Is it safe to fly after surgery?


Long haul flights are a health risk for everyone

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

Increased risks in specialized populations

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

Increased risk after surgery + Long trips

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

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

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

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

airplane3

But, is it safe to fly after surgery?

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

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

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

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

Additional reading

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

AATS poster presentation abstract:

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

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

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

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

Medical tourism on the heels of Obamacare


Happy Thanksgiving to all of my American readers!  I hope everyone has a wonderful and safe holiday.

I’m home for a while, sort of.

After returning from Mexico this October, I’ll be spending the rest of the Fall/ Winter here in the United States while I replenish my writer’s budget by completing some travel assignments.  (Coming soon – to a hospital near you!)

Now that I am home, I have been catching up on all of the local news – and it looks like Obamacare hasn’t really kicked off to a wonderful start.  Of course, it was naive to think that anything SO large/ SO involved / Affecting some many people could go off without (several) hitches, but as one of the people losing their coverage because of it – I certainly understand all of the anxiety and worry out there.

In the midst of continuing coverage of the current Obamacare fiasco, as millions of Americans lose their existing health care, several new articles on medical tourism have been making headlines across the country.  Here’s a look at some of the latest news and reports from this past month.globe ribbon

In the Bay Area, NBC news‘ Elyce Kirchner, Jeremy Carroll and Kevin Nious published “Medical tourism: the future of healthcare?” along with a televised report. It’s the usual patient narrative along with an overview of medical tourism.

Kevin Gray, at the Men’s Journal talks about the domestic and international options available in his narrative, “Medical Tourism: Overseas and under the knife.”  Gray takes a slightly different approach and discusses how consumers can comparison shop for health care services.

Among these publications, is “Medical tourism: Spanning the globe for health care,” by Kent McDill which includes information from one of my publications and a recent interview published right here at Latin American Surgery.com

The sky’s the limit?

Also, in counterpoint to the numerous press releases and newspaper articles talking about Iran, Bermuda, and various other medical tourism destinations seeking to “cash in” on the phenomena, British researchers (Lunt et al.) have published a report that contradicts the “if you build it, they will come” philosophy which has taken over the industry in many quarters.

Medical News Today published a summary of their findings early this month.  Researchers also point out that much of the credible data required to provide a full and accurate picture regarding medical tourism is absent.

On a related note: While I talked about the limitations in medical tourism, accuracy of reported statistics and public perceptions in-depth during my 90 minute NPR interview, you wouldn’t really know it from my 2 sentence quote.

Pitfalls..

USA Today also published a story on some of the pitfalls for destinations with thriving medical tourism.  Kate Shuttleworth takes a look at the strain that Eastern European medical tourists have placed on some Israeli facilities.

Is medical tourism on the rise?  or is it all a spin of the numbers?  I guess it all depends on who you ask.. But for now – Obamacare is not a viable alternative to medical travel.

CBS news on the cons of medical tourism


CBS published a refreshing take on medical tourism – an article reviewing the pros and cons of traveling for medical care along with an interview with an American orthopedic surgeon,  Dr. Claudette Lajam from New York University Langone Medical Center.

Video interview with Orthopedic Surgeon

While Dr. Lajam pretty much rejects any form of medical tourism – she made some excellent points in her interview.  In the discussion, she stressed the need for facility AND provider verification.  She also talked about the need for people to know specifics – and gives one of my favorite examples, “American trained”.

“American trained

As she points out in the interview, this is a loose term that can be applied (accurately) to a Stanford educated surgeon like Dr. Juan Pablo Umana in Bogotá  or in a more deceptive fashion to one of the many surgeons who have taken a short course, or attended a teaching conference within the United States. A three-day class doesn’t really equate, now does it?

The discussion (and the article) then turned to the need to ‘research’ providers.. Now, if only CBS news had talked to me..   That would have made for a more balanced, detailed and informative show for watchers/ readers.

(Telling people to ‘research’ their medical providers falls a bit short.  Showing people how – or providing them with resources would be more helpful.)

“Off-label medical travel”

In addition, the print article should have gone a bit further in discussing the pros and potential consequences/ harmful effects of traveling for ‘off-label’ treatments instead of merely quoting one patient.  Since the area of harm is actually far greater in this subsegment of the medical tourism population due to the amount of quackery as well as the sometimes fragile state of these potential patients  – a bit more discussion or even a separate segment on “off-label medical travel” would have been an excellent accompaniment.

Speaking of which, several weeks ago, I interviewed with NPR (National Public Radio) as part of a segment on medical tourism.  During that discussion we talked about all of the pluses and minuses mentioned on the CBS segment as well as the “Selling Hope” aspect of ‘off-label medical travel” and the potential harms of this practice, as well as some of the issues involved in transplant tourism.  I am not sure how much of my interview, Andrew Fishman, the producer for the segment, will use – or when it will air, but I’ll keep readers informed.

Dr. Ivan Santos

Just another reason for Latinamericansurgery.com


Dr. Ivan Santos

Colombian plastic surgeons operating

because you need someone who is objective (and informed) that is looking out for you, the patient..

In this article, at International Journal of Medical Travel, Kevin Pollard talks about the need for regulation of medical tourism in cosmetic surgery.  I wholeheartedly agree – in fact, Mr. Pollard and I conversed about this very topic in a series of emails last week.

After all – it is why I do what I do, and publish it here for my readers.  The industry does need to be regulated – medical tourism companies shouldn’t pick providers by “lowest bidder” and patients need to be protected (from unsanitary conditions, bad surgeons, and poor care).  But what form will this regulation take?

Will it be Joint Commission certification – which covers facilities and not the physicians (and their surgical practices themselves)?

Will it require facilities to pay a lot of money for a shiny badge?

Or will it be someone like me, low-key and independent, going into facilities at the behest of patients; interviewing surgeons and actually observing the process and talking to patients?

and who pays for this?  The beauty of what I do – is that I am independently (read: self) funded.  True, it hurts my wallet but I have no divided loyalties or outside interests in doing anything but reporting the unvarnished truth.

and ultimately – will this be done in a fair, open and honest way?  Or it is really a witch hunt led by disgruntled American and British plastic surgeons?  Will they bother to discriminate between excellent surgeons and incompetent ones who will it be by geography alone?

I guess we will just have to wait and see.

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.

Is your ‘cosmetic surgeon’ really even a surgeon?


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

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

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

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

Surgeon or a handyman

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

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

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

Follow up on wrong-sided surgery


We recently mentioned Dr. Denise Crute, an American neurosurgeon in a November blog post, Wrong-sided surgery.  We quoted News of the Weird as our source, with the original source being ABC channel 7 news.  We mentioned her story to illustrate the importance of safety checklists in the operating room.  It would have stopped there, but now we’ve received a threatening letter from a lawyer in Phoenix, Arizona representing Dr. Crute.  (Since we last heard that she was practicing in New York – the Arizona lawyer must be for my benefit.  I wonder if she would have hired a Colombian lawyer if she realized that’s where I spend the majority of my time.)

Harming her reputation?

Her lawyer claimed that by republishing this information that I am liable for damages  caused by the harm to her reputation.

In my opinion, she’s blemished her reputation all on her own (but I’ll let you read the letter for yourself).

To make it easy on everyone – I’ve also linked to my original post, which was a quote from Mr. Shepherd, who stands by his story.

In my defense – Truth is the truth

I think my statements are fair, accurate criticism, particularly given the known facts of the case.  Now, the last thing I want to do is report something erroneously.  After all, I stake my reputation on my honesty and integrity, so if I have made a mistake – I will freely admit it – and will happy display it in ALL CAPS here on the blog.    Not only that, but I will happily travel out to see Dr. Crute and interview her for the blog, so she can set the record straight – if it needs correcting.  But I can’t be cowed by an angry surgeon looking for an easy target.

Litigious behavior doesn’t change the facts

Notably, the lawyer’s letter doesn’t even address the accuracy of the claims against her. But I did see her own personal blog, where she has a one page statement addressing the charges, so I will link to it here.  In it she claims to have been the victim of a one-person driven witch hunt.

Yes, that could happen – but the breadth and width of the charges (hundreds) and the collaborating witnesses in the statements argues against it in this case.

Now, the initial report to the medical board may very well have been the result of professional jealousies, or whatever, as Crute and her legal team claim.  But there are so many charges – with multiple supporting witnesses that it seems highly unlikely.

Her main argument is against the neurosurgeon that helped the medical board evaluate the claims.  She chalks up his decisions and statements against her behavior to competition, since she is the superior surgeon, apparently.  Fine, but that doesn’t account for the majority of charges which have nothing to do with actual surgery – but with the ethics of her practice.  (You don’t have to be a neurosurgeon to know that altering a patient chart and falsifying data is wrong.)

Another point to consider:

But it also may have also taken another neurosurgeon who was finally bold enough to speak up against repeated, repeated and repeated episodes of unprofessional, dangerous and injurous behaviors.

In fact, a recent poll of 24,000 physicians demonstrates the reluctance of doctors to criticize their colleagues.  The Medscape 2012 Ethical Dilemma Survey results showed that just 47% of physicians would caution a patient about a colleague they felt was practicing ‘substandard’ medicine.

While her statement makes it sound like these sort of complaints against providers and surgeons are common – they really aren’t.

While it may seem so for Dr. Crute (and neurosurgeons do have a high rate of malpractice), for another colleague, several nurses and the surgeon’s own PA to make these statements about Dr. Crute to a medical board means that it was more that a personality conflict.

Not having her license stripped away is not proof of innocence.  In most states, medical boards offer disgraced physicians the opportunity to inactivate their licenses.  It’s similar to hospitals (and other organizations) allowing  doctors, CEOs and such, to resign instead of being fired outright.  This practice has been clearly established and well-documented in several notable cases.

Doctor’s story led to changes in the Colorado Board of Medicine

In fact, many say that the recent stories about Dr. Crute (by Denver reporter, Ferrugia) have prompted changes in the licensure and disciplinary processes at the Colorado Medical Board.

But it’s more than that – attacking my blog for using well-publicized and reprinted information (available at multiple sources) to illustrate a discussion here on patient safety, just seems to me like bullying, especially when there are twenty other articles about Dr. Crute on much larger websites with a lot more viewers.  So I also contacted Mr. Ferrugia and Mr. Shepherd (of News of the Weird) to see if they, too, had been contacted by Dr. Crute and her legal team.  No, they haven’t.. Just me.

This makes me suspect that this entire letter/ episode is just an attempt to bully someone smaller and less powerful, and that’s what makes me angry.  This would have been a good opportunity for Dr. Crute to rectify the record, if that’s truly the case (especially since legal action and media coverage appears to have ramped up in the last few days with more and more articles over the last week)  but she doesn’t appear interested in that.  (If she had, we would be seeing retractions from the other writers involved).

But – check out her site, read her defense, and let me know what you think.  It is also worth noting that despite all the ‘glowing’ quotes she has on her website, she doesn’t appear to be operating on patients in her new position.

I’m not sure that the fact that she volunteers or donates supplies to Central America holds any relevance to the discussion – but she put it out there, so I’m reporting it.

 Dr. Crute settlement agreement

documents related to medical practice

In the meantime, I stand by my statements in reference to safety checklists, etc. that a ‘time-out’ for patient safety can prevent many of these errors that are documented in the original papers, such as in 2004 when she performed wrong-sided brain surgery – which she is accused of, along with   then attempting to cover-up in her documentation (and actually had the gall to say that the patient “marked” the wrong-side.) The patient had a right subdural hematoma (and according to the notes on page 7 of attached document) – was in no condition to consent/mark or otherwise make any medical decisions.

Read the original documents – and see if it paints a portrait of someone who did whatever she wanted, when she wanted and thought that she could get away with it – like when she failed to come see an emergency surgical consult at night*.  She gave a telephone order for intubation, and still didn’t bother to come see this critically injured patient.   Then, after it was too late – came by at 7 am in the morning, and back-dated her notes.  (Yes, patient died).  Unfortunately, there is no checklist to address such an ethical lapse.

But in the spirit of honesty and integrity, and in pursuit of the truth, I have contacted the reporter of the original story, John Ferrugia to see if there have been any story updates, retractions or corrections. (Mr. Ferrugia also provided the supporting documents.)  I also offer Dr. Crute the opportunity to give a statement here.  She knows how to contact me, and apparently she’s reading the blog.

But – this isn’t what my blog is really about – so we will get back to our regular topics, like surgical checklists and surgical apgar scoring – on our next post..

Supporting documents – Mr. Ferrugia:

Dr. Crute 1

Dr. Denise Crute 2

Additional articles

Dr.Crute article by Melissa Westphal

* Just one of many incidents documented in the original documents.