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

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!Eres Absurdo!


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


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).

????????????????????????

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’.

The great fistula adventure


Just back from Sincelejo  – and off on another adventure!

sabanalargo

Dr. Barbosa was asked by a local nephrologist if he would be willing to come to Clinica San Rafael in Sabenalargo to make dialysis fistulas for several patients who are currently dialysing through subclavian catheters.  (These in-dwelling catheters, which are made of plastic, place patients at a much higher risk of infections including systemic infections like sepsis (due to easy access to central blood supply.)

This medscape article gives a nice overview regarding Dialysis Fistulas.  (However is mainly focused on maintaining fistulas rather than creating them.)

So off we went to Sabanalargo in the Colombian state of Atlantico.  While small, with just 2 operating rooms, Clinica San Rafael was a fine place to operate.

Despite its small size, the clinic had an intensive care unit, a neonatal unit and fluoro for catheterization and endovascular procedures (in operating room #1).  The hospital also had a large maternity unit.  Looking through the previous operating room procedure log showed that most of the procedures were C – sections and general surgery procedures (like hernia repair.)

One of the nicest aspects of this facility is something that is essentially unheard of in the United States.  At the end of the day, Dr. Barbosa was paid in full.

outside Clinica San Rafael

outside Clinica San Rafael

All of the staff were very welcoming despite the fact that it was our first time there.  The patients were happy to see us – and the surgeries proceeded at a rapid pace.  After receiving discharge instructions and prescriptions for a daily aspirin along with pain medication, all of the patients were discharged home.

with Liliana, circulating nurse

with Liliana, circulating nurse

All told, Dr. Barbosa performed 4 Cimino – Brescia fistulas with excellent results.  All of the fistulas had an easily palpable thrill at the end of the procedure with no evidence of limb ischemia or other complications.  (Cimino – Brescia fistulas utilize the native artery and vein versus PTFE grafts which are not as durable).

The way home was a lengthy process since one of the main roads was closed so we had to back track to Barranquilla to get on the main coastal highway.  (I’m sure it was lovely, but it was too dark to know.)

But all-in-all, it was a fun and interesting day.

The Road to Sincelejo


colombia_pol_map

The Road to Sincelejo

For me, the road to Sincelejo has been in the making for a long time.  Since meeting Dr. Cristian Barbosa, cardiac surgeon in February 2010, I have wanted to know more about his work.  I first meet Dr. Barbosa on my initial trip to Cartagena de Indias when I (literally) accosted him in a hallway in Hospital Bocagrande.  At that time he was the chief of cardiovascular surgery of the now defunct cardiac surgery program at Hospital Bocagrande.  He was minding his own business, walking down the hallway.  As he passed, I read the title on his lab coat, “Cirguia Cardiovascular.”

Back on 2010, my Spanish was even worse than it is now – just forgotten bits of high school Spanish.  But that didn’t deter me on my mission.  I had entered the hospital under stealth (okay, not really, but I was just a ‘gringa’ wandering around without authorization) to meet and talk to surgeons, so I wasn’t about to let this opportunity pass by.

with Dr. Hector Pulido (left) and Dr. Barbosa in Cartagena (2010) after a chance encounter in a hallway,

with Dr. Hector Pulido (left) and Dr. Barbosa in Cartagena (2010) after a chance encounter in a hallway,

Of course, since my Spanish was limited – I didn’t know how to express all the normal social graces in these sort of situations.   Instead,  I said, “please stop” as it was the first phrase that came to mind.  He did, and we managed to exchange enough conversation for me to explain who I was, and what I would like to know.  Despite my lack of manners, and random appearance, he didn’t seem to mind.   A visiting cardiac surgery nurse, “por supuesto!” (of course!)

I knew I was successful when he then asked, “Do you want to go to the cath lab and review today’s films with me?”  The rest is now history, on the pages of this blog, multiple articles and the Cartagena book.

Sometimes, the language of surgery is universal – which is what makes all of this possible.

in the operating room with Dr. Barbosa in 2010.

in the operating room with Dr. Barbosa in 2010.

Since that first meeting, Dr. Barbosa and I have both improved our language skills (his English, my Spanish) and we’ve kept in contact.  We’ve caught up with each at various conferences and meetings.  Therefore, I was saddened to hear of the closure of the cardiac surgery program at Hospital Bocagrande due to financial difficulties*.

Cardiac Care

I was excited when Dr. Barbosa told me about his new position in Sincelejo (Sucre) a few years ago, providing cardiac surgery services to the local community.  The program called Cardiac Care provides cardiac surgery services to a populace that would otherwise have to travel several hours (to Barranquilla or another large city).

When Dr. Barbosa invited to come join his team in Sincelejo, it took some re-arranging and re-scheduling to do – but it was an opportunity I just couldn’t miss.

The program remains small and relatively unknown even among Sincelejo residents.  For this reason, Dr. Barbosa and his team (cardiac anesthesiologist, Dr. Sebastian Melano and nurse perfusionist, Sra. Iris Castro) all live in Cartagena but maintain another apartment in Sincelejo.  When they have surgery scheduled, they stay in Sincelejo for several days to perform surgery and oversee the patient’s recovery.

Road trip

On Thursday, I took my first trip with the group to Sincelejo to see several patients (post-operative patients and new consultations).

Dr. Barbosa and his cardiac anesthesiologist see patients at the Clinic in Sincelejo

Dr. Barbosa and his cardiac anesthesiologist see patients at the Clinic in Sincelejo

This trip itself was very interesting.  Sucre is a region (state) of Colombia that is entirely new for me.  Even though the trip is just 125 km from Cartagena, it’s a journey into a new landscape of rolling hills (Mountains de Maria) and takes over three hours.

Leaving Cartagena, we pass through the various areas of the city.  We pass through barrio Manga, past several hospitals including Hospital San Juan de Dios, and toll stops.   As we pass through the industrial areas of the city,  the massive oil refinery expansion project dominates the landscape.  Evidence of other ongoing construction and expansion outside city limits is also present.

Like most roads outside cities, we pass through several security checkpoints.

As we leave Bolivar we pass several palm plantations, where palm oil is produced. (Alas, no palm wine – one of my favorites)**.

Like Texas with hills

March is the tail end of the ‘drought season’ of this tropical locale so much of the landscape is brown, and barren appearing (think of Texas, with hills.)  This year has been particularly dry with several wildfires due to the effects of the El Niño weather systems.  This year, they tell me is even worse than previous El Niño years.  A comparison to Texas is appropriate since this part of Sucre is mainly farms with livestock (horses, chickens etc.) and cattle grazing.  For this reason, Sucre is well-known to Colombians for both its beef and the richness of the local cheese.

Along the way, we pass several small settlements of tiny houses along with the fincas (working farms) of the wealthy.  Some of the homes are poured concrete with concrete floors and painted in gay colors, others are hard-packed manure with dirt floors.

one the modest dwellings roadside in Sucre

one the modest dwellings roadside in Sucre

As part of a promise made to improve the infrastructure of Colombia during President Juan Manuel Santos’ famous “five points” most of the roadways are either newly paved or in the process of being paved and expanded.

During the drive, my companions give me the history of the various settlements.

Palenque

One the first settlements we pass while still in the state of Bolivar is the town of Palenque.  Palenque is known for being the first settlement of escaped/ free Africans in Colombia.  (As one of the main ports for the slavery trade, Cartagena – escaping slaves would make their way to small settlements to live as free members of society.)

Palenque is known for adhering to mainly of the African traditions of their ancestors, as female residents wear traditional dress.  Residents speak a distinct dialect of a creole based, Spanish language mix  also called Palenque.

photo courtesty of Proexport Colombia.  Photo by Juan guFo.

photo courtesy of Proexport Colombia. Photo by Juan guFo.

A decade makes a difference – The Red Zone

Just ten years ago, this simple journey would have been venturing into dangerous territory***.  Guerillas and paramilitary groups controlled the area, and terrorized residents and travelers alike.  No where does the history of conflict in Colombia become more real than in the tiny town of Chinulito.  This town was one of the first casualties of paramilitary activity in the area.  Over 300 families had to flee the area for their very lives.  Many more were killed. (For a bit of eye-opening, remember that while we often think of these massacres  as a thing of the past, the violence is ongoing in parts of Colombia, and this incidence occurred in 2000, not 1970).

It wasn’t until 2008, that 56 of these former residents were able to return, under the protective watch of the Colombian military and police.  The military presence is significantly heavier than any of the other areas I’ve been to. 

Soon we enter the town of Sincelejo and head to the office to see patients.

Not a puebla

Despite being considered a somewhat rural area by more cosmopolitan coastal residents of Barranquilla and Cartagena, Sincelejo is no small puebla.  The city, which is the capital of Sucre, has a population exceeding 200,000.  The city has a long history and was initially inhabited by native peoples prior to Spanish exploration, and subsequent “discovered” in the 16th century.  The city was formally founded in 1535 in the name of San Francisco de Asís de Sincelejo.  (We will talk more about the city in future posts since I’ll be spending considerable time here.)

*Cardiac surgery services lines are particularly expensive to maintain in comparison to other hospital services.

** Apparently, I am not alone in my appreciation of this type of wine, which is widely considered among locals as the  Colombian equivalent of “bum wines” like Thunderbird, Ripple, MD 20/20 or other cheap drinks favored by alcoholics.

*** If you are thinking of doing something like venturing solo into the Red Zones, particularly if unaccompanied by Colombians, please read this article, “Backpacking in a red zone.”

Cartagena update: Dr. Cristian Barbosa, cardiac surgeon


with Dr. Pulido (left) and Dr. Barbosa in Cartagena (2010).

I wanted to post an update on a fantastic surgeon (who has since become a good friend).  In fact, Dr. Cristian Barbosa was one of the first surgeons I ever interviewed back in 2010 – and without his encouragement, the first book would have never gotten off the ground.  Maybe not the second book (Bogotá!) either – since once I said the magic words, “Oh – I interviewed Dr. Barbosa in Cartagena last year,” plenty of other surgeons who might not have talked to me – started to take me seriously.

with Dr. Barbosa back in 2010

Ever since then – I try to keep in contact with Dr. Barbosa – he’s a great person and an absolutely phenomenal surgeon, so I email him every so often..

Since my last visit, back in August – Dr. Barbosa has left Hospital Neuvo Bocagrande – and is now operating in Clinica Santa Maria in Sincelejo, Colombia.

Sincelejo is the capital of the state of Sucre, which is part of the Caribbean region of Colombia.  Like most of this part of Colombia – it has a rich history, and was founded back in 1535 in the name of St. Francis de Assis, though it was long inhabited prior to that by native Colombian tribes such as the Zenu.  Unlike nearby Cartagena (125km north), Sincelejo is a more mountainous landscape, and is known for their agriculture, particularly cattle.  (wow – my stomach just rumbled  – must be missing those gourmet Corral burgers, which are my one Colombian indulgence.. Argentina has nothing on Colombian beef.)

Dr. Barbosa is still living in Cartagena and making a three-hour commute to perform life-saving surgery, while he works on creating a new cardiac surgery program back in our favorite seaside city.  (Hopefully, when he does – we’ll be invited back to take a look!)

gate at the entrance to the historic el centro district

sunset in Cartagena, Colombia