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


Patient satisfaction and clinical outcomes

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

Patient satisfaction is not the same as patient rights.

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

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

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

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

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

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

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

Consumer or patient?

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

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

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

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

  This is where it gets dangerous.

Aortic Valve Replacement

Aortic Valve Replacement – photo by K. Eckland, 2012

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chasing patient satisfaction scores and profits in American healthcare

Chasing patient satisfaction scores and profits in American healthcare

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

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

Take home message:

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

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

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

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

Resources/ References and Additional Reading

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

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

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

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

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

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

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

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

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

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

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End of the road


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

Sincelejo Diaries, part 2


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’.

Adventures in Sincelejo


If there is such thing as a perfect day, it would have been today.  The weather was still hot, humid and sticky.  I still have student loans and the world continues to have accidents, disasters and wars.  But for me, today was as good as it gets.

VSD patch400

I spent the morning in the operating room while Dr. Barbosa performed a septal patch, and repair of the tricuspid valve.  The case went well and the patient did beautifully.  Before I left the hospital, the patient was already awake, alert and awaiting extubation.  There was no hemodynamic instability or bleeding.

Barbosa1x400

The local cardiologist did several cardiac catheterizations today – and we were consulted on four of them.  3 of the patients have excellent targets for bypass grafts and normal heart function.  The fourth patient is a little more fragile, but is still a reasonable candidate for surgery.

Best way to see Sincelejo: On the back of a bike*

Lastly, I spent a nice, breezy hour touring the city on the back of a friend’s motorcycle.  (Yes, mom – I wore my helmet – and he didn’t drive like a maniac.)  We went all over Sincelejo; from the scenic overlook over the valley below, to the football stadium, past the University of the Caribbean, over to a public park with tennis courts, several pools and a small zoo. (I don’t have any pictures because I figured I’d probably drop it).

My guide was Omar, the spouse of my friend, Elena.  He works in the Parks & Recreation department of the Sucre.

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After returning home, I took a walk down to the Plaza to buy some local cheese.  Then I spent the evening eating exotic fruits like guama, plums, uchuvas and fejoas.

*Also fairly dangerous..

All in all, it was a pretty awesome day.

Start here…


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

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

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

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

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

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

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

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

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

Reasons to write about medical tourism: a cautionary tale

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

What I do and what I write about

I interview doctors to learn more about them.

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

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

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

I talk about checklists – a lot..

The surgical apgar score

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

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

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

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

Cultural Content

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

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

How the site is organized

See the sidebar! Check the drop-down box.

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

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

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

Topics of particular interest like HIPEC have their own section.

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

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

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

Thank you for coming.

The cardiac OR


If you’ve never been to the cardiac operating room – it’s a completely different world, and not what most people expect.  For starters, unlike many areas of health care (particularly in the USA), the cardiac operating room is usually very well staffed.

 OR

Just a few of the people working in the OR. (photo edited to preserve patient privacy)

For example, there were eight people working in the operating room today:

Dr. Luis Fernando Meza, cardiac surgeon

Dr. Bernando Leon Urequi O., cardiac surgeon

Dra. Elaine Suarez Gomez, cardiac anesthesiologist

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient's privacy)

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient’s privacy)

Ms. Catherine Cardona, “Jefe”/ Nurse who supervises the operating room

Ms. Diana Isobel Lopez,  Perfusionist (In Colombia, all perfusionists have an undergraduate degree in nursing, before obtaining a postgraduate degree in Perfusion).  The perfusionist is the person who ‘runs’ the cardiac bypass machine.

Ms. Laura Garcia, Instrumentadora (First Assist)

Angel, circulating nurse

Olga, another instrumentadora, who is training to work in the cardiac OR.

This is fairly typical for most institutions.

Secondly – it’s always a regimented, and checklist kind of place.  (I wish I could say that about every operating room – but it just wouldn’t be true.)  But cardiac ORs (without exception) always follow a very strict set of accounting procedures..

For starters – there are labels.. For the patient (arm bands), for the equipment (medications, blood products etc..)  even the room is labeled.

Sign on operating room door (edited for patient privacy)

Sign on operating room door (edited for patient privacy)

Then come the checklists..

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

The general (WHO) operating room checklist.  The perfusionist’s checklist.. The anesthesiologist’s checklist.. and the big white cardiac checklist.

by then end of the case, this board will be full..

by the end of the case, this board will be full..

The staff attempts to anticipate every possible need and have it on hand ahead of time.  Whether it’s nitric oxide, blood, defibrillation equipment, or special medications – it’s already stocked and ready before the patient is ever wheeled in.

Most of these things are universal:

such as the principles of asepsis (preventing infection), patient safety and preventing intra-operative errors – no matter what hospital or country you are visiting (and when it comes to surgery – that’s the way it should be.)

Today was no exception..

In health care, we talk about “OR people” and “ER people”.. ER people are the MacGyvers of the world – people who thrive on adrenaline, excitement and the unexpected.  They are at their best when a tractor-trailer skids into a gas station, ignites and sets of a five-alarm fire that decimates a kindergarden, sending screaming children racing into the streets.. And God love them for having that talent..

But the OR.. that’s my personal area of tranquility.

This orderly, prepared environments is one of the reasons I love what I do.. (I am not a screaming, “by the seat-of-your-pants”/ ‘skin of your teeth’ kind of gal).  I don’t want to encounter surprises when it comes to my patient’s health – and I never ever want to be caught unprepared.   That’s not to say that I can’t handle an emergent cardiac patient crashing in the cath lab – it just means I’ve considered the scenarios before, (and have a couple of tricks up my sleeve) to make sure my patient is well taken care of (and expedite the process).

That logical, critical-thinking component of my personality is one of the reasons I am able to provide valuable and objective information when visiting hospitals and surgeons like Dr.  Urequi’s and Dr. Meza’s operating room at Hospital General de Medellin.

In OR #1 – cardiothoracic suite

As I mentioned in a previous post on Hospital General de Medellin, operating room suite #1 has been designated for cardiac and thoracic surgeries.  This works out well since the operating room itself, is modern and spacious (which is important because of the area needed when adding specialized cardiac surgery equipment like the CPB pump (aka heart-lung machine).  There are muliple monitors, which is important for the video-assisted thoracoscopy (VATS) thoracic cases but also helpful for the cardiac cases.  The surgeon is able to project the case as he’s performing it on a spare monitor, which allows everyone involved to see what’s going on during the case (and anticipate what he will need next) without shouting or crowding the operating room table.

Coordinating care by watching surgery

For instance, if the circulator looks up at the monitor and sees he is finishing (the bypasses for example), she can make sure both the instrumentadora and the anesthesiologist have the paddles and cables ready to gently defibrillate the heart if it needs a little ‘jump start’ back into normal rhythm..or collect lab samples, or double check medications, blood products or whatever else is needed at specific points during the surgery.

More on today’s case in our next post.

Shooting the breeze with Dr. Francisco Sanchez, cardiothoracic surgeon


As I mentioned in one of my previous posts, meeting and talking to surgeons in different countries can be anxiety-producing at times.. Other times, just plain interesting and enjoyable.

It was the latter during my conversations with Dr. Francisco Sanchez Garido  and his colleague, Dr. Geraldo Victoria.  (We talked about Dr. Victoria in a previous post.)

At 71, Dr. Sanchez has seen and experienced volumes; in medicine, surgery and in life.  We talked about all three of these during my visit – including some of his ‘war stories’ of yesteryear.

These included actual stories of war – such as trying to take care of the gravely wounded American GIs during the  December 1989 military invasion of Panama (Operation: Just Cause), when he was working at the Gorgas Army Hospital at the Howard Military Base.

 Dr. Sanchez talked about the difficulties of trying to save the GIs who parachuted in (and immediately became fodder for Noriega’s troops).

He also reflected on the fifteen years he spent training in the United States.  He attended medical school at the University of Oklahoma, and completed both his residencies in the US at George Washington University prior to returning to Panama in 1972.  He studied with a famous surgeon from the Cleveland Clinic  as well as hosting multiple visits by American cardiac surgeons,  Dr. Denton Cooley and Dr. Michael DeBakey (among others).  These included one ignoble attempt to convert a Panamanian hospital into the private operating room suite for the ailing Shah of Iran.  He laughed a bit when he explained how the illustrious Dr. DeBakey attempted to bluster his way into taking over the hospital but were foiled by Dr. Sanchez and his team, resulting in the Shah traveling to Cairo for his ill-fated surgery for lymphoma. (See the linked articles for more information about the fateful travels of an ailing ruler).

As he explained, “They just wanted to use our hospital [to perform a spleenectomy on the Shah] – and leave.  They didn’t want our help or involvement.  But you can’t just operate on someone and then go home.”  As it turns out – his concerns were warranted, as the Shah experienced surgical complications after surgery in Egypt, and his surgeons were long gone, leaving his care to people previously un-involved in his care. (Ultimately, the Shah died four months after surgery – closing a chapter in Iranian history and ending the controversies regarding his treatment).

These stories are, of course, just minor tales in the long career of one of Panama’s first heart surgeons.

Dr. Francisco Sanchez Garido, cardiothoracic surgeon

Dr. Francisco Sanchez Garido, cardiothoracic surgeon