Days of Summer


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

Let the buyer beware:

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

scalpel

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

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

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

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

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

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

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

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

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

Licensing isn’t everything..

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

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

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

airplane3

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

Colombia Moda 2014

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

(official image from Colombia Moda / Inexmoda)

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

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

dsigners

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

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

sew

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

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

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

Sponsors del Congreso ALAT 2014

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

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

 

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


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

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

Dr. Luis Botero, in the operating room

Dr. Luis Botero, in the operating room

The facility: IQ Interquirofanos

Interquirofanos is located on the second floor

Interquirofanos is located on the second floor

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

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

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

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

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

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

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

Prior to heading to the Operating Room:

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

Complication Insurance

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

Today’s Procedures: Liposuction & Fat Grafting

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

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

fat being removed by liposuction

fat being removed by liposuction

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

Types of liposuction:

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

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

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

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

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

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

Fat Grafting

Fat from liposuction procedure to be used for buttock augmentation

Fat from liposuction procedure to be used for buttock augmentation

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

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

Results are immediately appreciable.

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

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

The Surgery:

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

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

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

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

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

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

Controlled Hypotension

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

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

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

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

Dr. Julio Arrango keeps a close eye on his patient

Dr. Julio Arango keeps a close eye on his patient

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

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

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

Results of the surgery were cosmetically pleasing.

Post -operative care:

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

The patient also receives prescriptions for several medications including:

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

2. Non-narcotic analgesia (pain medications).

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

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

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

Follow-up appointments:

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

* Fat embolism is a risk with any liposuction procedure.

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

Medellin, my beautiful friend..


I don’t know how it always happens.. I set out on one kind of expedition and (frequently) it turns into something else.  So we have it.. I was planning to write extensively on Panama City, but looky, looky – here I am again, living in the fantastic, tragic beauty of Medellin.

As I wrote once before, Medellin is a city of great loveliness, but somehow Bogotá always blinded me to Medellin’s charms.. But it’s time to give Medellin a fair shake, so here I am..

Medellin 002

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

Punta Pacifica, Hospital San Tomas and Centro Medico Paitilla


**Due to some unforeseen changes in my itinerary, I can only provide just a brief overview of some of the facilities in Panama City, which falls far short of my usual.**

Centro Medico Paitillo (CMP)

Balboa Ave. and 53rd Street

Website: http://centromedicopaitilla.com/

Founded in 1975, CMP has grown to become the largest private facility, though  Punta Pacifica appears to rapidly approaching on their heels.  They have several well-established international health insurance programs and the hallways were well populated with English-speaking visitors and patients.  The hospital has community outreach and health promotion classes as well as a 64 slice CT scanner, MRI and other diagnostic capabilities.

Website is attractive, and well-designed with English and Spanish versions.

Clinica Hospital San Fernando

Via Espana Las Sabanas

Website: http://www.hospitalsanfernando.com

There are two facilities for Hospital San Fernando; a Panama City facility and another facility in Coronado. The Panama city facility is one of two Panamanian facilities accredited by Joint Commission International.  This is a private facility designed to entice foreign visitors and upwardly mobile Panamanians.

Website with English language version that includes price quotes for International travelers. Website is well-designed and easy to navigate.

I have not visited or viewed this facility

Hospital Punta Pacifica

Boulevard Pacífica y Vía Punta Darién
Ciudad de Panamá

Website: http://www.hospitalpuntapacifica.com/

Webpage with English and Spanish versions, and has been designed for international travellers. However, the overall quality of the website is poor. Information has been poorly laid out and is often mischaracterized. For example, visitors to the site who are seeking information about individual physicians are transferred to a poorly typed resume-style pdf. Physician specialties are mislabeled; with cardiologists listed as surgeons, which may cause confusion for potential patients.

Hospital Punta Pacifica was accredited by Joint Commission International in September of 2011. Hospital Punta Pacifica’s main claim to fame, as it were, is that it is John Hopkins International branded facility.  As such, it is aggressively marketed as a medical tourism destination.

It is located in downtown Panama City, just a kilometer from the CMP (Centro Medico Paitilla).

Victoria 001

Hospital Santo Tomas

Calle 34 Este y Avenida Balboa

Website: http://hospitalsantotomas.gob.pa/

Hospital San Tomas is the oldest public hospital in Panama. Originally started as a small facility for impoverished women in September of 1702, the hospital has grown over the last 300 years to become the largest hospital in the country. The hospital now offers multiple service lines including surgical specialties such as thoracic surgery, plastic surgery and general surgery, among others.  The campus includes separate facilities (Maternity hospital, children’s hospital), a blood bank and Cancer center.

Blue Cross Blue Shield of Panama – one of the international arms of the Blue Cross Blue Shield insurance company, and just one of the many insurances accepted at most Panamanian facilities.

What’s this about free insurance for tourists to Panama?

In one of their more effective (and dramatic) public relations gestures, the Panamanian government widely advertises “Free  medical insurance for the visitors”.  This catastrophic policy covers all visitors during the first thirty days of their stay for accidents and injuries (up to $7000.00) that may occur during a stay in Panama.  Visitors just need to show their passports on arrival to one of the participating medical facilities.

The policy also covers up to $500.00 of dental expenses, and economy class air tickets for return home for family members (in case of a death of a tourist) and repatriation of the deceased.  (This may sound like a grisly benefit but from previous discussions with tourists in various locations – this can be quite costly.)

*Just so you know – it doesn’t cover chronic conditions or pregnancy, so visitors can’t come here and expect to have free care for non-emergent problems (ie, elective hip replacement and the like.)

Dr. Alberto Martinez, Sports Medicine/ Orthopedic surgeon


Dr. Martinez (right) in the operating room

(Out of respect for patient privacy – I’ve done my best to crop the patient ‘bits’ from the photo.)

Spent some time last week with Dr. Alberto Martinez of Med-Sports Orthopedic Clinic here in Bogotá.  Dr. Martinez specializes in arthroscopic surgery of the hips, knees and shoulders.   As we talked about before, shoulder surgery is its own subspecialty in orthopedics due to the increased complexity of this joint.

We talked a bit about hip arthroscopy,which is still a relatively new procedure in orthopedics and the fact that one two surgeons in Bogota are currently performing this procedure.

Arthroscopy is the orthopedic minimally invasive counterpart to general surgery’s laparoscopy or thoracic surgery’s thoracoscopy.  It involves insertion of a camera and several tools through small (1 cm) incisions in the skin.  Arthroscopy itself has been used in orthopedics for many years but it is just now making inroads in hip procedures.

I’ll be publishing an upcoming article based on my observations over at ColombiaReports.com

For more information

Rath E, Tsvieli O, Levy O. (2012).  Hip arthroscopy: an emerging technique and indications.  Isr Med Assoc J. 2012 Mar;14(3):170-4.

Haviv B, O’Donnell J. (2010). The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients.  Sports Med Arthrosc Rehabil Ther Technol. 2010 Jul 29;2:18

The authors found that 16% of patients in their study eventually required hip replacement after hip arthroscopy during seven years follow-up.

Nord RM, Meislin RJ. (2010).  Hip arthroscopy in adults.  Bull NYU Hosp Jt Dis. 2010;68(2):97-102. Review.

Sunday in Usaquen


Sunday streets open for pedestrians

Since I am always talking about Sundays in Bogotá – I thought I would post some photos..

Today we walked along the streets (Carrera Septima) to enjoy the sunshine in Usaquen.

Streets closed to auto traffic to allow Bogotanos to enjoy the city, walking, on bikes, skates, skateboards – and strollers as families enjoy the sun.

We walked to the marketplace and enjoyed the park.  (One of things I particularly love is that when you go to the park – kids are playing soccer, not with their iPhones..  (of course they have iPhones- they just put them aside for a few hours.)

Flavia in park,, kids playing in background

Teaching Flavia some basic gymnastics today – cartwheels, handstands and such..

in the park

A girl offering puppies in the park (with parents, not pictured)

vintage rides in Usaquen

This guy was minding his own business – but he just looked cool (James Dean style)..

 

 

you can see the tips of the marketplace stalls (white tent tops)