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Archive for the ‘Surgery’ Category

Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

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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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Please note that this story was updated June 4, 2012 after receiving additional information.

Another case of apartment surgery in Nevada – this time by a Reno – Sparks man claiming to be a licensed doctor in Mexico..  Apparently no one from any of the papers bothered to even attempt to verify or deny his claims – but we did – here at Cartagena Surgery.  Not that any of that would make up for the lack of a Nevada medical license – or proper operating room facilities, but in the interests of fact checking the story, it seemed the least we could do..

Readers will be interested to note that he is is NOT listed as a certified general surgeon in Mexico.

While I was unable to find him listed as a certified plastic surgeon in Mexico when I contacted the certifying agency,  (the Mexican Council of Plastic Surgery, Aesthetic and Reconstruction), they reported that they do have a surgeon by that name.

Is this him?  Who knows?  It just may be, since it appears that none of the patients involved were actually hurt (versus cases with outright fake doctors injecting people with various items).   It appears he just showed exceeding poor judgement in turning a living room into a make-shift operating room theater.

But since I don’t have his birthdate or other particulars – we don’t know if it’s him for sure..  There could certainly be more than one Edgar Orozco Abundis.  But in fairness to his claims – it only seemed right to correct the original story.

Stay safe everyone, and remember – if someone offers to perform liposuction on your couch – it’s probably not a good idea.

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Today we are talking to one of my colleagues – Ms. Trisha Hutton.

Ms. Trisha Hutton, CRNFA

Ms. Trisha Hutton, CRNFA, ACNP (student)

Trisha is a certified registered nurse first assistant (CRNFA) .   She performs procedures in the operating room such as endovascular saphenous vein harvesting (EVH) for bypass surgery, and assists in other aspects of surgery, such as suturing, retraction and tissue dissection.

  Years in the operating room:   16

  Years working in cardiac surgery:  8

We’re talking to Ms. Hutton today about her current career and her developing role as an acute care nurse practitioner in cardiothoracic surgery.   Ms. Hutton is currently pursuing her master’s degree for certification in acute care, and will be part of a small but growing sub-specialty of acute care nurse practitioners in surgical practices.

As we’ve discussed during past posts; in the midst of a primary care crisis, advanced practice nurses such as nurse practitioners have moved to the forefront of the health care arena.  While NPs have worked (successfully) in this role since the creation of the specialty in the late 1960’s – the efforts of NPs in this (and other) roles are just now being recognized.

However, for nurses like Trisha Hutton, the increasing recognition (by surgeons) of the utility of nurse practitioners IN and OUT of the operating room is equally important.  So it’s important that nurses like Ms. Hutton receive the exposure to the public that may not always be aware of their role behind the scenes in caring for patients undergoing surgery.

What prompted you to return to school to become a nurse practitioner?

 “I felt like something was missing.  It was like chapters were missing from a book,” Ms. Hutton states, explaining that while she loves her current role, assisting and caring for patients in surgery – she wants to expand her role to encompass the care of patients outside of the operating room; from admission to discharge.

Ms. Hutton (pictured on the right) in the operating room

What drew you to cardiothoracic surgery, specifically?

I have always been interested in vascular surgery, and had been trained by and a vascular surgeon (Dr. Mark Donnelly) who I have worked closely with for many years.  When Flagstaff Medical Center started talking about beginning a heart program, I was immediately interested, and Donnelly encouraged me to be involved in it.  Also, because of our elevation (7000 ft), there was controversy about the success of our program, and that challenge excited me.

How do you see your role evolving after graduation?

To have the ability to continue my care to patients outside of the operating room.  I am looking forward to the opportunity to meet patients pre-operatively, participate in their diagnosis, operate on them, then continue their care through discharge.

Where do you see yourself in five years?

I hope to continue practicing within the CT and vascular specialty, and be comfortable within my expanded role.

Who are your role models?

I began as nurse in the operating room 16 years ago, and was instantly attracted to the vascular specialty.  I developed a relationship with a surgeon named Mark Donnelly, a very respected and talented General/Vascular surgeon.  When I decided to become a RNFA, he supported me, acted as my preceptor, and taught me how to operate.  As mentioned earlier, when word of a heart program started, he encouraged me to join the heart team.  That was a bitter-sweet decision for me….learning CT surgery has been a fantastic choice for me and has opened many doors, but it meant leaving a surgeon that I truly enjoyed operating and spending my day with.  He has been such an important role model for me and “life” coach (advice ranging from career to parenting!!), and I still miss working with him. More recently, our current heart surgeon Dr. Steve Peterson has been an important role model to me.  I joined cardiac surgery with good assisting skills, but he has pushed and challenged me even more.  He continues to test me daily, teaching me the finesse of cardiac surgery.  Without him I would not be  successful within this specialty, and I would never have considered continuing my education.  He has given me endless opportunities, pushed me to grow, and I am very grateful for him.

How do you see the nurse practitioner role in comparison to other peri-operative roles?  Do you think NPs provide any unique perspectives or contributions to surgical care?

NP’s absolutely offer unique contributions to surgical care!  Especially if they have had perioperative experience prior to becoming an advanced practice nurse.  I believe continuity of care is an important factor in delivering high quality care to our patients, and if the NP can follow her patient into the operating room, that continuity of care can be achieved.  They see and experience first hand what occurs during surgery, which can aid in their post op management.

For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the NP will know that post op blood pressure management will be even  more critical. If a different practitioner had been operating, that concern may not be communicated adequately.  The surgeon who practices with a NP First Assistant can feel at ease knowing that both HIS needs and the patients’ needs will be met.  The NP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient (ie family practice MD or TechFA) cannot offer that unique service.

Nurse Practitioners in the operating room?  Current issues and controversies

While this seems like a natural and normal progression for many nurses and nurse practitioners within the field – it isn’t as obvious to people outside the profession.  Many people including human resources personnel, staffing companies and the surgeons themselves have pre-conceived notions that exclude nurse practitioners, even those with extensive operating room (peri-operative) experience from assisting in the operating room.  That role is often exclusively assigned to Physician Assistants, often to the detriment of our profession, our nursing colleagues and the patients.

In fact, in this recent statement and study on the role of surgical assistants (2011) only mentions nurses as assistants as a side note.  It fails to recognize the different levels of qualifications (ie. a certified registered nurse first assistant (RNFA) versus a surgical technician (with weeks to months of formalized training).

Now, with the adverse economy, and changes in medicare regulations, nurse practitioners face even more competition for the operating room; the disenfranchised primary care physician.  In several of the facilities where I have worked in the past; more and more of these physicians were taking an active role in assisting in surgery.  These doctors, often primary care doctors ‘moonlight’ in the operating room as a way to augment their salaries.  Conversely, while these physicians had the least amount of surgical training, they were afforded the most reimbursement for their intra-operative role.    This array of peri-operative assistants has led to a wide range of skill sets in this patient care role with little research or comparison of effectiveness of these positions.

Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both nurse practitioners and physician assistants.  But only nurse practitioners can bring a holistic, patient-centered approach to this

* The ‘surgical assistant’ title like surgical technician/ technologist has also been designated to another career entirely, with similar focus.  However, in this post, we are using the term generically to refer to any individual (NP, RNFA, PA , MD or technician) who acts as an assistant to the surgeon intra-operatively, and performs procedures under the supervision of the attending surgeon.

References/  Literature surrounding nurse practitioners in the Operating Room

Hodson D. M. (1998).  The evolving role of advanced practice nurses in surgery.  AORN J. 1998 May;67(5):998-1009. Erratum in: AORN J 1998 Jun;67(6):1102

Pear, S. M., & Williamson, T. H. (2009).  The RN first assistant: An expert resource for surgical site infection prevention.  AORN, 89(6); 1093 – 1097.  No free full text available.
Schroeder JL. (2008).  Acute care nurse practitioner: an advanced practice role for RN first assistants.  AORN J. 2008 Jun;87(6):1205-15.
Wadas T. M. (2008).  Expanding the scope of acute care nurse practitioners with a registered nurse first assist specialty.  AACN Adv Crit Care. 2008 Jul-Sep;19(3):261-3.

Wadlund D. L.  (2001).  Graduate education: the perioperative nurse practitioner.  Semin Perioper Nurs. 2001 Apr;10(2):77-9

Zarnitz P, Malone E.  (2006).    Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training.  Mil Med. 2006 Sep;171(9):875-8.   No free full text available.
More about the Registered Nurse First Assistant (RNFA) role from the Association of peri-Operative Nurses (AORN).

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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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This post is long overdue since I interviewed Dr. Jose Juan Durazo Madrid, MD, FACS almost two weeks ago – but as readers know, things have gotten pretty busy lately.  I’ve seen Dr. Jose Juan Durazo a couple times since the initial interview – but alas! I still haven’t talked my way into his operating room.

Dr. Durazo, who is a fellow in the American College of Surgeons is a primarily Spanish-Speaking general surgeon specializing in gastroenterology (endoscopy, and capsule endoscopy) and general surgery procedures such as cholecystectomies, appendectomies, hemorrhoid surgery and Nissen fundaplication for GERD.  H also performs surgery for cancers of the GI tract.  He performs bariatric surgery but reports that this is only a small portion of his practice.

Dr. Durazo has been a surgeon for 22 years.  After attending UABC (Universidad Autonoma Baja California) here in Mexicali, he completed his general surgery residency in Hermosillo, Sonora.

He now serves as a professor of surgery for his alma mater, in addition to his private practice.  He primarily operates at Hispano – Americano, Hospital Almater, Hospital Quirugico de la Valle, and IMSS (government facility.)

Hopefully, I’ll be reporting back from the operating room one of these days.

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