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Posts Tagged ‘cirugia de torax’

Wow..  a long couple of days – but I am sure not complaining!  Still having a blast – and as they teased me in the operating room, “Cristina, Cristina, Cristina!” I felt more like I belonged – instead of as a student, often lost/ confused.  Even more so – when I found myself irritated on rounds – irritated when the answers were obvious!!  Obvious – that’s certainly making progress..  (Irritated is such an improvement over clueless, I must say..) But the interns are a good bunch, even if they don’t love surgery like I do!

Residents at Mexicali General

The good doc gave me some homework – as we work on a ‘mystery diagnosis’ which I am enjoying.  Of course, it won’t be a mystery as soon as the pathology comes back, but I am surely enjoying the intellectual challenge (and kind of hoping that my preliminary leaps aren’t completely off-base..)  Of course – the doc is so smart – he probably already has it all figured out, and is just checking on the faculties of his student.  (He is secretly brilliant, and just hides it behind his braces and freckles.. Kind of scares me sometimes.. )

Deceptively normal looking..

Bumped into Dr. Ramirez and Dr. Perez (the anesthesiologist) this morning, which reminds me that I still need to write about my visits to his operating room last week.  So I haven’t forgotten – expect it in just a couple of days..

It’s nice too when we run into people I know as we round at different hospitals around the city..  But then – as I glance at the calendar and realize that time is passing – I get a little sad.  Just as I am starting to understand things (Spanish, the hospital systems etc..) and I am enjoying it here so much, learning so much, yet time is flying, and before you know it – I will be returning home again (wherever that is!)

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Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8


[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

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As most readers know, Thoracic surgery is my absolute passion – and it’s a big part of my day-to-day life, too.. So, it was a great pleasure to spend this morning talking to Dr. Carlos Cesar Ochoa Gaxiola, here in Mexicali.

Dr. Ochoa is one of those surgeons that make this project so worthwhile.  He is enthusiastic, and enjoys what he does.  Talking with young surgeons like Dr. Ochoa seems to restore my faith in the future – which is desperately needed sometimes after reading (and reporting) all of the negative headlines regarding the health care crisis; shortages of vital medications (and surgeons!), escalating and out-of-control costs, fraudulent practices and patient mistreatment.

For more on this morning’s interview, see my sister site, www.cirugiadetorax.org

He kindly extended an invitation to visit the operating room, and see more about his practice – so I’ll give a full report on my next visit to this city.

In the meantime, I am enjoying the mild (and sunny) winter weather.

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A look at week’s posting at Cartagena Surgery and our sister sites.

Here at Cartagena Surgery we’ve been talking about the role of the acute care nurse practitioner, more about TAVI (transcatheter therapies of aortic stenosis), and our new features on domestic tourism.

Over at Bogotá Surgery.org we have a new, upgraded (free) Android application that we are testing out.  We also have a new post talking about the latest research results for uniport or single port laparoscopy.  We were pleased to see more information about Dr. Fernando Arias’s HIPEC program on the web, but a little dismayed at the borrowed content.

Also, at Cirugia de Torax.org, we recently completed a series on the lung transplant program at Duke  and updated our HITHOC files with information about the thoracic surgery program at the University Medical Center in Regensburg, Germany.

It’s been a busy week but we’ll try to keep up the pace for all of our readers out there!

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In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm.

Developing atrial fibrillation is problematic for patients because it increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).

‘The Cootie Factor’
Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick – they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)

But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..

But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – is to slow down the heart rate. We know that just by slowing down the heart by 10 – 15 beats per minute, we can prevent abnormal heart rhythms.

Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.

In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..

The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.

Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.

If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place.

Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue them during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)

Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk is minimal).

In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery.  (Heart patients are at high risk of atrial fibrillation too.)  We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies.
I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.
Vitamin C with beta blockers to prevent A. Fib
This is probably my favorite free text about Vitamin C and Atrial fib – it’s my sort of writing style..

Another article on Vitamin C – for pharmacists (note – article is sponsored by Ester C supplements.)
Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.

Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost hre since it’s limited access articles..

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