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Posts Tagged ‘cirugia’

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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The ‘Mexicali project’ is different from any of the previous surgical tourism projects I’ve undertaken.  For starters – since I am currently working full-time in Northern Arizona – I can’t just drop everything and move to Mexicali for several months, like I’ve done previously.

So I really am a tourist – just like you, while I am here.  (I just plan to be a repeated one.)  That’s a critical difference because one of the most important aspects of my writing is that in many ways, I am just like you.  Or, at least a lot like many of the people reading my articles.  The only difference is that I am a nurse with a lot of experience in surgery and medicine.  But as a stranger in a stranger land? – well, I’m a novice, like many of the people who are considering traveling for health care.

I don’t speak Spanish – or at least not much.  [It’s one of the first things people assume about me, “Oh, you must speak Spanish”, but they are wrong.]   I am kind of learning a bit as I wander my way around different locations, which is fun – but I’ll never be fluent.  That’s crucial when I am roaming around in a strange country – How well can I navigate?  How safe is it for foreigners?  Will I be able to find people to help me (get directions, find a restroom, etc.)

I’m not an adventurous person (actually, I am kind of a chicken.)  – Many of you might be adventurers at heart, but I don’t want people to assume that medical travel is only for the daring or brave-hearted because I can be one of the meekest, mildest, most easily intimidated people you could ever meet.  You might think that some of my recent travels would have made me more confident or brave – but that’s not really the case.  I still get nervous going to unfamiliar places, reading maps, finding the right bus – so I understand how other people might feel (and for much of my travels – I’ve gone alone..)  So I like to think that this is my own kind of litmus test – if “Cartagena Surgery” can manage to find her way around, then most of my readers will be able to also.

But this time, it’s a little different – I’m not traveling alone – I brought my husband this time – and he’s a big gringo too.. (okay, I’m five foot one, so I am a “little” gringo).   He speaks even less ‘Spanglish’ than I do..But since he’s with me – I’ve changed the pace a little bit.. No 16 hour days this time. [During the Bogotá trip, I lost almost thirty pounds, because I was basically working or writing during all of my waking hours, and things like regular meals were pushed to the wayside.]  So, now I am smelling the roses, so to speak – enjoying the local culture instead of breezing past most of it.  Also, having my husband here helps me maintain perspective – of how others may see Mexicali.  Not everyone gets excited by medical facilities and doctors’ offices.

the hotel del Norte

So for now, I am planning to make several short trips to Mexicali – to fact-find and bring you information; about medicine, doctors, and facilities and some of the other things we encounter along the way.

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A round up of our recent discussions on Medical Tourism

In several previous posts, we talked about various Medical Tourism topics:
– including medical tourism in India due to recent publicity; including Superbug (New Delhi – 1 ) contamination of water sources in India, and
President Obama’s adoption of India’s medical tourism industry (and the medical tourism industry in general) as a target for his derision, rather than more justly, as a symbol of America’s failing health system.

I’ve also talked about why I see Colombia, as an ideal medical tourism destination, for several reasons; many of which I outlined in an article published on Colombia Reports.com**  and a new article on Yahoo! Associated content.

We’ve even discussed the Colombian government’s role and support of medical tourism, and medical tourists.

We’ve talked about the global effects of medical tourism, and the ethics of medical tourism

** Astute readers may notice that I have referenced Colombia Reports.com several times (links). Colombia Reports.com is the largest, in country English language newssource, and is widely relied upon by English speakers, like myself, living in Colombia.
Colombia Reports.com has published my work in the past – as part of their series of articles (by various writers) on medical tourism in Colombia so back in April, I traveled in April to interview Adriaan Alsema, the editor -in -chief.

Hope you enjoyed this retrospective review of Cartagena Surgery, and medical tourism in Colombia.

UK doctors say medical tourism to India spreading superbug

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Intra – Operative Myocardial Infarction 

One of the most feared, yet preventable complications is intra-operative / post operative myocardial infarction (heart attack).  Alarmingly, a new paper published on Medscape by Reed Miller suggests that too often we aren’t doing enough to prevent this devastating complication and miss the diagnosis of this condition when it does occur*.

In many cases, patients are asymptomatic, which is no cause for relief – since the thirty day mortality after post-operative infarction is frightening high.  Part of my job in my practice as an acute care nurse practitioner in cardiovascular and thoracic surgery is to perform pre-operative risk stratification and risk reduction for this, and other potentially preventable complications.

There are several important, but easy things we can do to reduce the risk of our patients having a heart attack during or immediately after surgery:

Pre-operative Evaluation:

1. First, screen your patient for the presence of anginal symptoms and associated risk factors – before scheduling an operation.  Surprisingly, many patients are experiencing atypical angina, dyspnea on exertion and other symptoms in their daily lives, yet ascribe these symptoms to “being out-of-shape” or “getting old”.

If there is one thing, I’ve learned after greeting people in the cardiac cath lab to tell them they need heart surgery – it’s that the majority of people tend to ignore or overlook subtle signs until acute chest pain, or an infarction brings them to the hospital.  So, ask you patients about these symptoms, so you aren’t surprised in the operating room.

Ask yourself, What other risk factors do they have?

–     Diabetes, (of any duration) should prompt consideration for pre-operative cardiology workup and a possible exercise stress test.

–     Claudication (peripheral vascular disease), carotid stenosis (or hx of TIAs) or any other history suggestive of arterial disease

–     Elevated cholesterol or unknown cholesterol status, history of cholescystetomy or gallbladder disease or visible xanthomas (particularly on the face)

–    Advanced age – anyone over the age of 65

–    Hypertension, particularly if poorly controlled

–    Anemia, of any origin

–    Poor overall health, poor exercise tolerance (again this may be related to undiagnosed angina)

2. Secondly, Pre-operative Maximization!! This is important for  all major surgeries, but often isn’t implemented for orthopedic, general surgery and other large surgeries.  The other thing to realize is, this isn’t the anesthesia team’s job; it’s the attending surgeon and the primary care physician (jointly).  This means controlled, or correcting all of the items listed  in the previous section (as much as possible):

– cardiac evaluation for patients at medium / high risk for cardiac disease – and having an index of suspicion for people with vague  symptoms.

– treating underlying disease conditions – for example, if your patient has a hemoglobin A1c of 9.0 – delay elective cases until glucose is better managed.  Remember to monitor and manage glucose in the operating room too – unfortunately, this is often only done in cardiac surgery, but it’s important during all surgeries.  Intraoperative Hyperglycemia is an independent risk factor for myocardial infarction/ and is considered a ‘marker’ for infarction.

And check everyone, not just diagnosed diabetics – since hyperglycemia occurs in some normal individuals under physiological stress, and diabetes is grossly underdiagnosed.

Don’t discontinue statins pre-operatively – not only does evidence suggest that statins are protective against intraoperative strokes and sepsis, but the evidence to support discontinuing these medications preoperatively is slim.  Too often, we
discontinue patients needed medications as part of a routine, not an individualized treatment plan.  (Now clopidogrel (Plavix) and warfarin are a little different, but sometimes we continue these medications too – in very
select cases..)

Pre-operative beta blockade – the evidence is overwhelming
in favor of pre-operative beta blockade, yet some people are still neglecting
this (or even stopping these medications in people already on them.)  Continue metoprolol, carvedilol, propanolol, and make sure to ask why patients are taking them in the first place.  “Heart medicine” is an answer that should prompt further investigation.

– Consider and re-consider before discontinuing Aspirin.  In our thoracic (and cardiac ) surgery patients – we always continue aspirin, safely, and have had no increase in bleeding complications.  Often, surgeons can very safely operate on patients taking aspirin – but discontinuing it in these patients may contribute to the risk of intraoperative/ postoperative infarction.

Intraoperatively:

–  Control that heart rate!  We KNOW through decades of research that
slower is better.  Keep the heart rate at sixty or below to reduce cardiac demand.

–   Prevent hypotension – keep the MAP at 70 or above (and be particularly intolerant of hypotension in anyone with a cardiac history –you don’t want to collapse those grafts.
Remember that patients with vasculopathic disease don’t tolerate low
blood pressure as well as you or I – and don’t allow it (low blood pressure) to happen.

–    Monitor for changes in telemetry during the case.

–    Monitor and control hyperglycemia (as mentioned above.)

Article Re-Post from Medscape (Reed Miller):

MIs After Noncardiac Surgery are Often Overlooked

April 20, 2011 (Hamilton, Ontario) — A new study from the Perioperative Ischemic Evaluation (POISE) trial suggests that monitoring non–cardiac-surgery patients for asymptomatic MIs in the first few days after surgery could dramatically reduce their short-term mortality risk [1].

The study shows that “consistently, all over the world, people are at substantial risk of suffering a heart attack after surgery, and if they do, they’re at substantial risk to die or suffer a major event in the coming days, and we need to do a better job to detect them and manage them,” primary author Dr PJ Devereaux (McMaster University, Hamilton, ON) told heartwire. “We want to make the broader cardiology world aware that this is a huge emerging epidemic that’s going to confront cardiology, because there are 200 million adults having surgery every year in the world. . . . We need to get a lot more aggressive about monitoring for these events and recognizing that the majority of people won’t have symptoms when they have these events.”

Devereaux and colleagues followed 8351 patients at 190 centers in 23 countries with four cardiac biomarker assays for three days postsurgery. All of the patients were part of the original POISE trial, reported by heartwire, which showed that beta blockers reduce the risk of MI but increase the risk of severe stroke and overall death in patients undergoing non–cardiac surgery (including orthopedic, cancer, and noncardiac vascular surgeries). Results of the new study by Devereaux et al are published in the April 19, 2011 issue of the Annals of Internal Medicine.

“Surgery is sort of the ultimate stress test. It does everything that is relevant to causing acute coronary syndrome. It’s very proinflammatory, and it activates the sympathetic system, coagulation, and platelets. That’s why we have this problem of people having myocardial infarction after surgery, [and yet until now] there’s not that much research on the outcomes of heart attacks after surgery,” Devereaux told heartwire. Patients and physicians are often unaware of an MI during this early postoperative period because most of the patients are on high doses of narcotics that “blunt the discomfort of the surgery but may mask ischemic symptoms,” Devereaux said.

Within 30 days of randomization, 415 patients in the study (5.0%) showed evidence of a perioperative MI, defined as either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme assay plus ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. Nearly three-quarters of the MIs happened within 48 hours of the surgery, but almost two-thirds of the MI patients did not did not experience ischemic symptoms. In fact, patients with a periprocedural MI without ischemic symptoms had a higher mortality rate (12.5%) than those who had symptoms (9.7%).

The short-term prognosis for patients who suffer periprocedural MIs is very poor, with 11.6% mortality at 30 days postprocedure compared with 2.2% for patients who did not suffer a periprocedural MI (p<0.001). Furthermore, Devereaux noted that a recent meta-analysis by his group found that people who suffer a periprocedural MI continue to be at higher risk for death than those who do not for at least a year after the surgery.

Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room . . . [and yet] those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.

Regression analysis of the data showed that relatively simple therapies could have prevented many of these deaths. In the study, patients on aspirin had about half the 30-day mortality risk as those not on aspirin, while statins reduced the 30-day mortality rate by about three-quarters. Only 64.8% of patients who suffered an MI in the trial were on aspirin, only 17.8% were receiving clopidogrel or ticlopidine, 52.0% were receiving a statin, and 55.4% were receiving an ACE inhibitor or angiotensin-receptor blocker.

“Patients expect us to look for things that are modifiable and change their risks of very serious events quickly, and perioperative MI is definitely in that category,” Devereaux said. “Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room, which is completely appropriate, but those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.”

Commenting on the study by Devereaux et al, Dr Adrian Banning (John Radcliffe Hospital, Oxford, UK) told heartwire, “We are not optimizing medical therapy before surgery. There are existing guidelines and risk scores that are probably underused. Preoperative testing for ischemia and revascularization is probably overused in a minority of patients, leaving an occult majority without simple medical measures that are likely to be beneficial–including aspirin, statins, and good perioperative blood-pressure control.”

More Research Needed to Clarify Who Is at Risk and How to Treat Them

Devereux’s group is currently enrolling patients into the 40 000-patient prospective cohort VISION study, which is intended to define the optimal approach for predicting major perioperative vascular events, the extent to which troponin measurement after surgery can identify asymptomatic MIs, and these patients’ risk of vascular-related death within one year.

The first 20 000 patients in the study have been monitored with “fourth-generation” troponin assays, and the next 20 000 will be monitored with higher-sensitivity troponin assays. Commenting on the research, Dr Stephen Ellis (Cleveland Clinic, OH) pointed out that with the advent of highly sensitive troponin tests, more research will be needed to define what degree of troponin change is clinically important. “I’m sure there’s some level of troponin where you see a bump that doesn’t mean anything.” For example, Banning and colleagues recently completed a study that suggests the current standard troponin cutoff used to detect an MI has been arbitrarily set too low and leads to an overestimate of the number of MIs.

Dr John French (University of New South Wales, Australia) added that future research should also try to risk-stratify these patients by collecting both pre- and postprocedural troponin levels. Elevated preprocedural troponin may also be a risk marker, he told heartwire.

Devereaux hopes there will also soon be a large national trial to evaluate the best way to manage non–cardiac-surgery patients in the vulnerable perioperative period. Ellis agreed that “we don’t really understand the benefits of some of the medical treatments that we have in our armamentarium in this patient population. . . . There may be some other treatments that are less utilized at present that could cut down on the incidence of perioperative infarction.”

Banning agreed that further research is needed to understand how to prevent these perioperative MIs, not merely detect them. “Troponin measurement postoperatively can help define a risk group with adverse outcome, [but] it is uncertain that we can influence that adverse outcome once the event has happened in those patients already on optimal medical therapy,” he said. “There will be a group identified by routine troponin testing where this event is the first declaration of occult coronary disease, and perhaps this group potentially has the most to gain.”

Although the best approach to managing these patients has yet to be clearly defined, Devereaux emphasized that “in the short term, there’s a lot of intuitive things that we can do better that will likely improve the outcomes, and there’s lots of reasons to be optimistic that, even if we just start monitoring them, we can improve the outcomes.” Devereaux recommends that physicians caring for a surgery patient order a troponin test sometime between six and 12 hours after the surgery and then repeat tests for the first three days after surgery.

His institution has made perioperative MI prevention a priority for its cardiologists. “We’ve changed cardiology from regular cardiology to cardiology and perioperative vascular medicine,” he said. All surgery patients’ cardiac biomarkers are monitored, and the patients are triaged to the coronary care unit or less-intensive care based on their MI risk. He expects his group will be able to present data on the impact of this approach within the next year.

This study was supported by the Canadian Institutes of Health Research, the Commonwealth Government of Australia’s National Health and Medical Research Council, the Instituto de Salud Carlos III in Spain, the British Heart Foundation, and AstraZeneca.

part of patient education series – Ask your doctor about your risk for peri-operative MI, and what he’s doing to reduce your risk.

* Diagnosing MI after surgery is another article.

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There are plenty of reasons to consider medical tourism, and it’s not all about money.  While financial considerations may be the driving force today – I expect that to change over the next ten years as the developing surgeon shortage becomes more acute.  American surgeons are becoming older – and we aren’t attracting, training or replacing enough of them to keep up with demand.. Right now the shortage isn’t noticeable… or Is it?

A new article on Medscape (free subscription required, but multiple pages, and difficult to re-post) from the Annals of Surgery discusses increasing wait times for cancer surgery..

The surgeon shortage is expected to impact all specialties, but particularly cardiothoracic surgery where differing experts predict a 2,000 surgeon shortage by either 2020 (9 years!) or 2030, just as they estimate demand will double.  Currently, there are only about 4,500 cardiothoracic surgeons, if that gives you an idea of the scope of the problem.. Right now, the average age of these surgeons is 56 – 57 years old – and training programs are only at 65 – 67% occupancy..

(I can post references if anyone would like for these statistics.)

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Why Colombia for medical tourism/ surgical tourism?

Here are several of the reasons I have decided to focus on Colombia as one the emerging destinations for medical tourism:

1. It’s close to the United States (and North America): direct flights to several cities in Colombia are only 2 – 3 hours from Miami, Orlando and many other southern US cities.
This should be first and foremost in people’s minds – for more than just consumer comfort. Those coach-class seats can kill.
The risk of venous thromboembolism (VTE), a potentially fatal complication of air travel (and other stationary conditions) is very real; and this risk increases dramatically with flight duration. Flights to Asia can be anywhere from 16 to 20 hours – which is an endurance test for even the healthiest and heartiest of individuals.

This risk for DVT/ VTE which can lead to pulmonary embolism, and death is enhanced in elderly people, people with chronic diseases (diabetes, lung diseases, etc.), obesity and people who have recently had surgery.   Some data suggests this enhanced post-surgical risk may persist for up to 12 weeks. While there are treatments to prevent thromboembolism or blood clots, none of these strategies are fool-proof. (Some of these safety strategies for air travel are mentioned in the above attached links).

Proximity – Close to the USA/ North America:
-Cheaper flights (all the flights to Asia are in the thousands – and you shouldn’t be travelling alone)
– Shorter flight duration (safer, more comfortable)

2. Cost:
This includes medical travel costs as briefly mentioned above. Most cities in Colombia are relatively affordable for other travel accommodations (though this is sometimes included if medical tourism packages/ planning are used.) This is in addition to the known cost-savings of medical care outside of the United States, which is the main reason behind the popularity of medical tourism. For example, a recent CT scan at a local hospital cost around $250.00, versus several thousand.

For actual surgical procedures, the savings are much greater. Heart surgery in the USA ranges from $80,000 – 180,000.. of course, if you have good insurance – your costs are much lower.. If, of course, you have good insurance – and insurance doesn’t cover everything!
In Colombia, heart surgery costs around $12,000 – and most cardiac programs  (and other surgeons/ hospitals) here accept American insurance – so your 20% co-pay is going to be a lot more reasonable..

3. Similar culture, similar values, similar ideals – yes, the language is different (but many people and providers speak English) but the underlying primary core values, and core medical values are the same. This means, that while the US medical system is plagued with problems – some of these problems are related to our values such as the sanctity of life, and the preciousness of life.. That value is shared here – which is important – since that is not the case in many places – even western europe where medicine, surgery and expensive treatments are rationed, and sometimes denied – particularly to people over the age of 65.

Medical providers, nurses, and staff here care about their patients the same way, we do at home.. And arguably, in most cases, the doctor- patient relationship is a lot closer, and more personal here. Doctors want and expect patients to contact them – they give patients their email and cell phone numbers on their business cards, for just that reason, and they aren’t put out or annoyed if you use it.. (I know, I’ve been with doctors when patients call.)

4. Surgical proficiency, medical education, and available resources – this is the primarily reason I am currently here in Bogota, Colombia; the high level of skill and training among surgeons in Colombia. These doctors are professionals in the highest sense of the word, and have attended well-known, well-respected and accredited institutions. In many cases, these surgeons are at the forefront of emerging technologies, that are just now becoming popular in the USA.
As far as medical technology goes – many of the doctors, and hospitals I visited have the latest technology, which rivals if not beats what I’ve seen in the US. (Now, for those of you who have never stepped inside a rural hospital in the United States – you would be surprised at what resources they do and DON’T have.) Americans in general, and American medical professionals tend to view the world from this little bubble, thinking that we always have the latest and greatest – even when we know it’s not always true. It may have been true twenty years ago, but sadly, it’s not always true now.

Come back for part two – and we’ll discuss Why not India, why not Thailand.. (but in the meantime, here’s some food for thought)

* Antibiotic resistant infections of any sort (MRSA, VRE) are still fairly rare in Colombia.
Superbug Hits UK from Medical Tourism from India

Indian Resistant Bacteria from Medical Tourism

More articles/ links on SuperBug

Of course, to be fair, our own food supply contributes to this problem too..

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It’s been shaping up to be a bit of a weird week – as everyone that’s been following on Bogota Surgery knows – it was a rapid change of gears from neurosurgery to thoracics this week.. (and everyone knows how much I enjoy interviewing surgeons from my home specialty). But during this week – the same name keeps cropping up in conversations – Dr. Edgard Eduardo Gutierrez, and that’s when I realized that while we’ve mentioned him from time to time on the Bogota blog – he’s never really gotten proper face time, here at home at Cartagena Surgery.

Of course, my loyal readers of Hidden Gem already know Dr. Gutierrez – since he’s profiled in my book, but let me introduce him to the rest of the world** – since it seems all of Bogota is talking about him.. (okay, to be fair – the Bogota thoracic surgery community).

** since this is long overdue **

First off, I have to say that Dr. Edgard Eduardo Gutierrez Puente has got to be one of the most easy-going, good-natured people I’ve ever met – Which explains why I ended up following him on his rounds through out the hospitals of Cartagena one sunny day.. (or how he ended up hosting some gringa nurse who spoke really bad Spanish). He’d been nice enough to review cases with me – and have me in the OR one day at Medi-help after I’d practically accosted him in the hallway.. Then as we were leaving the operating room, he turned at me with a long stream of spanish over his shoulder ending in “aqui o vamos conmigo?” I missed the whole preceeding paragraph, but caught “or go with me?”

That was it – he was stuck with me. And it was definitely out of the goodness of his heart – and no other motive because, frankly, I don’t think Dr. Gutierrez:
a.) has time to think about medical tourism, or care about being in some first-time author’s book or b.) even knew why I was there..
So there he was, driving around with me, asking him questions the entire time, in my fractured, barely comprehensible, mish-moshed Spanish. But he’d patiently answer, and then wait for me to figure out what he’d said – and then we’d start all over again.

At the time, (he was one of my first interviews), I probably took his graciousness for granted – it’s only now after meeting, and interviewing, interviewing and interviewing my way through my second book, that I realize how kind he was to that naïve little nurse, wandering around a strange city, in a foreign country, writing a book that very few people are actually interested in.

But all of this, doesn’t really matter.. What matters is all the other things; all the qualities and skills I saw during the time I followed him around Cartagena, and its’ operating rooms.

It didn’t matter if we were in the upscale Medi-help clinic or the aged, struggling Universitario de Cartagena; he was kind, gentle and empathetic with all of his patients.

There are a lot of things I could say, and have said in my book about Dr. Gutierrez, his operating style, adherence to surgical protocols and overall dedication to his profession. But to me; his kindness and compassion said it all.

Update: 20 April 2011

Here are the top search terms for the blog this week:

Top Searches

doctor edgardo gutierrez puente, cartagena  colombia  real stste, what is overstenting, colombia cartagena edgar eduardo gutierrez puente, tourist attractions in colombia

– so I am glad to see Dr. Gutierrez get some well deserved recognition for all his hard work..  The blog was also one the featured daily blogs for wordpress yesterday – congratulations, Dr. Gutierrez!

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