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Archive for the ‘Medical tourism in Mexicali’ Category

after a visit to the ‘five dollar’ doctor at Far+Cia pharmacy

If you’ve read the prevous books, then you know that my family has been critical for much of my work.  If this group of accident and injury-prone people always stayed at home during my medical research travels, we wouldn’t have some of our great content from the dental offices, urgent care centers, and emergency rooms of Colombia.  (It’s the “collateral damage” aspect of my work, as members of the research team experience their own casualties.)

Now, it’s my husband’s turn again.  Like many of our readers, he has some chronic health conditions which are generally well-controlled.  However, he does have occasional flare ups, (which are exacerbated by stress), so it isn’t surprising that he started feeling poorly over the weekend.  It also isn’t surprising (to me at least, after ten years of marriage) that he deferred going to the doctor as long as possible.

But this time, I was ready for him.  I had noticed on previous ventures that one of the large chain pharmacies offered medical consultations* for sixty pesos (about five dollars at today’s exchange rate).

one of the many Far+cia pharmacies in Mexicali

Instead of listening to a litany of excuses, I bundled him up (so to speak), gave him the address and strict instructions to take notes – and sent him on his way.

He ended up at the Far+Cia on Calzada Justo Sierra (No. 505)  He’s a bit directionally challenged at times but you just can’t miss these big yellow and red stores.

He returned about fifteen minutes later.  (Readers, I am sad to report that despite phenomenal computer skills and a winning personality – he’s a pretty poor reporter, so Cartagena Surgery may be making a follow-up visit in the future.)

Cartagena Surgery:  “So, tell me about it..”

S. U. (Spousal Unit): “yeah. umm. He was nice.”  (Sheepishly and mumbled) “said I should have come in sooner.”

Cartagena Surgery:  “so, he spoke English?  Fluently?”

S. U.:  “Umm.. Yeah, about as good as me, I guess.”

Another twenty minutes of this was needed to pin down some specifics.

Dr. Esteban Diaz Cancino, MD, a fluent English-speaking physician who trained at the Universidad Nacional Autonoma de Mexico saw S. U. within moments of his arrival to the pharmacy.

The doctor did a quick evaluation, listened to his symptoms and provided recommendations and prescriptions for treatment.  He also recommended that S.U. return if his symptoms did not improve. (Not bad for five bucks, and a little arm twisting on my part.)

The prescriptions cost around $25.00

*In 2010, the Mexican government passed a law requiring a prescription for antibiotics in an attempt to curb the spread of antibiotic resistant bacteria.  After that, on-site medical clinics (similar to minute clinics, and Rite-Aid pharmacy clinics) became more popular.

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For internet searches for medical photography – all of my images are free for your use, but please give proper credit for my work, ie. “Photo by K. Eckland”.  For commercial uses, contact me, (so that I can contact the subjects of my work).

Please note that patient privacy is protected – and patient permission is obtained prior to photographs.  For the most part – I photograph surgeons – not patients, or surgery.

Spent much of the weekend in the operating room with Dr. C. Vasquez, cardiac surgeon at two different facilities, and the differences couldn’t be more apparent – and perhaps not what one might expect.  Much of it comes from perspective; as a person behind the lens, I see the scene differently than others might.

harvesting the radial artery

In fact, this prompted me to write an article on the subject of medical photography, complete with a slide show to illustrate the effects of color on surgical photographs. I’ve also re-posted much of the article here (see below).  Once you see the photos from today, you’ll understand the article.

the beige operating room

The case today went beautifully, with the patient extubated in the operating room.

Dr. Vasquez, and Lupita, scrub nurse

While we were there – had an unexpected surprise! Dr. Gutierrez ‘Lalo’ showed up.  I have been trying to get him into the cardiac OR since he confessed his interest in cardiac surgery.  It was great to see him – and I like encouraging him in his educational goals.   (I kind of miss being a mentor, and preceptor to students..)

Lalo peeks over the curtain..

Dr. Gutierrez (Lalo) in the cardiac OR

Medical Photography

Medical photography is many ways is more art, and luck that skill – at least for people like me who never set out to be medical photographers in the first place.  It was a natural development prompted by dire necessity during the early days of interviewing surgeons and medical writing.  I am still learning, and hopefully improving.

But as I said before, much of it is luck, and timing, particularly in this field, where the subjects are always in motion and a slight movement of the hand tying the suture knot can result in either a breath-taking shot or an utter failure to capture the moment.

The most dramatic and vivid photographs often come at mundane moments, or unexpected situations.  In medical photography, where the subject matter combines with a dramatic interplay of color, light and shadow to illustrate some of life’s most pivotal moments such as birth, death and life-saving operations – it is surprising how important the background elements are.

Here in Mexicali, I have been taking photographs of different surgeons for several weeks at different facilities across the city.  But, almost unanimously, all of the photographs, regardless of subject at Hospital Almater are lackluster and uninspiring.  Contrast this with the glorious photos from the public facilities such as Hospital General de Mexicali, and Issstecali.

The culprit is immediately apparent, and it demonstrates how such carefully planned such as aesthetics and interior design can have unintended consequences.  The very studied, casual beigeness used to communicate upscale living in the more public parts of the hospital are destroying the esthetics of the operating room services they are selling.  Whereas, the older facilities, which have continued the use of traditional colored drapes and materials do not have the problem.

Historically, surgical drapes were green for a very specific reason.  As the complementary color to red, it was believed to be a method of combating eye fatigue for surgeons looking at the red, bloody surgical fields for hours at a time.  Over the years, operating room apparel and drapes evolved away from this soft green to a more vivid blue, know as ‘ceil’.  The reasons for this change are probably more related to manufacturing that medicine, and since that evolution, surgical drapes now come in a variety of colors – hence the color matching here, of the paint, the tile, the patients, the operating room and the surgeons itself.  Somewhere, an interior decorator is filled with gleeful satisfaction – but I can only muster up a groan; knowing I will be here again and that most of my photos will be unusable.

While the consequences of poor medical photographs may seem trivial to anyone but myself (and my interviewees) at this junction – it runs far deeper than that.  With the advent of the internet, and the complicated legalities of getty and other corporate images, small, independent photographers such as myself are gaining wider exposure than ever before.   Alas! – much of it is uncredited, but several of my more popular images are downloaded thousands of times per week, to grace slideshows, powerpoint presentations and other illustrations for discussions of anything from medicine and surgery to travel, technology and even risk assessment.  In an era of branding, and logo recognition, places like Hospital Almater are certainly missing out.

In  other news/ happenings: Upcoming elections!**

Finally found someone to talk to and explain some of the issues in Mexican politics – but he hates Quadri, and doesn’t really explain any of it except to say ‘He’s corrupt..”  (From my understanding, ‘corrupt’ is an understatement, and that all of the parties are corrupt – and it’s pretty well understood by everyone involved – so of course, if I hear something like that – please explain.. explain..)  It’s not like I am capable of voting anyway, but I’d sure like to hear perspectives..

It looks like I’m not the only one who is a little leary of pretty boy pena’s party’s dubious history.  His numbers have fallen in recent polls in advance of tonight’s televised debates.  (Let’s hope these debates are better than the last.)

My personal “favorite”, Quadri is still trailing in the dust, but it looks like Lopez has a chance to take the election from Pena (much like it was ‘taken’ from him in 2006 with his narrow defeat..  Lopez is a socialist which is hard for Americans like me to understand – but then again, it’s not my country, and the levels of inequity here are certainly wider than at home – so maybe someone like Lopez can bring some much needed support to the lower classes.

I mean, a lot of what we take for granted in the USA doesn’t exist here, like a decent free public school education.   (Okay – I know critics will argue about the value of an inner city education – but we still provide a free elementary & secondary school education to all our citizens.)  So socialism for the purpose of providing basic services in all areas of Mexico seems pretty reasonable.  (It would help if I could read some primary source stuff – without using translation software, so I would have a better idea of the specifics of AMLO’s ideas.)

I did ask my friend about the student demonstrations for Yo Soy 132.  I guess as an American growing up after the 1960’s – we tend to not too make much of a big deal over student demonstrators – after all – we have the ‘Occupy’ movements going on right now in our own/ other countries – but he was telling me that this is pretty uncommon in Mexico.

** No, I’m not really into politics but I feel like it’s important to try and understand as much as possible about the places (countries) where I am residing.

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No – I haven’t changed the name of the blog, just reflecting the nature of my current assignment.  Spending some time in Interventional Cardiology this week as part of a story I am writing about chest pain emergencies for Mexico on my mind.com.  Today, I checked out the cath lab at Hispano Americano Hospital.  It’s a bit crowded, but all the equipment is brand-spanking new, and practically sparkling.  (Don’t worry – I have photos to prove it!)

Nurses in the cath lab at Hospital Hispano Americano

Dr. Fernando Monge was kind of enough to give me a guided tour.  While we were there he (assisted by Dr. Raul Aguilera) placed a stent in a patient with recurrent angina.  A doctor from the ER also stopped by to have him review a couple EKGs..  I’ll post a link when the full story is done.

Also stopped in to talk to Dr. Jose Antonio Olivares Felix, MD, a general surgeon who reports to me that he is doing single port laparoscopy – so of course, that got me interested.  Hoping to set a date to go to the operating room.

I’ll be spending all of tomorrow in the company of Dr. Marnes Molina, MD to learn more about some of the other stuff he’s doing in urology (and hopefully grab a picture of that green laser!)

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Dr. Gabriel Ramos, Oncologic Surgeon

Been a busy week  – (Yea!) but now that it is the weekend, I have a chance to post some more pictures and talk about my day in the operating room with Dr. Gabriel Omar Ramos Orozco. 

Despite living in a neighboring apartment, interviewing Dr. Ramos proved to be more difficult than anticipated.  But after several weeks, I was able to catch up with the busy surgeon.

Outside of the operating room, he is a brash, young surgeon with an off-beat charm and quirky sense of humor.  But inside the operating room, as he removes a large tumor with several cancerous implants, Dr. Gabriel Ramos Orozco is all business.

It’s different for me, as the interviewer to have this perspective.  As much as I enjoy him as a friendly neighbor – it’s the serious surgeon that I prefer.  It’s a side of him that is unexpected, and what finally wins me over.

Originally from San Luis Rio Colorado in the neighboring state of Sonora, Dr. Ramos now calls Mexicali home.  Like most surgeons here, he has a staff position at a public hospital separate from his private practice.  It is here at IMSS (Instituto Mexicano del Seguro Social) where Dr. Ramos operates on several patients during part of the extended interview.

Operating room nurses at IMSS

During the cases, the patients received a combination of epidural analgesia and conscious sedation.  While the anesthesiologist was not particularly involved or attentive to the patients during the cases, there was no intra-operative hypotension/ alterations in hemodynamic status or prolonged hypoxia.

Dr. Ramos reviewed patient films and medical charts prior to the procedures.  Patients were prepped, positioned and draped appropriately.  Surgical sterility was maintained during the cases.  The first case is a fairly straight forward laparoscopic case – and everything proceeds rapidly, in an uncomplicated fashion.  45 minutes later, and the procedure is over – and Dr. Ramos is typing his operative note.

Dr. Gabriel Ramos in the operating room

But the second case is not – and Dr. Ramos knows it going in..

The case is an extensive tumor resection, where Dr. Ramos painstakingly removes several areas of implants (or tumor tissue that has spread throughout the abdomen, separate from the original tumor).

The difference between being able to surgical remove all of the sites and being unable to remove all of the gross disease is the difference between a possible surgical ‘cure’ and a ‘de-bulking’ procedure, Dr. Ramos explains.  As always, when entering these surgeries, Dr. Ramos and his team do everything possible to go for surgical eradication of disease.  The patient will still need adjunctive therapy (chemotherapy) to treat any microscopic cancer cells, but the prognosis is better than in cases where gross disease is left behind*.  During this surgery, after extended exploration – it looks like Dr. Ramos was able to get everything.

“It’s not pretty,” he admits, “but in these types of cases, aesthetics are the last priority,” [behind removing all the tumor].  Despite that – the aesthetics after this large surgery are not as worrisome as one might have imagined.

The patient will have a large abdominal scar – but nothing that differs from most surgical scars in the pre-laparoscopy era.  [I admit I may be jaded in this respect after seeing so many surgeries] – It is several inches long, but there are no obvious defects, the scar is straight and neatly aligned at the conclusion of the case – and the umbilicus “belly-button” was spared.

after the successful removal of a large tumor

As I walk out of the hospital into the 95 degree heat at 11 o’clock at night – I admit surprise and revise my opinion of Dr. Ramos – he is better than I expected, (he is more than just the kid next door), and he deserves credit for such.

*This may happen due to the location of metastatic lesions – not all lesions are surgically removable.  (Tumor tissue may attach to major blood vessels such as the abdominal aorta, or other tissue that cannot be removed without seriously compromising the patient.)  In those cases, surgeons try to remove as much disease as possible – called ‘de-bulking’ knowing that they will have to leave tumor behind.

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Finally caught up with the busy Dr. Gabriel Ramos, MD, oncologic surgeon and spent several hours with him in the operating room at IMSS (the social security hospital) for a couple of cases on Wednesday..  I’ll be writing more about him soon.

Dr. Gabriel Ramos, Oncologic Surgeon

Yesterday was a full day with clinics here and San Luis.  Also – more homework, so I have to get some studying in before heading back in this afternoon.

On the radio with Cartagena Surgery:

Recorded my very first radio interview with Ilene Little at Traveling 4 Health..  I hope I don’t sound too bad (when I get nervous, I laugh..)  It’s not a pre-determined format, so I didn’t know the questions until she asked them – which makes it more interesting, but I sound less polished as I search my brain for names, dates, places etc.  Trying to remember the name of the researchers who published a paper in 1998, 2008, or 1978 is daunting when you worry about ‘dead air’.. I was so nervous I was even forgetting my abbreviations.  I hope it comes across better to listeners.

We talked about the books, what I do (and how I am surviving on savings to do it).  We also talked about some of the great doctors I’ve interviewed, treatments such as HIPEC as well as some of the quackery and false hope being peddled by people with a lot to gain.. I kind of wish HIPEC and quackery weren’t in the same segment.  Since it was off the cuff – I didn’t have all of my medical references and literature to talk about to distinguish the two (so if you are here looking for information on HIPEC – search around the site – I have links to on-going studies, and research going back over a decade, both here at BogotaSurgery.org .  Of course, the crucial difference between the two is:

HIPEC is a new treatment, but there is NO assurance of success – in fact, some patients die from the treatment itself.

– There is a body of scientific literature on HIPEC for advanced abdominal cancers (ovarian, uterine, etc)

Quakery or pseudo-science can be a bit trickery.  Maybe they take an existing or  promising treatment (like therapies for stroke, Parkinson’s etc.) and apply it to something else – like treatment of serious cancers.  (Yes – people will find papers written about the ‘treatment’, but these papers may not meet scientific rigor, or may not be about the condition or treatment that they are receiving.)  They also promise miracles and cures.

In medicine, even the very best doctors and surgeons can’t promise these things – because medicine itself isn’t an exact science, and different people respond to the same treatments differently – ie. one patient may have complications and another patient doesn’t.

Lastly  – we just touched on it – but I think it’s an important concept – is patient self-determination.  That no matter what I, or anyone writes, does or says – people always have the right to determine their own medical treatment.

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Actually, it is on my mind quite a bit these days, as you can imagine.  But that’s also the title of the new website where I will be contributing to articles about life, and health care in Mexicali.  It’s a website designed for Americans and other extranjeros living in Mexico, so I thought it was the perfect place for some of my articles on medical emergencies and medical services.

I think that if you are an ex-pat living in a different country/ culture/ etc. even if you’ve been here for a while – if you become ill, it’s a little more frightening and confusing than it might be in your old hometown.  So, hopefully the addition of a fellow gringa to help navigate the system, so to speak, is more comforting and helpful to readers..

Of course, many of the readers of the site are living in different areas of the country, so this is also a chance for me to speak up and promote Mexicali – and after being here for a couple of months – I really think that Mexicali is often judged harshly.

Sure, I don’t want it to become the next Cabo San Lucas – where Spanish is drowned out by drunken teenagers hollering, puking and carrying on in English, and Mexican culture has been submerged beneath a sea of tacky shops, Starbucks, and the homogenous effect of chain restaurants and fast food.  But I also think that when people skip over Mexicali, they are missing a chance to see an interesting side of Mexico – a side that is often downplayed to tourists unless you are heading to Mexico City.

But first – let’s be sure to say what Mexicali isn’t.  It isn’t a quaint seaside resort, or charming village.  It also isn’t a crime-infested border city, as we’ve talked about before.

If you are looking for cute, charming and rural – this isn’t the place for you.

But that’s not to say that Mexicali is without its own considerable charms.  It is first and foremost – a city of industry.  While this contributes to wide areas of industrial blight (factories and their by-products aren’t particularly attractive) – it also means that there is a significant sector of skilled labor and a higher overall standard of living.  Some of this industry is medical, but much of it is more traditional – factories and companies who came here to take advantage of NAFTA.  Frito-Lay is here, Modelo brewing is here, as well as several juice distributors and machineries.  But there is also Intuitive Surgical – the makers of the DaVinci Robot, a two million dollar piece of extremely sophisticated medical technology.

street art in Mexicali

It is also the capital of Baja California, so there is a large contingent of government offices here too,  along with the Universities and educational facilities of higher learning.

But most importantly, it is a city of people.  These people are the true heart of ‘Mexican culture’, in a very real sense.  I am fortunate that as a student, in my daily activities – I get to encounter these people on a day-to-day basis – and the people of Mexicali have proven to be as friendly and welcoming as any city I’ve ever lived.  Despite the close proximity to the border, this is the real Mexico – and it hasn’t been diluted.  Spanish remains predominant, and real working class citizens populate the streets and buildings as opposed to the more touristy destinations where everything has been ‘Americanized’ for our comfort.

Want to learn Spanish?  Then come here.  You will get to practice every day.  People will help you, correct your grammar, offer you the occasional missing word – and they do it with patience and a smile, but they will expect you to speak Spanish all the same.

The charm is here – on the quiet, upscale streets in the different barrios of the city, in the music emanating from well-kept homes, in the kitchens of mom and pop restaurants serving native dishes, and in the way that residents still welcome outsiders like myself.

They have pride in their city, their way of life and take pains to encourage me to sample it – pieces of their culture, whether as part of traditional festivities for a national holiday, or a bite of food from a street vendor or even just directions to the best [blank] in town.

an art museum in Mexicali

It also has its own identity, distinct from larger Mexico.  Some of this comes from dealing with the heat – 120 degree days in the summer are not uncommon – on these dry, sun-baked and parched streets.. Some of it comes from the unique make-up of this city – which boasts a shared heritage with a large Chinese community who fled the states after building the railroads.  So, yeah – they probably have the best Chinese food in Mexico too.

So hopefully, as I write about the doctors, and hospitals of Mexicali, visitors to the city will see the other charms that make me appreciate this place a little more every day.

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Frankly, I wasn’t sure what to expect when I returned to see Dr. Victor Ramirez.  I had enjoyed talking to him during the first interview back in November of 2011, but as most people know – a lot had happened since then.  It took me a couple of weeks to re-connect with the now somewhat wary and (media-weary) surgeon, but when I did – he didn’t hesitate to invite me to the operating room.  And then – after the first case, he immediately invited me back**.

Dr. Victor Ramirez, plastic surgeon

For readers unfamiliar with the concept of my work – let me tell you, this is usually an excellent prognostic indicator.  It’s certainly not fail-proof – but as a general rule; when a surgeon invites you to his operating room, he is generally confident because he is a good surgeon. 

You’ll notice a couple of things about the statement above – when the surgeon invites me, is important.  Often when I have to ask – it’s because the surgeons are hesitant to let me watch.  Most (but not all of the time) – there is a good reason that a surgeon doesn’t want an observer in their operating room.  (And there are a multitude of reasons – not just a poorly skilled surgeon.)

But there are certainly no absolutes.  I have met fantastic surgeons who initially were not crazy about the idea (but quickly warmed up to it) and I have met less than skilled surgeons who happily encouraged me to visit – and everything in-between.. I’ve visited great surgeons who were hampered by poor facilities, unskilled staff, or limited resources.  That’s why the on-site, operating room visit is so important.  Anything less, is well – less than the full picture.

But back to Dr. Victor Ramirez – in the quirofano (operating room) performing surgery.

Dr. Victor Ramirez, Dr. Perez and Ricardo (RN)

I observed Dr. Ramirez operating at two different facilities – Hospital Quirurgico del Valle, and the Bellus clinic.  Hospital Quirurogico is a private hospital – with excellent operating room facilities.  While there are only two operating rooms, both rooms are large, well-lit, new, and very well equipped.  There are three separate ‘big screen’ tv sized monitors for video-assisted procedures – so if you are looking for a facility for video-assisted procedures such as endoscopy, laparoscopy or thoracoscopy – this is the place.  All the equipment was modern, in new or ‘near-new’ condition.  As a facility specifically designed as a surgical hospital – with private rooms, patients are segregated from ‘medical patients’ with infectious conditions.  (The facility is not designed for pneumonia patients, and other medical type hospitalizations.)

Dr. Ramirez applied the sequential stockings himself (kendall pneumatic devices), and supervised all patient preparations.  Patients received a combination of conscious sedation, and epidural analgesia – so they were awake, but comfortable during the procedures.  (This eliminates many of the risks associated with general anesthesia – and reduces other risks.)  The anesthesiologist himself, Dr. Luis Perez Fernandez, MD was excellent – attentive and on top of the situation at all times.  There was no hypoxia or hemodynamic instability during either of the cases.  (I have been favorably impressed by several of the anesthesiologists here in Mexicali.)

Dr. Perez monitors his patient closely

As for the surgery itself – everything proceeded in textbook fashion – sterility was maintained, and Dr. Ramirez demonstrated excellent surgical techniques.

For example – One of the signs of ‘good’ liposuction (and good preparation) is the color of the fat removed.  Ideally, it should be golden or light pink in color.  Over-aggressive liposuction or poorly prepped liposuction results in more bleeding.  As I watched fat being removed – the fat remained golden-yellow in the suction tubing, and even at the conclusion of the procedure, the accumulated suction canister contents remained just slightly tinged pink.

Results were cosmetically pleasing in both cases with minimal trauma to the patients***- but there will be more details forthcoming in the free book (since the post is becoming pretty long, and may be more detail than casual readers would like.)  I’ll have more information about the doctors, including the anesthesiologists, the clinics and the procedures themselves..

I did want to post some specifics – especially in this case, as the patient told me that her/his parent is a retired physician and had concerns about surgical conditions.

Mom, Dad – you don’t have to worry – Dr. Ramirez runs an excellent OR. Even in the tiny Bellus clinic, there is a full crash cart, a defibrillator and an emergency intubation cart – just in case.

**Given what I know about Dr. Ramirez, I am pretty confident – that if I wanted – I’d be there right now, and every day for a month, or until I said, “stop”..  That’s the kind of person Dr. Ramirez is.

*** In some liposuction cases – the patients appear as if they have been beaten (extensive bruising) due to the amount of trauma and force used during the procedure.

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