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.

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In the operating room with Dr. Wilfredy Castaño Ruiz


I am still working on several posts – but in the meantime, I wanted to post some photos from my visit to the operating room with Dr. Wilfredy Castaño Ruiz, one of the thoracic surgeons at Hospital General de Medellin.

Readers may notice that some of the content of my observations of the operating room have changed.. In reality, the reports haven’t changed – I have just chosen to share more of the information that I usually reserve for the books since I probably won’t get time for a “Medellin book”.  So, if you are squeamish, or if you don’t want to know – quit reading right about now…

It was a surprise to meet Dr. Wilfredy Castaño Ruiz because it turns out we’ve already met.  He was one of the fellows I encountered during one of my early interviews in Bogota, with Dr. Juan Carlos Garzon Ramirez at Fundacion Cardioinfantil.

Since then (which was actually back in the early spring of 2011), Dr. Castaño has completed his fellowship and come to Medellin.

Dr. Wilfredy Castaño Ruiz, thoracic surgeon at Hospital General de Medellin

Dr. Wilfredy Castaño Ruiz, thoracic surgeon at Hospital General de Medellin

Yesterday, I joined him in the operating room to observe a VATS decortication.  The case went beautifully.

Dra. Elaine Suarez Gomez, an anesthesiologist who specializes in cardiothoracic anesthesia managed the patient’s anesthesia during the case.  (This is important because anesthesia is more complicated in thoracic surgery because of such factors as double lumen intubation and selective uni-lung ventilation during surgery).

Anesthesia was well-managed during the case, with continuous hemodynamic monitoring.  There was no hypotension (low blood pressure) during the case, or hemodynamic instability.  Pulse oxymetry was maintained at 98% or above for the entire case.   Surgical Apgar: 8 (due to blood loss**)

Monitors at HGM are large and easily seen from all areas of the OR

Monitors at HGM are large and easily seen from all areas of the OR

Dr. Wilfredy Castaño Ruiz was assisted by Luz Marcela Echaverria Cifuentes, (RN, first assist*). The circulating nurse was a very nice fellow named Mauricio Lotero Lopez.

Enf. Luz Echaverria assists Dr. Wilfredy Castaño Ruiz during surgery.

Enf. Luz Echaverria assists Dr. Wilfredy Castaño Ruiz during surgery.

*”Registered nurse” is not terminology common to Colombia, but this is the equivalent position in Colombia, which requires about six years of training.)

** In this particular case, the surgical apgar of 8 is misleading.  The anesthesia was excellent, and the surgery proceeded very well.  However, due to the nature of surgical decortication (for a loculated pleural effusion/ empyema) there is always some bleeding as the thick, infected material is pulled from the lung’s surface.  This bleeding was not excessive for this type of surgery, nor was it life-threatening in nature.

Colombia as a medical tourism destination: my experiences & observations


I submitted an article on Colombia as a medical tourism destination to Yahoo! for publication.  The article discusses several of the factors I’ve mentioned before, and includes my observations from the last several months.  We’ll have to wait and see if they think it’s suitable for publication.. Of course, if they reject it – I’ll be sure to post it here, for all of you and your critiques..

In the OR with Dr. Mauricio Largacha, Orthopedic Surgeon


The rest of Bogota may be quiet for the Easter holidays (la semana santa) but the operating rooms were busy at Unidad Medica Cecimin.

Dr. Mauricio Largacha, Shoulder and Elbow surgeon

I spent an interesting and enjoyable morning in the operating room with Dr. Mauricio Largacha, MD for an arthroscopic Rotator Cuff Repair. Dr. Largacha is a natural teacher, and did an excellent job at explaining different aspects of the procedure, expected post operative outcomes, and specialized equipment – since I am less familiar with shoulder and elbow surgery than other surgical procedures. (Unsurprising since as I mentioned previously, he is an expert in this area, and the author of several chapters in multiple orthopedic surgery textbooks on elbow, shoulder and ankle surgery).

Dr. Mauricio Largacha (left) and author

Surgery went beautifully, and surprisingly quick.. No intraoperative complications.

Dr. Celso Bohorquez, plastic surgeon


When we first met Dr. Celso Bohorquez, he was donating his time and surgical skills for the repair of congenital facial malformations in Chia, Colombia as part of Operacion Sonrisa.

I went back, yesterday, to Clinica Shaio, to learn more about the man, and the surgeon that so generously contributes to improving the lives of the less fortunate.

Dr. Celso Bohorquez, plastic surgeon

We spent the day in the operating room, watching Dr. Bohorquez perform several techniques including a case with facial endoscopy as part of a face-lift. The results of the cases were striking.


 

In other news, we are discussing pre-operative and intraoperative risk reduction for peri-operative/ post operative MI (along with the high incidence of missed diagnosis) over at our sister site.

Dr. Ernesto Andrade, plastic surgeon


Dr. Ernesto Andrade is another one of Bogota’s celebrity plastic surgeons, of “Cambrio Extremo” fame.  (A latin television version of ‘Extreme Makeover’ that was popular here several years ago.)  Unfortunately, he was delayed today so I was unable to meet with him, but I did speak with a young doctor in his office, Dr. Eliana Garces.  She filled in a bit of Dr. Andrade’s biography.

I’m hoping to meet with Dr. Andrade himself  tomorrow after I get out of the operating room with Dr. Celso Bohorquez.  If you remember, I met Dr. Bohorquez out in Chia while he was volunteering his surgical skills as part of Operacion Sonrisa (Operation Smile.)