more accountability, transparency and formal accreditation for medical tourism programs and facilities.  Of course, accreditation is only as valuable as the organization offering it.

*Certainly this dynamic was at play in the care and death of pop star Michael Jackson under the care of Dr. Conrad Murray.

Additional articles for interested readers:

Al-Lamki, L. (2011).  Medical Tourism: Beneficence or maleficence? SQU Med J Nov 2011, 11(4): 444-447.  This is an excellent editorial that offers a concise overview of many of the ethical issues we have discussed here at Latin American Surgery including brain drain, transplant tourism, quality assurance, continuity-of-care and the overall impact of medical tourism on local communities.

In a related article, ” A European perspective on medical tourism: the need for a knowledge base” Carrera & Lunt (2010) argued for the urgent need for record-keeping  and statistical data collection in the medical tourism industry.  While this article is not available for free on-line, a related presentation by the authors is available here.

For readers interested in learning more about the correlation between patient satisfaction and clinical outcomes, I encourage you to read the works of JJ Fenton.

Fenton JJ, Jerant AF, Bertakis KD, Franks P. (2012).  The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.  Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.  This study in particular is a must read:  in this study, Fenton et al. followed a group of more than 36,000 patients and found that high patient satisfaction was correlated with increased health costs, greater rates of inpatient admissions to the hospital and a higher overall mortality.  Fenton et al have also conducted several additional studies examining the relationship between patient satisfaction and quality of care.  The findings of these study question the utility of new programs linking patient satisfaction with provider compensation (ie. pay-for-performance) and question the commonly held beliefs that patient satisfaction = high quality care.  It may be that the best care comes at a price:  unhappy patients.  But then again, isn’t not a popularity contest – or at least, it shouldn’t be.

Medscape subscribers can also view a series of articles on this topic including an inteview with Dr. Fenton on his body of work.  Medscape has a series of articles examining both sides of the argument linking patient satisfaction with provider compensation.

Patient satisfaction is overrated – an excellent editorial about the cost to patients (in health and money) related to demands for ‘patient satisfaction”.

Days of Summer

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A cautionary tale for my on-line friends in another botched surgery case in Florida.

Let the buyer beware:

In the most recent case, four individuals have been arrested for impersonating surgeons and operating an unlicensed surgery clinic. According to the media reports, only one of the four people charged is a licensed physician, nurse or other trained healthcare provider – but that didn’t stop them from performing major operations such as liposuction and abdominoplasty procedures on their unknowing patients.  While Dr. William Marrocco* was the doctor on record for the clinic – patients report that he wasn’t the one operating!

scalpel

Unlike many of the ‘chop shops” we’ve written about that take place in garages, motels and private ‘parties’, in this scenario, unwary consumers were duped by a savvy group of criminals who had owned and operated the “Health and Beauty Cosmetic Surgery” clinic in downtown West Palm Beach.

*The good doctor Marrocco remains a legally licensed doctor in the state of Florida – though interestingly enough – he does not have prescriptive privileges.  One the Florida Department of Health website, Dr. Marrocco (whose secondary address corresponds with the clinic address) reports active licenses in Virginia, Pennsylvania, Michigan, Indiana and Nebraska.

But let’s check it out… so I did my own preliminary online search –

Virginia: No records found.  No active or past licensees (expired in the last five years) found.  So he may have had one – but not recently.

Pennsylvania: William Charles Marrocco held a license in Pennsylvania for a brief two-year period between 1998 to 2000. This includes his period of medical residency training at Temple University Hospital.

Michigan: Three expired licenses – one for student status (resident) and one as a pharmacist.

Indiana: Dr. Marrocco was a licensed plastic surgeon in the state of Indiana from 2000 to 2011 and has a notation “reinstatement pending‘.  Maybe Dr. Marracco is planning on heading back to Indiana – where his license remains unblemished – despite the scandal surrounding the 2003  death of his wife after he performed liposuction on her).  License # 01052282A

Nebraska:  Expired, license #2909, educational license permit (training) affiliated with Indiana University

Jorge Nayib Alarcon Zambrano – (one of the individuals charged) is listed as a member of the Colombian Society of Plastic Surgeons – from Cali, Colombia.  So he may be a trained surgeon, just not a very good one (and not licensed in the United States).

Licensing isn’t everything..

Kind of goes to show some of the pitfalls of relying on licensing boards for consumer protection.  Dr. William Marrocco was a licensed plastic surgeon, but that’s little consolation for many patients at that West Palm Beach clinic.

In fairness to Dr. William Marrocco, Jorge Alarcon and the other individuals in the case – they have been charged with multiple counts, but have not been convicted of any crime.  Until that time, they remain innocent until proven guilty.

Apologies to my loyal readers for the long lapse in posts but my plate has been pretty full.  But I will be finishing my latest assignment in a few weeks and starting a couple of new projects for the summer months.

airplane3

I applied for and received a new assignment from Examiner.com to expand my focus to include more than just health topics.  Now I will be able to write more articles focusing on life and culture in Latin America.

Colombia Moda 2014

To kick-start my new assignment, I have applied to attend Colombia Moda 2014.

(official image from Colombia Moda / Inexmoda)

As many of you already know, I was able to attend last year – and got a fascinating glimpse into the fashion industry and the future of both fashion and consumerism.

Last year’s speakers were promoting the concept of “re-shoring” and changing from the traditional ‘seasonal’ lines and collections to an ongoing, evolving fashion line with new designs and items being designed, developed and sold to the public in shorter mini cycles.

dsigners

This year – I’ll be able to cover all of this – along with interviews with individual designers, fashion lines and the Colombian fashion and textile industry.  (Last year, my articles were focused on the role between fashion and plastic surgery).

Fashion is so intrinsic to Colombian life, and many parts of Latin America, so I am really excited about it.  It plays such an important role in the economic, social and an even personal lives of many Colombians.

sew

I won’t have an assistant this year – but I am getting a new lens for the event (I will be journalist/ photographer for the event).

After Colombia Moda, I will be flipping back and forth between writing about culture and my ‘usual’ medicine and health storylines.

I will be staying in Colombia for several weeks as well as covering the Latin American Association of Thoracics (ALAT) conference at the end of July.   It’s one of the biggest international conferences in thoracic medicine/ surgery with many of the legends of thoracic surgery planning to be in attendance.

Sponsors del Congreso ALAT 2014

In August, I’ll be heading across the globe to interview the head of an innovative surgical program.

I’ll be checking in along the way – and posting photos, interviews and articles as I go.

 

Is it safe to fly after surgery?

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Long haul flights are a health risk for everyone

While the risks of prolonged immobility and pulmonary embolism with long distance travel are well-known, many potential patients are unaware of the increased risks of thromboembolism after surgery.

Increased risks in specialized populations

People with a personal or family history of previous blood clots (PE or DVT), women on oral contraceptives, and patients who have undergone orthopedic surgery are some of the people at greatest risk.

Increased risk after surgery + Long trips

The heightened risk of thromboembolism or blood clots may persist for weeks after surgery.  When combined with long-haul flights, the risk increases exponentially.

In fact, these risks are one of the reasons I began investigating medical tourism options in the Americas – as an alternative to 18 hour flights to Asia and India.

Want to reduce your risk – Follow the instructions in your in-flight magazine

Guidelines and airline in-flight magazines promote the practice of in-flight exercise to reduce this risk – but few have investigated the risks of thromboembolism in post-surgical patients by modes of transportation: car travel versus air travel.

airplane3

But, is it safe to fly after surgery?

This spring, Dr. Stephen Cassivi, a thoracic surgeon at the world-famous Mayo Clinic in Minnesota tried to answer that question with a presentation of data at the  the annual meeting of the American Association for Thoracic Surgery.

This question takes on additional significance when talking about patients who have had lung surgeries.  Some of these patients require oxygen in the post-operative period, and the effects of changes in altitude* (while widely speculated about) with air travel, have never been studied in this population.

Now, Dr. Cassivi and his research team, say yes – it is safe.  Mayo Clinic is home t0 one of the most robust medical travel services in the United States for both domestic and international medical tourists.

After following hundreds of patients post-operatively and comparing their mode of transportation  – Dr. Cassivi concludes that the risks posed by automobile travel and air travel after surgery are about the same.

Additional reading

For more information on deep vein thrombosis, pulmonary embolism and safe travel, read my examiner article here.

AATS poster presentation abstract:

Safety of Air Travel in the Immediate Postoperative Period Following Anatomic Pulmonary Resection
*Stephen D. Cassivi, Karlyn E. Pierson, Bettie J. Lechtenberg, *Mark S. Allen, Dennis A. Wigle, *Francis C. Nichols, III, K. Robert Shen, *Claude Deschamps
Mayo Clinic, Rochester, MN

Schwarz T, Siegert G, Oettler W, et al. Venous Thrombosis After Long-haul Flights.  Arch Intern Med. 2003;163(22):2759-2764. doi:10.1001/archinte.163.22.2759 .  This is some of the definitive work that discussed the risk of long flights with blood clots in the traveling population due to prolonged immobility.

*Most flights are pressurized to an altitude of around 8,000 feet – which is the same level as Bogotá, Colombia.  This is higher than Flagstaff, AZ, Lake Tahoe, Nevada, Denver, Colorado or Mexico City, D.F.  – all of which are locations where some visitors feel physical effects from the altitude (headaches, fatigue, dyspnea, or air hunger.  In extreme (and rare) cases, people can develop cerebral edema or other life-threatening complications at these altitudes**.

** Severe effects like cerebral edema are much more common at extreme altitudes such as the Base Camp of Mt. Everest but have occurred in susceptible individuals at lower levels.

Dr. Fernando Arias

the meat and potatoes of HIPEC

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So I have returned to the United States and back on assignment for the next couple of months, so it’s time to get down to business.

A couple of new HIPEC articles came out – which I thought readers might enjoy.  For lighter fare, we will start with an article from the Vancouver Sun.

The first article, by Erin Ellis of the Vancouver Sun, is a Canadian fluff piece complete with sensationalistic headlines and dramatic patient interviews designed to draw attention to Vancouver General Hospital’s new HIPEC program.

 Dr. Fernando Arias

Dr. Fernando Arias, Chief of the HIPEC program at Santa Fe de Bogotá

Now for the meat and potatoes

The second article, which is more academically and scientifically based, is  focused on a study presented at the Southern Surgical Association  in December by Levine, et. al. (2014) “Intraperitoneal Chemotherapy for Peritoneal Surface Malignancy: Experience with 1,000 Patients” looks at long-term survival with HIPEC in patients with disseminated peritoneal malignancies.  This study is remarkable for both the duration of the prospective study (which began in 1991) and the large amount of participants for a single site study.  The vast majority of patients enrolled in this study had appendiceal cancer as their primary, but the study also included patients with ovarian, gastric, mesothelioma and colorectal cancers.

The evolution of the procedure and institutional experience led to improved outcomes and reduced complications over the course of the study.  Part of this was due to the development of better patient selection criteria.

This information comes as a ray of hope for patients with these diagnoses and previously given only dismal prognoses.

Dr. Edward Levine, the primary investigator, is the Chief of Surgical Oncology and Director of the Comprehensive Cancer Center at Wake Forest Medical Center in North Carolina.

It was published in the Journal of the American College of Surgeons, and summarized here, at Heme/Onc Today

Levine, et. al. (2014).  Intraperitoneal Chemotherapy for Peritoneal Surface Malignancy: Experience with 1,000 Patients.  Journal of the American College of Surgeons, 218(4): 573–585 (April 2014).  No free text available.

Additional HIPEC posts: the HIPEC archives 

On the Streets of Cartagena

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After a couple of super serious posts – It’s time to change the pace, back to the colorful life of Cartagena..  When we aren’t in Sincelejo, I’ve had a considerable amount of free time to enjoy the city.

Iris and I have had some great adventures (particularly gastronomic ones), but I have also spent a lot of time roaming around on my own, trying to make the city my home.

So I thought I would introduce some of the nice people I’ve met on my daily walks around the city. I don’t have photos of everyone, but I thought I would share the ones I do have..

aistedes 002

With Aristedes

 

(According to this picture, the  rumors are true – at least the part about my looks)

I almost didn’t post this picture of Aristedes Ayala and I – just because I look pretty awful but that would be a disservice to Aristedes, who has been a good friend while I’ve been here.  We’ve hung out various afternoons while he’s practiced his English with me.  I’ve tried to impart my southern accent during our lessons along with key American and southern idiomatic phrases, but I am not sure how successful I was.

But then again, it seems like my own accent has started to fade away from disuse.  (I have tried very hard to speak very clearly, and not to use colloquial phrases when I talk to non-native English speakers over the last few years – and I think I might have been a bit too successful.)

Gustavo

Gustavo

This is Gustavo.  He sells aromatic coffees, gum and stuff like that – one of the streets near my home, in a shady spot by the beach – so I see him almost everyday.  (I also have a slight gum addiction).

Gustavo is an interesting guy – he’s worked here near the beach in Cartagena for ten years – so he’s seen a lot of interesting and crazy things, particularly on holiday weekends when the beach is packed with tourists.

Prior to that, Gustavo, who is from here in Bolivar, worked in Agriculture in the coffee sector.

Miguel

Miguel

Miguel is a nice young kid I met who works for Aguilar as one of the delivery drivers (so he has what I consider to be an ‘essential’ job here in Cartagena).  I don’t know if the city of Cartagena issues badges for expedited travel during states of emergency like we had at the hospital in St Thomas, (USVI) but he should probably get one.  I can’t even image how life might grind to a halt if alcohol was suddenly absent from all the bars, restaurants and fancy hotels.

 

Willie

Willie

Willie is one of the vendors who works on the busy touristy zone in Bocagrande.  He sells a lot of the Colombian craft items.

Willie with his wares

Willie with his wares

Since I have been working on my first mochilla, we talk about my progress sometimes.  (I’ve made a lot of progress on my latest trip to Sincelejo).

making progress on my Colombian bag

making progress on my Colombian bag

Then there’s this guy.  I don’t know his name, so I will call him Juan Carlos (which is one of my favorite names).  Imagine my surprise to see that he has been here at the military base every day watching over me (which is across the street from my apartment).  I never even noticed him until today.

Meet Juan Carlos

Meet Juan Carlos

So I asked Juan Rodriguez (at the base) to introduce me – and he did.

Officer Rodriguez

Officer Rodriguez

I know the military here has a bad reputation (particularly for past misdeeds) but all of my encounters with them have been pleasant, professional and friendly.

I always feel safer when they are around.

Manuel

Manuel

Manuel sells jewelry and beads on the beach – but he was happy to make time for a short chat.

I didn’t get the names of some of the other vendors I spent a couple of afternoons chatting with.  (I wasn’t shopping – just passing the time).

Cartagena playa 015

 

I joked with this guy about being from Bucaramanga (he’s not, BTW) because I have the female shoe shopping fantasy about Bucaramanga.

Selling shoes

Selling shoes

 

I always imagine it would be a shoe paradise for me – lots and lots of shoes in small sizes!  (I wear a what is a child’s size shoe in the USA so it’s hard to find shoes without cartoons on them at home.)

Now  – that I think would be a great tourism opportunity – “Shoe Shopping Excursions”.  I’d be more than happy to sign up for a weekend trip to Bucaramanga to find at least one pair of comfortable shoes that actually fit!

I’ve actually tried to enlist my good friend Camila in a do-it-yourself shopping adventure, but to no avail.  (She’s expecting a baby soon which has put a damper on major excursions – but hey – a new baby isn’t so bad..)  She’s be the perfect accomplice because she used to own an upscale clothing boutique so she is very knowledgeable about the quality of leather, clothing, shoes and other apparel items.  She also has excellent taste.  (I have gringo taste which is nothing to brag about – so I accept all help offered.)

I dread shoe shopping at home because it’s an exercise in frustration and is often accompanied by tears..

But maybe I can enlist some of my fantastically fashionable Bogotanas on my next visit..

Cartagena playa 012

This nice kid was just hanging out, outside Juan Valdez – but he was happy to let me take his picture..

Cartagena playa 019

Now I don’t have a photo of one of my favorite people here in Cartagena.  His name is Juan Fernandez and he repairs shoes along one of my exercise routes.  He’s about 60 and from a small town outside Cartagena, though he has lived here for about 40 years.  I always stop and chat with him for at least a few minutes, and he always greets me by name.

When we both have a little more time, we talk about philosophy, life in Colombia and our shared experiences.  I look forward to seeing him – and he always asks about my adventures in Sincelejo.

Now I know I talked about some of the things I don’t like about Colombia in a recent post –  but it’s people like Juan Fernandez that make me love Colombia so much.  Just nice people – who are happy to talk to a stranger, make her feel at home and pass the time.

End of the road

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I know many people were not thrilled about my latest post, “What I don’t like about Colombia,” but I felt it was a fair question (posed by a reader) and it deserved an honest answer.  Whitewashing my opinions / experiences and perspectives or painting a pretty picture does a disservice to this beautiful country and its people.

Colombia, like any country – has its beauty, its strengths, its joys and its share of problems.  Ignoring issues because they may appear less than favorable undermines my integrity and the integrity of my work.

So I apologize if I have offended anyone, particularly any of the wonderful people who have graciously extended hospitality and friendship to me.  That was not my intention.  But I cannot apologize for sharing my perspectives as an outsider looking in.

As my time here in Cartagena and Sincelejo comes to a close – I hope that my readers, colleagues and friends can appreciate my experiences for what they are, my experiences.

Last week in Sincelejo

My last week in Sincelejo was a bittersweet one.  Sweet because we had two coronary cases but bitter because it was sad knowing this was the last time I would see everyone.

Anita, Patricia and Estebes

These three ladies have made all the difference in my operating room experiences here, and I am grateful for that.  I have really enjoyed getting to know them – and I feel sad at the thought that I may never see them again.

Raquel (right) and Anita, the instrumentadors

Raquel (right) and Anita, the instrumentadors

I am really going to miss Patricia and her perpetually sunny nature, easy smiles and ready laughter.  She was so sweet to introduce me to her son so I would have an escort and companion if I wanted to go out dancing.

Patricia and Estebes, circulating nurses

Patricia and Estebes, circulating nurses

I will miss Estebes, who always seems to go out of her way to help me.  She is always there to adjust the light, offer a stool or anything else that might make it easier for me while I am peering into one of the dark tunnels of someone’s leg.

with Estebes

with Estebes

Anita, too, has wonderful.  I feel like we have also had some fun, working at the ‘back’ of the table.  I’ve tried not to be in her way – and to actually be somewhat helpful.  (I’ve probably failed at this – but she has been very sweet and has never made me feel unwelcome.)  She’s also extremely knowledgeable about surgery so it’s good to have her there.  It’s hard to feel nervous with Anita watching over me.  Or when I need a third hand – she is always there – even while managing everything at the top of the table too.

barbosa 045

Tuesday

We arrived in Sincelejo this morning for surgery this afternoon.   I did a fitting with Dr. Barbosa and his new headlamp apparatus so I could fit the final piece of Velcro.  It’s not the prettiest thing in the world, but it’s functional and fully washable.  (The previous headlamp anchor is an uncovered foam that crumbles with washing).  I added a border to the old one as well, and repaired it the best I could, so he would be able to swap them out as needed.  I hope he liked it – despite its ‘ugly duckling’ appearance.  I thought it would be a nice gesture since he has done so much for me – and I don’t know how to say “Thank You.”

Dr. Barbosa models his new headgear.

Dr. Barbosa models his new headgear.

 

The patient only needs one small segment of vein – so Dr. Barbosa decided it would be a good time for me to learn open saphenectomy.  (I think I have convinced him on the soundness of my theory of learning the principles of saphenectomy, especially with my argument on the need to know for emergency cases.)

performing a saphenectomy

performing a saphenectomy

It was amazingly fast and essentially a bloodless field.  Since everything is open before you, it is easy to ligate and clip all of the collaterals.  I was surprised by how quickly I was able to free the vein.  Closure didn’t take much longer than normal because even though it was an ‘open saphenectomy’ since it was only one graft it wasn’t that long of an incision.

I am glad I had an opportunity to try it because it certainly gave me more confidence than I would have had if I was expected to learn it during an emergency case.  I also felt it gave me a better feel for the anatomy – because it’s all laid out in front of you. (It doesn’t matter how much you read or study a textbook – people are ‘never’ completely textbook, and ‘real’ anatomy looks different from the pretty drawing in my Grey’s Anatomy, especially when you are peering down a dark tunnel tract.)

Wednesday

The patient from yesterday is doing well.  The morning chest x-ray showed significant atelectasis but the patient was hemodynamically stable and without other complications.  I reviewed post-operative teaching (pulmonary toileting, ambulation) with the patient and explained that due to underlying COPD, he needed to be more aggressive in pulmonary toileting, and post- operative exercises.

Just a nurse?  I don’t think so…. But you are only a doctor.

Today a doctor attempted to insult me by stating, “You aren’t a doctor.” (Don’t worry, dear readers – it wasn’t Dr. B – I think he ‘gets” me.)  It made me want to laugh out loud but I managed to restrain myself since I was scrubbed in at the time.  Of course I’m not a doctor – and thank the lord that I am a nurse!  I never have and never will want to be anything else!

I feel sorry for someone so limited that they can’t see all that is missing from their life because they are “just a doctor.”  They are just a doctor, but I am fortunate enough to be a nurse!  I get to be everything that they can’t.  For him, the people who come to us for help are just patients – part of an endless cycle of work, a means to pay the bills, buy a big house and have the status that being a doctor brings.

But for me, well, I am not usually overly religious in my speech but there is no other way to describe it but to say, I am blessed. I do feel it’s a ‘calling’ of sorts.   I am blessed with the opportunity to care for these people, each one unique; with their own hopes, dreams and rich histories.  I have the privilege of being one of the people alongside the family and friends who cares for them.  I am lucky enough to be invited to share in that care.  The patients may leave the hospital, but they never leave my heart.

I am so much more than just a nurse to my patients; I am a teacher, a friend, a source of comfort and compassion during a life-changing experience.  I am the one who holds their hands when they are frightened – and the person who brings a smile to their face when they think they will never smile again.

Just a nurse?

Just a nurse?

I am a little bit social worker, a tiny little angel, a physical therapist, a cheerleader and friend, and even to many, their favorite ‘doctor’.  Often, I am the one they feel comfortable talking to – I am the one they bring their questions and concerns to.  Usually, I am the one they trust – to tell them to truth and to assist them on their journey back to health.  And, that sir, is a privilege you may never know.

To my surgeons, I am the extra right hand they didn’t know they needed.  I am always where I am needed – often behind the scenes, taking care of small issues so the surgeon can continue to do the things he needs to do – namely operate.  I am someone to bounce ideas off of – someone to teach (and wants to learn).  I am the very best resident a surgeon will ever have.

To the other doctors (who may have limited experience with cardiac surgery patients), the ones who are willing to admit it – I am an advisor, a teacher and a trusted colleague.

To my nursing colleagues – I am a mentor, a teacher and someone willing to listen to their concerns.  I know their jobs and I know their intrinsic value.  I know their talents – even if you don’t.  I never shrug off a nurse’s concerns, and that has saved lives.  If the nurse caring for the patient comes to me and says, “I don’t know what it is but something isn’t right,” than I know that something isn’t right.  And together, we figure it out and make it better.  I know that these nurses, the ones you dismiss – they have hopes and dreams too – and they take pride in excelling in their job.  If they don’t know something, it’s not for a lack of trying – it’s for want of a mentor.

Ever Luis, one of my favorite floor nurses

Ever Luis, one of my favorite floor nurses

And yet – there is still more to this nurse – I am an investigator, a researcher and a bit of a detective.  But you sir, are only a doctor.

In today’s case, the patient needed two grafts.  Dr. B started the initial incisions (I was off by a centimeter yesterday on my initial incision, so I think he lost confidence in my skills – I was worried about avoiding the patients more superficial varices.)  I am a little afraid of jumping in too quickly and harming the patient – so I am cautious in making my initial incisions – but once that’s done, I feel like I am in familiar territory.  I looked at my case log after the surgery – and it seems incredible for me that I’ve only had eight cases because it feels like I’ve been doing it for longer – parts of the procedure feel almost automatic now.  I wish it was 25 or 3o cases but the service just isn’t that busy.  I knew that would be the case when I came here – so I am grateful for the eight cases.  Eight is still more than none, and none is how many cases I was getting back at home.  (It’s that tired cliché – everyone wants someone with experience but no one wants to give a person a chance to get experience.)

I am still hoping that future employers will take my willingness and eagerness to train into consideration and offer me a chance even though I am a locum tenens provider.  I have just been burned too many times in permanent positions to risk taking another one in hopes that they will fulfill their promises to train me.

Thursday

No surgery today but a full clinic!  It was a good day in clinic because I got to see all the post-operative patients from our previous surgeries, and it was just a bit heart wrenching.  But then again, I am always a big sap for my patients.

All the patients seemed so happy to see me – and I was so happy to see all of them too!

Everyone looked really good, and I was impressed by their questions and attentiveness during the appointments.  My patients knew all of their medications by name, and were eager to discuss this and other post-operative instructions they received at the time of discharge.  (Usually it seems like people forget a lot of what we talk about in the hospital – but I think my horrible gringa accent sticks in their minds).

The only disappointing aspect, was seeing one of our patients (who had been really fragile pre-operatively) amble in.  She looked great – and said she felt pretty good, (other than the usual sternal soreness) but one of her leg incisions had partially dehisced.  (Luckily it was a very small skip incision and the patient had been fastidious about cleaning it as directed).  The wound was very clean, with no signs of infection.  It was healing well by secondary intention but I was disappointed in myself that the wound closure didn’t hold up.

After clinic – we headed back home.  All the while, I was thinking of how I will miss Sincelejo.  I will miss my friends, my patients and Clinica Santa Maria.  I will miss the chance to work with Dr. Barbosa – who was always such a great teacher, even if we didn’t always see eye-to-eye.  Most of all, I will miss Iris, who has been my best friend, confident and colleague during this journey.  I will miss working with her – I honestly think that between the two of us, we could be a force to change the world (or at least cardiac surgery) for the better.

From the bottom of my heart, I sincerely say, Thank you Iris, Thank you Dr. Barbosa, Thank you, Estebes, Anita and Patricia – and thank you Dr. Salgua for having me here among all of us – and making me part of the team.  I will miss you all.

Dr. Salgua Feris

Dr. Salgua Feris

So what don’t you like about Colombia?

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This question comes from a recent email by one of our loyal readers.. (It may have been sarcastic, but I’ll answer it honestly and candidly.)

So,  what don’t you like about Colombia?

Fair enough, but let me preface the discussion by saying that EVERY SINGLE THING that I mention below also exists in the United States.  So I won’t pretend that my country is some kind of gender utopia.  It’s not – In fact, the “war on women” has been waged between political parties and in headlines of newspapers all over the United States.  My home state of Virginia, along with Texas has been some of the worst offenders on this front..

Still… Due to the overwhelming machismo here – the things that bother me the most in Colombia  somehow manage to be extremely pervasive, sometimes subtle yet face-slappingly* shocking at the same time.

1. You are never more than your looks.  Sure, everyone knows that unfortunately, attractiveness, particularly female attractiveness is the unspoken prerequisite for career success in the United States.  But it tends to remain unspoken, highly illegal and in the background for most of us.

It is one of the biggest ways that males here (Colombia) are able to maintain authority and superiority and subjugate women.  Too many people buy** into it – so even women who hate it are forced to conform to survive (professionally, financially).

It’s different here – and it’s probably the main reason I haven’t chosen to call Colombia my long term home.  It’s never in the background here, and it never fades away.  It doesn’t matter whether you’ve known someone here for five minutes or five years – you are still being judged by your looks.  It doesn’t matter what your background is, your skillset or your intelligence.

Men (who are the majority rule here) won’t even hear what comes out of your mouth if you don’t meet the “minimal attractiveness” levels.  It’s almost like a physical disability – as if they literally can’t hear you.

a PhD in physics? Sorry, sweetie - I can't hear you.. Maybe after you get some breast implants..

a PhD in physics? Sorry, sweetie – I can’t hear you.. Maybe after you get some breast implants..

Not only that – but in general, Men here judge harshly.  If you aren’t a supermodel, with large (or enhanced) curves – then you are lacking.  Not only that – but they will be certain to inform you that you are lacking (using during your initial introduction, and probably every single subsequent meeting thereafter.)

(Obviously – this doesn’t apply to ever single male in Colombia, but it’s still quite prevalent even among the better educated upper classes).

Even if you are beautiful – your time for professional and career success is limited.  Maybe you have some cellulite, or your breasts aren’t perky enough – or you’ve had the gall to age.

So as you can image, as a chubby, woman over 30, who has never, ever been “mistaken” for a model even on my very best days as a young ingénue, this constant spoken criticism is extremely disheartening.  Not only that – but it makes it extremely hard to get any work done.

2. Don’t ever attempt to discuss any of this with male Colombians.   While women here talk about these issues often and express their feelings towards these attitudes of male machismo, don’t bother trying to address these issues with male Colombians.  (Sure, there is always the odd exception – usually a more cosmopolitan man who has lived outside South America at some point, but it’s not common.)  As I said before, ‘selective deafness’ comes into play.  Not only that – even when having a so-called polite conversation (on American customs, polite behaviors etc.) attempting to explain (to people planning to visit the USA) that these behaviors may be perceived negatively in the United States, will be dismissed.  Very often this will also result in comments such as “you are just jealous of the beauty of Colombian women.”  This comment was made in response to a discussion about the fact that calling an American woman ‘gordita’ (chubby/ fat) or ‘vieja’ (old) may impede abilities to make friends and have serious repercussions, particularly if it occurs in the workplace.

It will also get you labeled as a lesbian.

an aging lesbian speaks out

an aging ‘lesbian’ speaks out

3. Aggressive homophobia, particularly in the coastal areas of Colombia.  Despite the fact that an estimated 8% of the population identifies as gay, homosexuality remains a big taboo in many parts of Colombia.

While Bogotanos and residents of more cosmopolitan cities like Medellin and Cali tend to express more tolerant / accepting attitudes regarding an individual’s sexuality – this is not the case in places like Cartagena.  (Costenos have a reputation for being less than sophisticated.  There is even a Colombian version of the “Beverly Hill-Billies” which features several Costenos living in Bogota). Homophobic slurs are extremely common in every day speech.

Like their American ‘redneck’ stereotype counterparts – many Costenos are bigoted, biased and intolerant of others.  This includes the darker-skinned Costeno residents, and gay people.  While I try to keep my mouth shut for the most part, (even though it pains me) when I hear the blatant racism / homophobia – on the one occasion when I objected to hearing the repeated use of an extremely ugly Spanish pejorative for gay people  (akin to the American slur of “faggot”), I was literally shouted down for my audacity in attempting to censor his “bible given” right to spew hate.

Even the sly suggestion that a particular apartment is in a “gay neighborhood” is enough to prompt something akin to panic, and further discussions on moving/ selling said apartment.

Of course, this sort of bigotry happens in the USA – and everyone knows that.  But I would like to think that a lot has changed in the last ten years in that the majority of Americans are not only tolerant of gay individuals but support their right to equality under the law, the right to pursue personal happiness and to get married and have families. Even the majority of Southerners***.

So now you have a unattractive, middle-age lesbian in Colombia.  Try and imagine how this impedes daily interactions.  Oh, did I mention that I am also considered a slut.

4. Rampant Slut shaming.

So if you have committed any of the faux paxs listed above, don’t be surprised at what comes next, namely Slut Shaming.  Especially if this “puta gringa” has also committed the unforgivable sin of also learning the names of the Building porter or the person who sells you gum (daily) or other members of Cartagena’s “lower class.”  It’s not something as simple as good manners – it’s because you are a slut and are sleeping with all of them.

In a country where married men openly brag about their numerous sexual conquests, ‘amigitas’ and secret families are common, women are still placed within the narrow confines of the “Madonna/ slut” paradigm.  As a married foreigner who often travels solo due to financial concerns, the lack of my husband’s physical presence makes me even more of a target for this labelling.

Women here are supposed to dedicate long hours, and thousands of dollars in pursuit of ‘sexy’; wearing tight, short revealing clothes, tilting around on high heels while attempting to balance outsized breasts with generously rounded bottoms – yet maintain an ‘inner purity’ that prohibits open and frank conversations about gender issues.  The end result of this – is that men are able to strictly control the financial and economic mobility of women in a society that castigates outliers.

So I am fairly certain that my candid response to this question won’t go unpunished.  I probably should have stuck to easy answers.

ie. What don’t you like about Colombia?  Answer: FARC/ paramilitaries.

But then, I don’t have run-ins with paramilitaries on a daily basis..

So what does this mean?

Does it mean that this slutty, unattractive, lesbian gringa should give up any hopes of doing business in Colombia?  AKA “Gringa GO HOME” (as has been suggested on multiple occasions).  Or should I fire up my time machine, emerge as a fresh 20 something, head directly to the nearest plastic surgeon and keep my damned mouth shut?  Should I wear tighter clothes, stilt like heels and hope to blend in?

Maybe it is time for me to go home – and return when I can remember and enjoy the thousands of things I LOVE about Colombia; the cool air of Bogota, the richness of a country with an in the amazing array of natural wonders and geographic splendor, the overwhelming variety of fresh fruits and vegetables, the joy of learning to Salsa, the cultural depth of a country with over 500 years of history, the incredible variety of friendly, and interesting people I meet on any given day (machismo not withstanding).

But don’t worry – nothing can get me down for long – and I will return to the beautiful, wonderful, culturally rich Colombia very soon.

Notes:

* Yes, I made that word up, but that’s how I often feel as I confront these issues every single day here.

** Literally.  It’s one of the reasons plastic surgery is such big business here.

*** Before readers get upset that I am “propagating the American redneck stereotype”, consider this – I say this as a self-proclaimed ‘redneck southerner’ who happens to express a ‘Live and Let live” philosophy towards others. That being said – my experiences in Colombia – are mine, and I don’t attempt to speak for, or represent anyone else’s experiences here.  If anything – I hope your experiences (as a female) in Colombia have been different.

Additional articles on related topics

This study compares eating disordered behavior and plastic surgery rates in the USA and Colombia.

Gender, eating habits and body practices in Medellin, Colombia – article by Ana Maria Ochoa.

Narco-aesthetics: How Colombia’s drug trade constructed female ‘beauty’ – article by Mimi Yagoub

Life in Plastic – it’s fantastic! about the culture of plastic surgery in Latin America (specifically Cali, Colombia) and the link to narco-trafficking.

LA Times article: A Scathing Attack on Culture of Machismo.

Acid attacks show the face of machismo in Colombia

Earning a living is the biggest obstacle for Colombian women.

Colombia: Human Rights Situation of the LGBT Population: Shadow Report Submitted to the United Nations Human Rights Committee (2010).  While laws were passed to protect the human rights of the LGBT community in 2011, the situation remains precarious for the LGBT community particularly in rural areas.

U.S. groups file briefs in Colombia marriage case. (4/14/2014).

Bogota mayor invites residents to come out of the closet.

Women on Waves resources: promoting women’s rights internationally. Provides practical, not philosophical information for women in a multi-lingual site on women’s health & gender issues.

Women on Web: women’s health information – multi-lingal site.

Featured Image courtesy of Sodahead.com

Made in Colombia

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The operating room may have stayed dark for the last several days, but that doesn’t mean it’s been a quiet holiday week here in Cartagena.

Cartagena 010

the quiet streets of last week are just a memory

The relaxed, fun atmosphere of the city – due to the tourists, the beaches, the clubs (and the Chivas!) is contagious.  It’s impossible not to be affected by all the smiling, happy people out and around…

Boy

 Adventures with Iris

Iris and I have had a fantastic week – wandering around the city and enjoying all that it has to offer.  (I swear, my next book is going to be called, “Adventures with Iris” and I am going to chronicle all of our various escapades).  But since she’s camera shy, it would be kind of a crazy book – with photos of me standing alone in all sorts of cool places..

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Hanging out with Iris usually looks like this (as she hides from the camera).  You can also see my new haircut from a recent ‘day of beauty’ with Iris.

We’ve been all over town, sampling various cuisine, drinking a micholada here and there, and enjoying the refreshing evenings that serve as a relief to the sultry heat of the day.  We get along great so there is always something to talk about when we hang out.

Coconut water from the source

Coconut water from the source

I have a bit of a routine here – in the early mornings (if I wake up early enough), I head out to walk along the beach for some exercise.  By 7:30 or so – the sun, heat and humidity are already out in full force, and it’s time to head back indoors.

bikes in el centro

The rest of the morning is spent sewing, writing, reading, or crocheting.

After lunch it’s time for a siesta to pass the afternoon before the ocean breezes come to shore and cool off the city.  (Without the daily afternoon cool down, I think the city would just be unbearable, particularly for someone like myself, who is unaccustomed to the heat.  People from South Florida probably don’t even notice it.)

Visiting with Iris' Colombian craft class

Visiting with Iris’ Colombian craft class

In the late afternoons – we head out for various activities..

at a recent Colombian cuisine and craft event in El Centro

at a recent Colombian cuisine and craft event in El Centro

Colombian crafts – continued

I am making a lot of progress on my first crochet project – the universal, ever popular  ‘Colombian bag.’

Made in Colombia

Made in Colombia – the typical/ classic Colombian handbag, “Mochilla”

Of course, mine won’t be as fancy as these here (since it’s my first) but I did add a jazzy yellow stripe.

Colombian bag progress update

Colombian bag progress update

Avenida Brasil – More drama than the hair-pulling, cat-fighting “Dynasty” style dramas of the 1980’s.  (That’s probably not their advertising slogan).

I also work on the bag some evenings while we watch “Avenida Brasil” which is one of the typical melodramatic (always crying or screaming) telenovelas on television.  As the name implies, it’s actually a Brazilian show.  It’s a bad stereotype of Latin American soap operas with tired story lines (everyone cheats – no one uses contraception, so everyone gets pregnant (but somehow never gets HIV).  It has none of the substance of “El Patron” but it’s popular here, so I watch it.   But maybe all soap operas are like this – I was never a big fan of the Young & the Restless or whatever…

For the last week of episodes: the wicked Carmina  has been crying/ carrying on (and manipulating everyone) in every episode.  She recently caught her husband, Tifon cheating on her with one of his old friends, Mona Lisa.  But that’s no surprise to chronic watchers despite the fact that Mona Lisa just married another guy..  ( and Of course, Carmina has not only been cheating on Tifon for several years – but actually lives in a shared home with her amante, Max, his unsuspecting family, as well as her in-laws and her daughter (whose father is actually Max.)

Probably the only interesting story line for me is the serial polygamist. I don’t know the name of the character – but he’s suave and handsome in kind of a bland Argentine kind of way.. It’s like he just can’t help himself – as he marries woman after woman and maintains several separate lives.  He was recently found out by his three wives (who were completely unaware of each other) – while dating and wooing a fourth woman.  It’s only interesting to me in that he seems completely oblivious yet totally manipulating and calculating at the same time.  It’s a common theme that reflects much of the ‘machismo‘ here.

Then there is Jorgita (Jorge), the son of Carmina and all of his trials and tribulations.  Of course, he is in love with one woman, while dating and impregnating another.   He’s supposed to be so wonderful and charming – but I find him quite revolting with all of his flashy jewelry and declarations of ardent amor.

Of course there are a myriad of other characters and story lines but this is probably enough to give an accurate depiction.

Hecho en Colombia

 

Handmade dress - about half way done

Handmade dress – about half way done

I’ve also been sewing a dress using some fabric and patterns I bought here.  I altered the pattern (quite a bit) to make it more of my 1920’s style and on a whim – have been sewing it by hand.

One of my preliminary handsewn seams. (They are prettier when I finish).

One of my preliminary handsewn seams. (They are prettier when I finish).

Maybe when I get done – I can label it ‘Hecho en Colombia’ since I made it here in Cartagena using a Colombian sewing pattern, and Colombian fabric.  (Both the pattern company and the fabric manufacturer are in Medellin.)

Iris has a perfectly fine Brother sewing machine – (I used it to create a new helmet guard for Dr. B’s helmet light) but I just felt like doing it by hand.

photo (52)

 

Dr. B’s new helmet liner

It’s a cushion made of fabric covered foam that keeps the metal frame that holds the surgical light from shifting or weighing too heavily on his head during surgery.  It’s navy blue so it’s hard to see in the photos.  It has velcro strips to affix it to the metal frame, and adjust for individual sizing.

photo showing Dr. B and his helmet light.

photo showing Dr. B and his helmet light (and the old liner).

Haha.. Kind of funny how even sewing always circles back to surgery, isn’t it?

 

Downtime in Cartagena

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Ribbons, fabric and sewing supplies in just one of several stores in El Centro

Ribbons, fabric and sewing supplies in just one of several stores in El Centro

As I mentioned in my last post – with no surgeries scheduled due to Easter week (Semana Santa), we returned to Cartagena Thursday evening.

For those of you who are unfamiliar with the custom, Semana Santa is a big deal here in Colombia.  People from Bogotá and other cities escape to Cartagena and the coast areas to celebrate and join in the parades and processions.

The city is already packed with tourists – enjoying the historic quarter, and the beaches.  The tour buses are full and blaring loud music for laughing visitors.  Clubs and restaurants are full to bursting and swimsuit clad vacationers wander the streets along side Cartageneros.

For my roommate, Iris and I – it’s a great chance to enjoy a leisurely Saturday.  We headed down to the old quarter to do some shopping. But instead of chotskies, tacky knickknacks or random souvenirs, we have a special mission in mind: Fabric shopping!

Outside a fabric store (with a very well-endowed friend) in Cartagena (photo Aug 2011)

Outside a fabric store (with a very well-endowed friend) in Cartagena (photo Aug 2011)

One of the things I love about El Centro is the abundance of stores devoted to fashion, sewing and clothing design.  There are stores filled with ribbons, lace and buttons; stores just for knitting and crochet with thousands of yards, threads and other accessories in a rainbow of colors.. Stores filled with sequins, beads and pattern magazines.

Then there are the fabric stores – all clustered within several blocks.  The richness of the fabrics displayed in the windows draws you in: elaborate laces, rich, silky satins, shimmering sequins and super-stretchy spandex.  There stores are different from the United States – where crafting and quilting have dominated and shunted fashion sewing to the side.  Instead of a huge assortment of quilting cotton, a large array of home decorator fabrics and a miniscule array of fabrics for clothing – here – fashion is king!  There are meters and meters of silky jerseys, swimsuit fabrics, lighter than air sheers, wrinkle-resistant polyester blends and traditional hot weather favorites like linen.   I am in heaven – and I’ve only just entered the first shop.

Magazines containing 10 - 40 different patterns

Magazines containing 10 – 40 different patterns

The next great surprise is the pattern department.  It’s not in the fabric stores – it’s at the bookstore or magazine stand.  Bianca, Quili and other brands offer the latest in fashionable attire in handy magazines.  Each magazine contains paper patterns for 10 to 40 different pieces of clothing  – and each costs 9,050 (COP) or less than five dollars.

Better yet – they have all the specialty patterns a girl like me could ever want.  (I enjoy making swimsuits/ exercise apparel in my spare time – and Kwik Sew is the only company in the USA that makes these sorts of patterns in any kind of variety.)

I am like a kid in a candy store – and I can’t resist buying a small handful of glossy magazines.

But before we go home, we head to the Getsemani neighborhood just outside El Centro – to a small local restaurant specializing in seafood called “A Casa del Buen Marisco“.  It’s down the street from a much more expensive place, Antilles de Mar, but has its own reputation for excellence among the locals.

photo (40)

I had the house favorite, the seafood soup and it was delicious.  I snuck glances at fellow diners plates – and everything that came out of the kitchen looked pretty savory.

After a terrific lunch – it was time to return home for an afternoon siesta.  Once the afternoon cooled off, we slipped out to get Dr. Barbosa a surprise gift before returning to work on my evening project: Learning to crochet.  (Don’t worry readers – Dr. B doesn’t read the blog so it’s still a surprise).

making progress on my Colombian bag

making progress on my Colombian bag

As I mentioned before, Iris is teaching me to crochet a traditional Colombian style handbag.  She’s been taking classes for months and recently received her certification from a specialized government agency.

It’s a pretty cool project, actually:

The Colombian government has a division that certifies artists who make authentic style Colombian goods.  The government offers classes to teach people how to make these crafts (or cuisine) in the time-honored way.  These free classes offer (predominately) women with a way to supplement their income, while preserving Colombian heritage.  These classes and the resulting certification process are also used to ensure the quality of the goods / services provided.

 

San Jacinto and taking the long way home

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San Jacinto

As we left Sincelejo to return to Cartagena, I noticed that we made an unexpected turn away from our usual route.  This was confirmed as we passed the fitness center on the other side of town and headed towards Corozal.

The department of Sucre as outlined in RED

The department of Sucre as outlined in RED

“Ah, this will be my adventure today,” I said to myself.  Sure enough – I kept quiet and enjoyed the change of scenery as we drove away from Sincelejo into a mountainous area that reminded me of my high school years in Angels Camp – Murphy’s area of  California (Sierra Nevada foothills).

The terrain was dotted with trees interspersed with dry straw-colored grasses.  Cattle grazed in pastures on either side of the small, winding two-lane highway.

As we drove through Corozal, I ventured to voice my suspicions.  The good doctor laughed and confirmed that it was, indeed an ‘adventure’ designed for me – since he and Iris knew of my love of Colombian countryside.

avocados 002

the apple is just there for scale

First stop on our tour was for the famed avocados.   (Indeed – these famous avocados have been the source of much amusement among the cardiac surgery team due to a previous episode involving a “bait and switch” by another team member (who ‘stole’ a bag of these avocados from the good doctor, and left behind a small bag of more ordinary avocados in their place.)

woven fabric made on traditional looms

woven fabric made on traditional looms

We then passed into Bolivar –

Our next stop was San Jacinto, which is a town that is locally known for their artisanal crafts.  (The Sucre – Bolivar regions are noted for many of their textile crafts.  Some of the techniques date to the pre-Colombian era).

Having Iris as my tour guide was wonderful.  As a certified artisanal artist of traditional Colombian crafts, Iris was able to give me a detailed explanation of each of the different types of craft making – including information about regional differences in weaving designs, colors used, and other traditional items.

(For more information about the processes used in this craft work, click here.)

sincelejo 002

Since I am in the midst of  (very slowly) learning how to crochet one of the traditional Colombian bags  – I can certainly appreciate the amount of time and skill that goes into crafting each of these individual items.  There is no assembly line, factory floor or Made in China” labels here.  (Yes, I looked).

sincelejo 003

 

As the road wound its way back to the fork where we usually take the other branch) we stop at our usual coffee shop.  There we were greeted by a Palenque resident selling baked goods.

sincelejo 005

We bought a sweet, round ball of a popcorn(ish) treat called Alegra which contains corn with coconut and panela.  She then came and sat with us and attempted to teach us to speak a few words of Palenque.

After our brief respite, we continued to the main highway to Cartagena and proceeded home.  It took a little longer, but to me – it was well-worth it.  Thank you, Iris and Dr. Barbosa for my unexpected surprise!

!Eres Absurdo!

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aortic barbosa

Eres Absurdo!

I’ve heard that several times since I’ve been here – but it’s not exactly as it sounds.  It’s slang: like saying “goofy-footed” when referring to snowboarders.  It means that I am left-handed, or left-hand dominant, since the operating room requires you to be somewhat ambidextrous.

So this week – that was one of the things I set out to do – to become more proficient with suturing with my right hand.  It wasn’t as hard as I expected but I certainly don’t have the speed I have with my left hand (which sadly, isn’t that fast).

Barbosa aortic

Monday

Today wasn’t a great day. Everything went well – harvested vein, closed incisions, in the operating room so it should have been another fantastic day – but…. I just a felt, a little lonely today, I guess.  Or maybe lonely is the wrong term – since I live with three other people here in Sincelejo.  I guess what I meant to say is it’s the first time I’ve really felt alone since I’ve been here – and it was kind of surprise to feel that way.

I guess because I am used to traveling frequently and in making unfamiliar surroundings my home that it came as an unexpected pang when I suddenly missed the camaraderie I have had at other hospitals.  Everyone has been fantastic here – particularly Iris, who I consider to be a good friend, but it’s not quite the same.

My name is Kristin.. Kristina is someone else

Here in Colombia, many people struggle to pronounce my name so it’s usually simplified to “Kristina”.  But that’s not me.  Just like my name, I feel like a bit part of my personality just doesn’t translate into Spanish well.  Not as a cultural metaphor or anything ‘deep’ like that – but literally.  When something that you take for granted – like having an extensive vocabulary at your disposal, is redacted, it kind of changes how you express yourself.  It also changes peoples’ perceptions of you.

Just for five minutes – I desperately wanted at least one person who really “knew” me to be there.

Dr. Barbosa is a fantastic teacher and a very intelligent and kind person – but we don’t have the kind of friendship that I had with either Dr. Embrey (in Virginia) or Dr. Ochoa (in Mexicali).  Part of that is probably due to the fact that I just haven’t been here all that long.  I worked with Dr. Embrey for almost three years.  Dr. Ochoa and I were together five to six times a week for months.

aortic valve 010

The other part is Dr. Barbosa himself.  Our perspectives are fairly different, so that tends to complicate things.  He is always friendly but still a bit reserved with me.  That might be due to the fact that I am still lacking fluency in Spanish.  (I understand a heck of a lot more that I can speak – but even so, colloquial phrases and subtle nuances in speech are usually a complete mystery to me).  So I miss most of the jokes in the operating room, or figure it out about five minutes too late to be part of the conversation.

But after a little while that feeling of intense ‘alone’ dissipated – and everything went back to normal, whatever that is.

aortic valve 012

Tuesday

This morning I went by the Cancer Institute of Sucre.  I had written to them last week, but received no reply, so I decided to stop in.  After about an hour, I was able to talk to one of the administrators but she said that I had to submit all my questions about their cancer treatment programs in writing, in advance.  I explained that is not how it usually works, and left my card.  I am sure that will be the last I hear from them.  It’s a shame because the facility is beautiful, sparkling and new.  They advertise a wide variety of cancer treatments including brachiotherapy and thoracic surgery so I would have liked to know more.  (The website looks like something circa 1996, so it’s not really possible to get information from there.)

Another case today – another saphenectomy!  But this one came with a potent reminder.   While I still need practice, I feel more capable of performing the procedure that I did before.  Things proceeded well, if slowly (still need a headlamp!) but then it turned out that the internal mammary wasn’t useable so Dr. Barbosa needed more vein conduit.  Which he proceeded to harvest himself, in about five minutes.  So – I still plenty to aim for.

The holiday week started mid-week, but I am still hopefully for a few new consults tomorrow.  I know we probably won’t have any surgeries over the ‘Semana Santa” period, but I can’t help but keep my fingers crossed anyway.

Wednesday

Aortic valve replacement*** today.  Dr. Salgua showed up early today – and looked pretty determined, so I decided just to stay out-of-the-way.  I figured since it wasn’t a vein harvesting case, I shouldn’t make a fuss.  After all, I am just a visitor here – and I’ll be leaving soon.

aortic valve 027

Not my best photo by far – but my favorite part of this surgery – placing the new aortic valve into position

Instead, I stayed behind the splash guard and took pictures – since aortic replacement is the “prettiest” of all cardiac surgeries.  Unfortunately, my position was a little precarious, balanced in two steps – and still barely above the splash guard.  So many of the best shots – ended up partially obscured.  (But I don’t want to give up any more surgeries to get better photos.)

Received a consult from the cath lab today but surgery will probably be delayed due to the Easter week holiday.  (The team is willing to operate 24/ 7 – but few else are.)

Both our patients from earlier this week are doing great.  Monday’s patient passed me several times doing laps on the med-surg floor.  He’ll probably go home tomorrow or Friday.

Thursday

No surgery scheduled for today.  Rounded on the patients from this week and spent some time explaining medications, post-discharge instructions and other health information with the patients and their families.  While I love the operating room – this is the part I enjoy the most: getting to know my patients, and getting to be part of their lives for just the briefest of moments.  It is this time with patients – before and after surgery that makes them people, families – not legs or valves or bypasses.  Without this part, I am not sure I would have the same satisfaction and gratification in my work*.  I love seeing patients when they return to the clinic for their first post-operative visit – to see how good they look, and how much better many of them already feel.

This afternoon – was exactly that as one of my first patients returned to the clinic after surgery.  The patient looked fantastic!  All smiles, and stated that they already felt better.

After seeing patients in the clinic, we packed up and headed for home.  Since we currently have no surgery scheduled for next week (Semana Santa), and our other consults are pending insurance authorization, I don’t know when or if I will be returning to Sincelejo before I depart for the United States.

*As I say this, ironically, I am hoping for a ‘straight surgery’ position for one of my future contracts, so I can refine/ improve my surgical skills for future contracts in different settings that encompass a variety of duties.

***More Aortic Valve articles, including my famous “Heinz 57” post can be found here:

Aortic Stenosis and Heinz 57 : (what is Aortic stenosis?)

Aortic Valve Replacement and the Elderly

Aortic Stenosis : More patients need surgery

Cardiac surgery and valvular heart disease: More than just TAVR

There is a whole separate section on TAVI/ TAVR.

 

 

Sincelejo Diaries, part 2

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Sincelejo

Tuesday –  We drove back from Cartagena this morning before heading to surgery in the afternoon for a bypass grafting case.  For the first half of the way, I sat in the back and enjoyed looking out the window.  It’s amazing how dry parts of Bolivar are.

The drought has been responsible for the deaths of over 20,000 farm animals here in Colombia.  The small lakes are disappearing, from my first trip to Sincelejo to my most recent visit just a few weeks later.  The trees and bushes besides the roadways are completely coated with layers of dust from passing vehicles.  It gets greener as we pass into Sucre, but it’s a sad reminder of the devastating effects of climate change.

After stopping for breakfast along the way, where we met up with Dr. Melano, Iris went with Dr. Melano and I stayed with Dr. Barbosa.  We talked about music mostly.  At one point, a former patient from several years ago called, just to say hello.  The patient had recently heard that Dr. Barbosa now had a surgery program in Sucre. (The patient had previously traveled to Cartagena from a small town in Sucre for surgery.)

Once we got to Sincelejo, we headed to the hospital to see our patient before surgery and go over any last-minute questions or concerns.

(Of course) I was worried about finding vein but we easily found good quality conduit.  Dr. Salgua has been very nice about helping me with the saphenectomies.  The team teases me because I have a difficult time pronouncing her name.  We have a kind of system: While I finish closing the leg, she moves up the table to assist the surgeon in starting the grafts.  Then when I finish wrapping the leg, I stay at the back of the table with the instrumentadora, learning the Spanish names for all the instruments.  Once the chest is closed, she does a layer of fascia and I close the skin incision.

It’s a little crowded sometimes with the new instrumentadora learning the essentials of cardiac surgery, but the atmosphere at the back of the table is a lot different from the climate at the top.  (Dr. B is always calm, pleasant and entertaining – but Dr. Salgua is almost completely silent the whole time).  I am a lot quieter than my “out of OR self” when I am across the table from the surgeon too..

Wednesday – Another coronary case, on a fragile-ish patient (multiple co-morbidities including chronic kidney disease etc).  It was a long case and I was a little worried the whole time but the patient did well.  (I always worry about the frail patients).

I did okay too – performing a saphenectomy with Dr. Barbosa.  The patient had a vein stripping procedure previously (on one leg only) so I wanted to be sure to get a good segment of vein on the remaining vein.  I think Dr. Barbosa was worried about the quality of the conduit (because he kind of hovered – and didn’t relax until we started harvesting it.)

skip harvesting

Skip harvesting

I wish I would have more opportunities to perform a traditional saphenectomy (one very long incision).  I assisted on one several years ago – and I think if I had a chance to do a couple more, I would feel more comfortable skip harvesting.  Of course, a headlamp would also help.  (It’s kind of dark looking down the skip ‘tunnels’).  Then once I’ve mastered skip harvesting, I think it’s just another small jump to endo-harvesting with a scope.  I know a lot of people never bother learn to skip harvest, but I feel more comfortable building on the principles of open procedures first.  I might need them in an emergency case which is kind of why I wished I had more open saphenectomy experience.

Thursday – Saw three patients in the clinic today.  However, on reviewing the patient records and an intra-office echocardiogram, one of the patients definitely doesn’t need surgery at this point. (Asymptomatic with only moderate valvular disease).  We were happy to let him know he didn’t need surgery even if that means fewer cases.

Two surgeries today.  The first case was a bypass case for a patient with severe coronary disease and unstable angina.  Dr. Salgua and I did the harvest.  I think Dr. Barbosa is a little nervous about handing over the reins to me for harvest because he keeps a pretty close eye on me while I am doing it.  But then again, it might be because I am a little overly cautious and hesitant at this point.  If I didn’t have Dr. Salgua to look over my shoulder and encourage me onward, I’d put clips on everything and proceed at a snail’s pace to make sure I do it right.  But since it’s still my first week, maybe I shouldn’t be so hard on myself.

On the other hand, he must think my suturing is pretty good, because he just trusts me to do it correctly.

The second case was a patient from last week, who developed a large (symptomatic) pleural effusion and cardiac effusion (no tamponade or hemodynamic instability) which is a pretty common surgical complication.  The case proceeded well – I placed the chest tube, with Dr. Barbosa supervising.  Dr. Barbosa performed the cardiac window portion of the procedure.

Sadly, one of our patients from last week died today.  It was a fragile patient to begin with, and even though surgery proceeded well, the patient could never tolerate extubation and had to be re-intubated twice after initially doing well.  From there, the patient continued to deteriorate.

Friday

Today we had a beautiful aortic valve surgery.  This has always been one of my favorite cardiac procedures.  Somehow its elegant in the way the new valve slides down the carefully coördinated sutures.  (I don’t have pictures from this case – since I was first assisting – but I will post some from a previous case – so you can see what I mean).

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Dr. Salgua worked an overnight shift, so I was at the top of the table – (and yes, noticeably quieter than normal.)  I was surprised at how fast it seemed to go – but maybe that’s because everything went so smoothly.  Or maybe because we’ve done a lot of coronaries lately, which is a much more tedious and time-consuming process.

Iris and I are working on a patient education process – as a way to improve the continuum of care for patients (particularly after discharge).  I really enjoy working with Iris because I feel like we are always on the same page when it comes to patient care.

While it’s been a tiring week for the crew – I am, as always! exhilarated and happy to be here in Sincelejo.  Just knowing it’s the end of another week (and I am that much closer to going home) has me feeling a little sad.  But I guess I can’t stay forever, and I sure don’t want to take advantage of all the kindnesses that have been extended to me.

That being said:

At the end of every surgery, every day and every week in Sincelejo – I am grateful.  Grateful to Dr. Barbosa for being such a willing and patient teacher – grateful to the operating room crew (especially Iris Castro and Dr. Salgua) and particularly grateful to all the kind and generous patients I have met and helped take care of*.

The medical mission

This week I had another inquiry about ‘medical missions’.   I know people mean well when they ask about medical missions, or when they participate in these types of activities but…

Long time readers know my philosophy on this – don’t go overseas so you can pat yourself on the back over the ‘great deeds’ you performed ‘helping the poor’.  It’s patronizing to the destination country and its inhabitants – and generally not very useful anyway.  An awful lot of volunteers with real skills and talents go to waste on these so-called mission trips when their skills might be better served (in less exciting or glamorous ways) in free clinics in our own country.

But it does give everyone involved a chance to brag about how selfless and noble they have been; traveling thousands of miles, sleeping somewhere without 24/7 wi-fi (and who knows what other hardships).

Instead, change your orientation – and maybe challenge that assumption that everything you’ve learned about medicine, health care and taking care of people is better and superior.  Open your eyes and be willing to learn what others have to teach you instead.

* I always opt for full disclosure and transparency with the patients.  I introduce myself and explain that I am a studying with Dr. Barbosa, what my credentials and experience is to give them the opportunity to ‘opt out’.

Iris & Ximena

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Here in Cartagena, I have been fortunate enough to have two great roommates; Iris and Ximena.

Dr. Barbosa made all the arrangements for me, and I was a little nervous about bunking down with another nurse (we can be temperamental and territorial at times) but living with Iris has been absolutely wonderful.

I was kind of worried I’d be living with some young, possibly flighty nurse who might resent having a middle-age woman in her home, cramping her style.  Instead, it’s like having an instant best friend and I love it.

For starters – we have a lot in common:  we are both academically and professionally inclined.  Iris is the perfusionist for Dr. Barbosa’s cardiac surgery service and is extremely knowledgeable.

Part of the machinery that makes up Iriis' professional life: the heart-lung machine

Part of the machinery that makes up Iriis’ professional life: the heart-lung machine

(In Colombia, Perfusion is an advanced nursing degree.  Iris obtained her master’s degrees in both critical care (National University) and Perfusion at (CES.).   She is widely acknowledged as one of the best perfusionists (if not the best) in all of Colombia.   Her peers frequently consult her seeking advice for a variety of surgical circumstances.

She is the only nurse to collaborate (and be listed on the cover) of a comprehensive Colombian textbook on Cardiology.  Her name is listed along side such esteemed Colombian physicians as Pablo Guerra, Nestor Sandoval and Sergio Franco.

Cardiology textbook

She also serves as a reviewing editor of several Colombian medical journals.  Research articles are sent to Iris to review the methodology/ study design and overall quality.  Articles she rejects will not be accepted for publication.

In her free time, it’s not unusual to find her reading the latest journal articles on cardiac surgery or working on presentations for the latest meeting or international conference on perfusion.  In fact, she recently returned from the annual Colombian conference on cardiology and cardiac surgery in Medellin.  She is equally enthusiastic about all aspects of nursing and the position and rights of women (nurses) in Colombia and in medical society in general.

She is particularly outspoken against much of the machismo that dominates life here.  She is the one person I have learned to expect to never ask me the unpleasantly intrusive questions that seem to pass for almost introductory conversation here such as “Why don’t you have children?  Don’t you want them?  What does your husband think of that?  Your husband permits you to be here [in Colombia] without him?”*

Even when we don’t agree on all issues, she never judges my opinions or thoughts.  She endeavors to understand my reasoning instead.  It’s refreshing.

This combination of intellect, insight and experience makes for a lot of interesting and engaging discussions in the evenings as we relax and enjoy the fragrant breezes that bring daily relief to the sweltering city.

A strong woman in a culture of machismo

Iris is also extremely forthright and independent (traits that also resonate with me.)  She takes no ‘guff’ from anyone and lives how she pleases in a society that has a lot of difficulty accepting that (unmarried, no kids with Ximena as a part-time roommate.)

Even my professor, as charming and intelligent as he is, defaults into this kind of ‘macho’ thinking.  He tells me he worries about Iris, as “she is all alone” without a man to protect her.  He worries she is missing out on true happiness and is destined to be sad, alone.  Nothing could be further from the truth.

Rather, Iris has chosen to defy tradition, and live life on her terms.  She has friends, family and romantic attachments like anyone else.  She just maintains both her privacy and her independence despite that, sort of like Elizabeth I of England.

It is sometimes hard as an outsider to understand why this attracts some much attention – a single woman living quietly in her own apartment.  But then I think back to some of the comments I get from friends, acquaintances, co-workers and even strangers regarding locums life, and I realize, that as female professionals; whether the United States or Colombia, we still have a long way to go.

It’s just that as an American, I think I have fallen for the illusion of the possibility of female equality in way that women in other countries never have.  (The irony is that at this moment in my home country, women’s rights; to reproductive, financial and professional freedom are being eroded more that any other time in recent history.  Hard won battles of the 60’s and 70’s are being erased with nary an outcry.)

Here ‘paternalism’ rules the day – and no one pretends any different.

But there is more to Iris that a forthright, intelligent, independent individual.  She is also a nurturer, a caregiver, a nurse in the very sense of the word.

What could be more nurturing that offering up her home to an unknown stranger from another land?

“Ximena”

photo (38)

Iris and the other members of her apartment complex have adopted a white and orange stray cat that answers to a variety of affectionate terms.  One of these is “Nena”.  One my first day here, I confused “Nena” as a shortened version of Ximena, so Ximena she is.

This straggly looking, mangy little ball of fluff is adored by the residents of the small apartment building.  Typical of most cats, she is “owned”  by none, but owns each neighbor in turn.  But it was Iris who took up donations to get Ximena surgery she needed and routine veterinary care.  All the residents share in the feeding and care of the street cat – including applying a cream to her healing surgical scar, but it is Iris whom Ximena usually seeks.

While most of the residents leave their doors open during the afternoons to invite Ximena in, Ximena is most often found either inside our apartment, or bellowing outside the door (on the rare occasions that is is closed.)  She wanders in with the grace and arrogance that only a cat possesses.

She carries herself with a dignity that belies her ‘homeless’ state as to say she isn’t a vagabond but a seasoned traveler as she visits each apartment in turn – but always comes back to Iris to stay all afternoon and overnight.

Some of the neighbors our jealous of Ximena’s attention, but with our weekly journeys to Sincelejo, they always have an apportunity to host ‘Nena as their favored guest.

Iris loves to cook – and does so easily, deliciously.  She embraces a healthy lifestyle filled with daily exercise and fresh fruit and vegetables.

salad made of exotic fruits

salad made of exotic fruits

We talk about my love of Colombian food – and together one day in the kitchen, we make brevas.  She tells me with a smile that she has never made them, but used to watch her grandmother cook them for a sweet tweet.

Boiling brevas: Photo by Camila

Boiling brevas: Photo by Camila

We savor the sugary treat, one breva at a time over the next several days.

In  addition to learning how to perform saphenectomies from Dr. Barbosa, Iris is teaching me how to crochet.  My first project will be one of the small bags that is in a style typical for Colombia.  I think it is ironic that it seems easier to suture that it is to crochet.

Iris 003

But Iris is endlessly patient with me – and slowly, slowly as I unravel my mistakes and start again, I am making progress.  She has a blogspot where she showcases her latest creations.  She recently received national accreditation as a ‘native artist’ to participate in festivals and art fairs that specialize in traditional Colombia crafts.

Today, as we sit on the sofa, crocheting, we talk about plans for the Semana Santa (Easter Week).  The secretarial staff in Sincelejo has vacation plans and wants to keep the office closed all week so she can visit a boyfriend in Medellin – but Iris and I think it should remain open for the patients.  We plan to offer to staff the office, so that patients won’t have to wait a week to be seen.  We will have to navigate and negotiate carefully and diplomatically to prevent causing any hard feelings but as Iris points out, it’s the right thing to do for the patients – and the doctors, and that’s what matters. (My motives are admittedly more self-serving: more clinic = more surgery.)

*This type of questioning is fairly pervasive throughout Colombia, and is often performed as part of introductory conversation.  Once a taxi driver in Bogotá directed me to the nearest fertility clinic when I responded “No” to the question about children.  He wasn’t rude, on the contrary, he thought he was being helpful.

** Iris prefers not to have her picture taken.

Sundays in Cartagena

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El Centro

El Centro

Sundays in Cartagena are a bit different from Bogotá or Medellin. As a major tourist destination, Cartagena never really slows down the way other cities do in Colombia.  In Bogotá, my neighborhood (Chico) was essentially deserted on Sundays.  The only signs of life were on the streets closed for  pedestrian walking.  La Candeleria and Usaquen were the destinations of choice for Bogotanos who chose to stay in the city.

Instead the activities change – instead of business, the weekends are for boat trips to the Islands of Santa Rosario, long leisurely lunches, wandering around El Centro and looking at arts and native crafts, and walking along the beach.   Tourists stroll along Bocagrande window shopping at designer storefronts, eating ice cream.  The hotels host popular events in Castillogrande, and restaurants and bars feature the sports of the day, to standing room only crowds.

So today, after sleeping in a bit, Iris and I headed to El Centro for another leisurely stroll around El Centro.  Sunday mornings are a nice time for this – the streets are still pretty quiet and not yet packed with tourists.  (That comes later in the day.)

Cartagena 013

As we wandered down the tree-lined streets, I can’t help put take photos, even if I’ve photographed these same areas many times before.  Somehow, every time I encounter the colorful buildings with the beautiful blossoms on the curving cobblestone streets, I am enchanted all over again.

Cartagena 026

 

After walking around the neighborhood and making our way up the wall, we headed to the nearest Juan Valdez..

Cartagena 027

After our leisurely coffee, we walked back home to escape the heat of the day.  Now I am heading back out – to the beach.

 

The Sincelejo Diaries

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Sincelejo from the balcony

Sincelejo from the balcony

 

Since I have very limited wi-fi while in Sincelejo, I have been keeping a diary of my time on the cardiac surgery service of Dr. Cristian Barbosa.  But then again, maybe I should explain why I am here.

I came to Colombia to learn how to perform skip harvesting saphenectomies with Dr. Barbosa.  As I mentioned previously, we’ve kept in contact since we first met, and he was gracious enough to offer to teach me.

Before I ever left Virginia, it took a lot of paperwork and diplomacy, but we were able to secure administrative permissions for me to study sapheneous vein harvesting with Dr. Barbosa at the hospital in Sincelejo.  While this isn’t medical tourism, I thought my readers might enjoy hearing about daily life as part of Dr. Barbosa’s cardiac surgery service.

 

 Cardiac Surgery in Sucre, Colombia

 

outside the operating room

outside the operating room

While the cardiac surgery program is located in Hospital Santa Maria, Dr. Barbosa and his team often travel to nearby hospitals and clinics to see new consultations.  This program is the only program in the state of Sucre and patients come from all parts of the state.

Many of the patients come from tiny pueblos of a few hundred (or thousand people).  Many others come from impoverished backgrounds.  (Colombia has a tiered health care system with a national health care plan for people from lower socio-economic classes, kind of similar to the Medicaid concept.)

We arrive in Sincelejo on Monday, March 24th in the evening.  We have a busy day tomorrow and the doctor wants to get started early (without facing the 3 hour drive in the morning.)

En Familia

In Sincelejo, we live en familia, in a large airy apartment with big windows that overlook much of Sincelejo.  There are four of us here, the surgeon, the anesthesiologist (who is Director of the program), the perfusionist and myself.  Iris and I share a large room with a private balcony.  Meals are shared and we usually travel as a group to the hospital and on errands.

After our arrival Monday evening, the doctor, the perfusionist and I head to the largest grocery store and shopping center in town.  We shop as a family, picking out fruit, arepa corn flour, coffee and other essentials.   We then head to the food court.  (They are treating me to Corral, due to my proclaimed love of Corral’s famed hamburgers).   

It sounds like it could be uncomfortable – this domestic scene with my boss and the cardiac surgery team, but surprisingly it isn’t.  Iris, the perfusionist (and my roommate both here and in Cartagena) always says they are a “cardiac surgery family,” and it feels that way – in a comforting, cozy way.

I joke and call Dr. Barbosa, “Papa” as he is the natural father figure of the group, and somehow it feels appropriate.

 

'Papa' of our cardiac surgery team

‘Papa’ of our cardiac surgery team

25 March 2014 – Tuesday

Today we travelled to Corozal to see two consultations in the intensive care unit.  Then we returned to Sincelejo to see another patient at another hospital, Maria Reina.  We eat lunch at the apartment, en familia .  Afterwards, we go back to the office to see patients before heading off to surgery.  (We had to delay surgery for several hours because the patient decided to eat breakfast.  I guess s/he was hungry too).

barbosa 081

 

Finally after this delay (to prevent anesthesia complications), we head to the operating room.  There are the typical delays while the patient is being prepped and prepared.  This gives me a chance to get to know the rest of the crew, Anita (the instrumentador or surgical tech) who runs the operating room table, Raquel, an experienced instrumentador who is training to work in the cardiac suite, and the two circulating nurses,  Patricia and Estebes.

Raquel (right) and Anita, the instrumentadors

Raquel (right) and Anita, the instrumentadors

The circulating nurses are responsible for taking care of all the duties that fall outside of the sterile field, like fetching additional supplies, medications or instruments.  They also control the environment by regulating the temperature, and adjust the electronic machinery (like the electrocautery unit, or the sternal saw) according to the surgeon’s immediate needs and specifications.

Patricia and Estebes, circulating nurses

Patricia and Estebes, circulating nurses

Dr. Salgua is the medical doctor who works in the office, seeing patients and assessing their medical (nonsurgical needs.) For the last year, she has also worked as Dr. Barbosa’s First Assistant in Surgery.  If there is any chance for friction in the operating room, most likely it will come from her.  I am cautiously nice but optimistic when I realize she is fairly quiet, and not overly aggressive.  (I relax, but just a bit.  I am still nervous about how the team will take to me, even though the common Oops! “accidental” needle stick scenario seems unlikely here.

Dr. Salgua

Dr. Salgua

 

Everyone is very friendly and welcoming and even before starting the actual surgery, I am breathing easier and starting to think that maybe I could belong here, with this group.

The surgery went well (valve replacement and annuloplasty).  After the surgery, we transport the patient to the intensive care unit and give report to the doctors and nursing waiting to assume care of the patient.

Note: patient did well and went home on POD # 3 on 3/28/2014.

 

26 March 2014 – Wednesday

More surgery today, but still no coronaries (and thus no saphenectomies).  It was a great day in the operating room – I closed the sternal incision..  (BTW, surgery went beautifully).  I am already starting to feel more at home with the operating room staff, and I feel like they don’t mind having me around.  Dr. Salgua has been very kind in assisting me during procedures, which is a relief.  She still stays pretty quiet during the cases, but I think maybe sometimes she is a bit nervous too.

 

with the team

with the team

After transferring the patient to the ICU, our second visit to the patient from yesterday finds her over in the general surgery ward.  (This morning she had been sitting up in a chair in the ICU when we arrived.)  She looks good and states she is sore, but otherwise fine.

barbosa 082

The cardiac catheterization lab calls; there are four cath films they want us to review, and patients to discuss regarding surgery.  The patients themselves are resting in the recovery area after the cath procedure, so our administrative assistant, Paola makes appointments for each of them and instructs them to bring their families, medications and any questions.

The most interesting part of the cath lab is who is doing the caths.  It’s a nurse, while the cardiologist sits behind the protective radiation shielded glass enclosure viewing the films and calling out for additional views.  I wonder if the nurse knows that in the United States, a similar position would pay over 100,000 dollars.  But this is one of the things that I see a lot of her in Colombia and in Mexico.  Well trained nurses being essentially nurse practitioners (making diagnoses, treating disease, performing invasive procedures) but without the status or the compensation.

My roommate and I talk about this disparity sometimes.  She’s a master’s trained nurse herself, so it makes for some very interesting discourse and insights. (She doesn’t like to have her picture taken, so I haven’t.)

We finish seeing patients and head home.  The doctors head off for a siesta.  Dr. Barbosa has been up since before five for his daily exercise before surgery.

As for me – after some scouting of the immediate areas around the hospital and the apartment, I went on my motorcycle tour.  It was great fun but I got an important reminder of the perils of motorcycles just a few days later.

Note: After and uneventful surgery (defect repair), patient recuperated quickly, and was discharged 3/29/2014.

 

27 March 2014 – Thurday

The week is really flying by.  I’ve been having fun with the operating room team.  They are a great group. Everyone has been extremely nice and welcoming.  (You can never be sure how your presence is going to be tolerated or change the existing dynamic.)   Dr. Melano and I have a couple of animated discussions over current practices, literature and recent meta-analyses.  It’s an enjoyable discourse even though my vocabulary often fails me.  I hear myself making grammatic mistakes and repeated errors in Spanish but it seems with some much going on (reviewing my anatomy, practicing my suture ties, assisting in the operating room and trying to keep up on my writing )- I just can’t seem to remember as much as I should in Spanish.  I inwardly cringe when I substitute ‘conocer’ for ‘saber’ yet again, but the word is out of my mouth in reply to a question before I can corect myself.

Dr. Salgua assists Dr. Barbosa

Dr. Salgua assists Dr. Barbosa

I sit out this surgery (still no coronaries) and spend some time taking pictures to document my experiences here.  I got a couple of shots that I really like, including one of Dr. Barbosa, Dr. Salgua and Raquel.

one of my favorite pictures from that day

one of my favorite pictures from that day

 Note:  Patient discharged home 3/29/2014.

28 March 2014 Friday (and coronaries!)

Today is my big day – and I am excited and a little scared too.  I got up at five this morning and went with Dr. Barbosa to the exercise park, so I would have a place to walk while he played tennis.  It helped me get ready for the day, and I got to see where Dr. Barbosa uses up all of his pent-up aggression.  He turns it into a power slam. (I don’t know tennis terms, but whatever swing he was doing – it must be responsible for his tranquil overall demeanor.)

After breakfast, we head to the hospital.  We check on our hospitalized patients before going to see today’s surgical patient in pre-op.

Our patient is a bit fragile-looking so (of course!) I worry about her and how she will do with surgery.   I also worry that I might not sew straight, now that it’s time for me to get to work.

Some of my previous OR “lessons” have been brutal, including several at a troubled facility that sent me running away from cardiac surgery (of all kinds) for several months*.  This is what fuels my anxiety.  (I am not anxious by nature).

But here in Sucre, in this OR,  this experience is nothing of the sort – Dr. Barbosa is an excellent teacher.  I don’t know why it’s a surprise.  He’s always been a bit of a  Clark Kent of the operating room; pleasant, calm and methodical.**  This is just the same.  In his soft burring voice he goes over the procedure with Dr. Salgua and I.  The he oversees our attempts, gently encouraging and coaxing.  It is yet again, a comfortable experience, instead of a traumatizing, horrible one.

a pretty great teacher

a pretty great teacher

 

I don’t have any pictures which would show my twinkling eyes which are the main indication of my happy grin beneath my mask as I finished closing the last leg incision.

We wrap the leg when we finish and move up to the ‘top’ of the operating room table.  (I’ve learned that the top and the bottom of the operating room table are two very different places.)

I close the chest incision – surgery is over.   We transfer the patient to the ICU.  She remains a little fragile but has no immediate problems.

barbosa 047

After making sure the patient is stable, the team heads over to Clinica Maria Reina.  We have received a call that a trauma patient is being placed on ECMO (to support his lungs) after developing a fat embolism.  We are standing by to help, as needed.

As I look around, and talk to the staff, I find that there are three patients in the small ICU, all young men in their twenties, all intubated with critical injuries, all due to motorcycle accidents.  One patient, just barely an adult has lost a limb as well.  He is awake and hitting the siderails with his remaining hand to capture the nurse’s attention.  She holds his hand and speaks soft to him and he calms down.  Watching this, along with the patient struggling to survive as doctors rush to connect ECMO is a sobering reminder of how devastating my joyride could have been.

The patient is connected to ECMO without incident.  As a weary unit, all four of us return home.

Cartagena 004

The view from my private dance floor..

Everyone is exhausted – but I am exhilarated!  I just want to dance – so I do, by myself, on the balcony with my phone blaring out some music.  Later that evening, we go out for dinner to celebrate a successful week.  I am still in a joyous dancing mood which probably drives my companions a little crazy but it’s been such a great day..  so when we return home, I dance some more.

March 29th, 2014 – Saturday

In the morning after my dancing spree – Dr. Barbosa and I walk down to the hospital.  Our fragile patient from yesterday is doing okay, and our other two patients are ready to go home.  I review discharge instructions with each patient, and hope that I am not mangling my Spanish too badly. But they seem to understand me, so maybe I am doing alright.  The doctor is nearby, writing prescriptions, to clarify anything I have trouble explaining.

One patient asks about getting out of a chair without using his arms (and stressing the sternal incision) so I demonstrate my favorite technique, and together we practice.

After we finish, we head back to the apartment to eat breakfast, finish packing and head back to Cartagena.  Dr. Melano is staying behind (along with Dr. Salgua, who lives in Sincelejo) to check on our remaining patient.

The ride back is pleasant, but I start to feel some of the fatigue from all of the excitement of the week.  I also feel a little sad to be leaving our little cardiac ‘family’ for a few days, which is probably crazy considering how much time we’ve all spent together.  I guess it’s because I know it’s just temporary.

Iris and I head back to ‘our’ Cartagena apartment where the neighborhood cat, Ximena is waiting for us.

Now we will relax, write and get ready for the return trip on Tuesday.

* A deliberate elbow to the face was just the beginning of a series of humiliations at a previous facility.

**Pulling on his superman cape when needed.