miércoles, 17 de enero de 2018


 Even when I acknowledge that not everybody is equal I am true believer in giving everybody the same opportunities. I think it would be nice if everyone could also have access to the same level of healthcare regardless your incomes or the place that you happen to live in. 

That is a nice ideal that I cannot avoid to have. However, I have had some experiences in both systems, that make me doubt about the feasibility of matching a good level of care with a public system. This is based only in my personal experience working in Spain and now in USA. I am not saying that all the hospitals are the same, but this is what I have seen and lived within the surgery world:


Public system: Anyone can go to the ER of a public hospital and have the same level of health care. If you are not citizen or do not have Social Security number you will be required to pay the bill. Anyone with Social Security Number or citizenship can make an appointment for a Family Doctor for free. This Doctor will decide about the need of having a specialist consult for free.

Private System: Anyone can go to the ER and have the same level of care. A copay will be required most of the times. Anyone can make an appointment with either family doctor or specialist. A copay will be required, likely.


Public System: The patient belongs to the hospital. Whoever is working that day in that particular speciality or outpatient clinic is going to make the decisions that day regarding that particular patient. If it is an inpatient, the Dr. responsible will change with shifts. The surgeon who decides about the indication for a determinate procedure is not necessary the one who will perform it. Believe it or not, I knew patients first time the same day of the surgery that someone else had decided that I had to perform.  My father, who lives in a different city than I did, had a surgery done by a Doctor he had never met before (or later).

Private System: There is a Doctor who is responsible for the patient. If he is not at the hospital when the patient comes, someone reaches him/her to consult. The Surgeon, who asses the patient give the patient the options to decide about his/her healthcare. I cannot imagine a surgeon, out of the setting of emergent surgery, knowing the patient for first time in the OR table.


Public system: As a surgeon you may have 40 patients between 8:00 and 15:00. An average of 10 minutes per patient of which 7 are spent in ordering the chart because more likely you do not know that patient’s chart from before.

Private system: You follow your patients. You know them unless it is the first visit. You run your schedule, so you take as much time as needed which any of them. If a surgery is needed you decide with the patient, which, when and how it will be done. You will make the follow-up later on and you will have to deal with any outcomes resulting of your decision. 


Public system: 2 Attending Surgeons are scrubbed in any surgery. You can find a 5PGY General Surgery Resident as a second Assistant in a laparoscopic hernia. I am sure any surgeon reading this know what that means. There is no board. Nobody is going to asses how well (or bad) you train your trainees. In the hospital where I was trained residents were not allowed to have outpatients. I tricked the system by doing my follow-ups in the ER when I could… But I finished my residency without doing outpatients follow-ups. 

Private system: Your residents and fellows are your pride. The way they are trained will speak not only about them, but mainly about the place where they learnt. They are evaluated for external committees.  If they fail, you fail. You want them to be the best.


I will only say there is at least one zero of difference for a Surgeon in both systems. However, personally I would not mind that difference, If all the other went away.

I still think it would be nice merging the best of both systems. What do you think?

sábado, 18 de noviembre de 2017

Immunology and Medicine

Disclaimer: This information is absolutely biased and has been written by a General Surgeon

Innate Immunity: 

Provides the body’s first line of defense against infectious agents. It is responsible for reacting quickly to invading microbes and for keeping the host alive while the adaptive immune system is developing a very specific response (the surgery).

The innate cellular response includes phagocytic cells (monocytes/macrophages, neutrophils and dendritic cells). A special type of lymphocyte, the Natural Killer is also Included here.

Macrophage: ER Doctor

Located in tissues produce IL-8 that provides the initial signal for the Neutrophil to leave the bleed and go to the inflammation site. In other words, they page the neutrophil to come and help. However, they are able to eliminate many agents by themselves.

Neutrophil:  The Internal Medicine doctor

 They are the first cell to arrive to any place where there are inflammation once they receive the signal to extravasate. You find them in any inflammation place, regardless the cause. They need to be able to deal with any organ failure, at least at the beginning, and many times they get ride off the threat (the desease) the same as the internist. Furthermore, once they are there they can recruit more cells by means of LT and other cytokines. They can page more doctors.

Natural killer: The surgical PA

They are still part of the innate system (not Antibodies implied) but they share a common progenitor with the other lymphocytes in some point they decided not underwent the hard process of selection than the others lymphocytes suffer. They work in the same team, and they are very efficient at killing tumor and virus-infected cells. With the difference of the previous cells type that could address any issue the NK have a specific training (Neuro PA, Trauma PA…)

Adaptative response: The features of adaptive immunity are designed to give the individual the best possible defense against disease. 

B cell: The surgical resident

There are many stages founds here, from a B cell naive to a plasma cell (from the first year to the Chief Resident). The membrane receptors of B lymphocytes are designed to bind unprocessed antigens of almost any chemical composition, i.e., polysaccharides, proteins, lipids. They can be called to asses anything suspicious to be surgical. They undergo selection in the bone marrow with the goal of avoid auto-reactive cells that could harm. They need to know when to operate, but more important they need to know when not to operate, or they will be deleted. Once they have been trained they are able to recognize and eliminate pathogens quicker. T cell present specific protein antigens to T cells to help elicit a humoral immune response.

T cell: The surgical attending:

They undergo a hard process of selection. Only 5% of the lymphocytes that start the process at college (the bone marrow)  become Board Certified in the thymus. T cell receptor (TCR) is designed to bind only peptides complexed to MHC. They are not required for non surgical processes. 

T-Helper cell: 
Plays a central role within the immunity. Assist other white blood cells in immunologic processes, including maturation of B cells into plasma cells and memory B cells, and activation of cytotoxic T cells and macrophages. These cells can differentiate into one of several subtypes, including TH1TH2TH3TH17TH9, or TFH, which secrete different cytokines to facilitate different types of immune responses (General, Neurological, Oncology, Vascular…). They only interact when the information is presented to them by the profesional APCs by means of a MHC classII. They do not assess every patient and do not listen every cell, only those cells that are antigen presenting cells and knows how to present the information properly.

Cytotoxic T-cell or T-Killer: The Trauma Surgeon:

They have also a very specific response. These cells recognize their targets by binding to antigen associated with MHC class I molecules, which are present on the surface of all nucleated cells. In other words, you do not need a profesional APC to present the information to them you just need to have a nucleus (or a brain). They are trained to treat tumor cells and virus infected cells (Trauma patients).

sábado, 5 de agosto de 2017

Canción del Pirata -José Espronceda-

Con cien cañones por banda,
viento en popa a toda vela,
no corta el mar, sino vuela,
un velero bergantín:
bajel pirata que llaman
por su bravura el Temido,
en todo mar conocido
del uno al otro confín.

La luna en el mar riela,
en la lona gime el viento,
y alza en blando movimiento
olas de plata y azul;
y ve el capitán pirata,
cantando alegre en la popa,
Asia a un lado, al otro Europa
y allá a su frente Estambul.

«Navega, velero mío,
sin temor,
que ni enemigo navío,
ni tormenta, ni bonanza,
tu rumbo a torcer alcanza,
ni a sujetar tu valor.

«Veinte presas
hemos hecho
a despecho
del inglés,
y han rendido
sus pendones
cien naciones
a mis pies.

«¿Qué es mi barco? Mi tesoro.
¿Qué es mi Dios? La libertad.
¿Mi ley? ¡La fuerza y el viento!
¿Mi única patria? ¡La mar!

«Allá muevan feroz guerra
ciegos reyes
por un palmo más de tierra:
que yo tengo aquí por mío
cuanto abarca el mar bravío,
a quien nadie impuso leyes.

«Y no hay playa
sea cual quiera,
ni bandera
de esplendor,
que no sienta
mi derecho
y dé pecho
a mi valor.

«¿Qué es mi barco? Mi tesoro.
¿Qué es mi Dios? La libertad.
¿Mi ley? ¡La fuerza y el viento!
¿Mi única patria? ¡La mar!

«A la voz de «¡barco viene!»
Es de ver
cómo vira y se previene
a todo trapo a escapar:
que yo soy el rey del mar,
y mi furia es de temer.

«En las presas
yo divido
lo cogido
por igual:
sólo quiero
por riqueza
la belleza
sin rival.
«¿Qué es mi barco? Mi tesoro.
¿Qué es mi Dios? La libertad.
¿Mi ley? ¡La fuerza y el viento!
¿Mi única patria? ¡La mar!

«¡Sentenciado estoy a muerte!
Yo me río:
no me abandone la suerte,
y al mismo que me condena,
colgaré de alguna antena,
quizá en su propio navío.

«Y si caigo,
¿qué es la vida?
Por perdida
ya la di
cuando el yugo
del esclavo,
como un bravo,

«¿Qué es mi barco? Mi tesoro.
¿Qué es mi Dios? La libertad.
¿Mi ley? ¡La fuerza y el viento!
¿Mi única patria? ¡La mar!

«Son mi música mejor
el estrépito y temblor
de los cables sacudidos,
del negro mar los bramidos
y el rugir de mis cañones.

«Y del trueno
al son violento,
y del viento
al rebramar,
yo me duermo
por el mar.

«¿Qué es mi barco? Mi tesoro.
¿Qué es mi Dios? La libertad.
¿Mi ley? ¡La fuerza y el viento!
¿Mi única patria? ¡La mar!

miércoles, 19 de julio de 2017


I wrote this post this in 2009 in Spanish while I was doing my clerkship in the Stroke Unit in Madrid. For some reason, today, I have recalled Carmen (Needless to say that this was not her real name):


The light coming through the window told her it must be about noon. Carmen was 85 and she did not recall getting up so late anytime before in her whole life. She opened the eyes with the feeling of not being fully awake. She had been listening unknown voices in the last minutes. She could also hear voices from relatives who she had not seen for a while. She had a terrible headache. She did not remember such a heavy hangover.
Such a weird dream, she thought while she decided to cook something. She was going to cook some turkey with redcurrant sauce. It was her special recipe, and if she cook enough food, her children would have a reason to come home to visit her. She had the feeling of  being listening one of her sons.

-How is she doing, Doc?
-It is too soon yet, we need to wait to see her progress.

But Carmen did not feel bad. She was going to get up and see what was happening. She hold her arms to get up. It took a while to realize that she could not. Then, she tried to run away, but she could not. She was inside of one of these dreams where you want to move, but your body is too heavy and you are not able to do anything.

Without announcing she felt a blinding light in her eyes. She closed them because it bothered her. She opened them again later. There were people coming back and forth from her visual field. She knew that they were there because she could listen them, she felt their presence and she could even smell them.

-Can you hear me? Of course, I can! I am not deaf! Despite the arrhythmia that she has been suffering from some years and her obesity, Carmen was doing well so far. She would tell him that to end the situation.

She tried very hard, but the words did not come to her mouth. Then, a younger female doctor told her: blink twice if you understand what I am saying. She did. She still could open and close her eyes that was something, given the circumstances.

In the right side of that room, in the middle of the shadows that were progressively  darkening Carmen's life, there was a student who learnt what a locked-in syndrome was. She would never forget how awful could be a basilar stroke. She remembered a Theater that she had seen some weeks ago in her college, "Johny got his gun" and she felt really sorry for not being in a fiction this time.

Those days, nobody was able to speak to Carmen and tell her what was really happening to her. It was her last week of life. She was trying to run away far from that bed for that long week without her body following her. She was locked-in a body that did not respond. It was the longest week in her life. Eight days later she died from pneumonia. I hope she went to a place were her body was not too heavy. Hopefully she could eventually rest in peace.

viernes, 12 de mayo de 2017

Madrid, mi hogar

Es difícil de describir. Hace ya 15 años que llegué a Madrid para quedarme a vivir en aquel colegio mayor que todos conocían como "El Johny". Llegué con miedo como se llega a todos los sitios desconocidos. Con ganas de comerme el mundo y una ingenuidad que casi, sólo casi, he perdido ya. Recuerdo el momento en que mis padres se fueron y me quedé sola en aquella habitación pensando que coño se me había perdido a mi allí, donde no conocía a nadie.

Desde entonces han pasado muchos abriles. Muchas primeras veces. He crecido. He conocido a muchas personas que merecía la pena conocer y he visto muchas cosas que la mayoría prefieren no saber que existen. Acabé una carrera, una especialidad y hace ya 2 años que no vivo a diario en Madrid.

Y sin embargo... Cada vez que piso el suelo de Madrid, no puedo evitar esa nostalgia que uno siente al llegar de nuevo a casa. Esa comodidad de lo familiar. Esa tranquilidad del que encaja la última pieza del puzzle.

Esta mañana llegaba a Madrid. Me parece que los músicos callejeros hacen un trabajo, escasamente remunerado para el que invierten mucho tiempo en su formación personal y que consiguen a veces acariciarte el alma lo cual no tiene precio. Eso precisamente es lo que me ha pasado hoy al subir al metro de Madrid. Un tipo ha sacado la guitarra y la armónica y se ha puesto a tocar esos acordes tan familiares de la Senda del Tiempo. Imposible no sentirme de nuevo en casa ante esa bienvenida.


lunes, 1 de mayo de 2017

Are you ready to flip? Then, try Flipmed

Os presento un proyecto en el que he tenido la suerte de participar este último año. Se trata de una app de preguntas y respuestas que sirve como entrenamiento para los que van a presentar los boards americanos. Ahora está disponible en inglés y español, se me ocurrió que también podía servir de ayuda a los que vayáis a presentar el MIR.

Os dejo el enlace, podéis probar si os gusta en la versión de prueba. Además a partir de ahora está incluido en la lista de imprescindibles que sale en la columna de la izquierda con el título: Flipmed.

¿Are you ready to Flip?

sábado, 29 de abril de 2017

Why am I interested in strokes? ¿Por qué me interesan los ictus?

My grandma is the best person I’ve ever met. She used to be the glue that put together the whole family. She has always taken care of each one of us any time that was needed. She is one of the people that makes the world a better place. I still have some shirts she made us. She worked as a needlewoman, I used to joke with her that as a surgeon, me too. 

Mi yaya es la mejor persona que he conocido. Solía ser el pegamento que mantenía unida a toda la familia. Ha cuidado de cada uno de nosotros cada vez que ha hecho falta. Es una de esas personas que hace del mundo un lugar mejor. Aún tengo camisas que nos hacía. Trabajaba como costurera, yo solía bromear con ella, que como cirujano, yo también.

4 years ago my sister was to her house to have lunch. She found her on the floor. She might have been lying down there for hours. She couldn’t speak well. She was 84 then, so once she was admitted in the hospital little was done despite she was a fully independent woman before that date. Furthermore, the exact moment of the stroke couldn’t be determined because she was alone so no therapy could be done. 

Hace 4 años mi hermana iba a su casa a comer. La encontró en el suelo. Podía haber estado allí tumbada durante horas. No podía hablar bien.. Tenía 84 años, por lo que una vez fue ingresada en el hospital no se hizo gran cosa, a pesar de que hasta ese día, era una mujer completamente independiente. Además no podía determinarse el momento exacto del Ictus, por lo que el tratamiento no estaba indicado. 

That was her first ischemic stroke. There has been another ischemic and one more hemorrhagic. Her previous life was stolen. He has no long term memories. She is completely dependent and lives in a nursing home. We go to see her every single day, since she is there. But still when she realize where she is she became badly depressed. The good point is that she forgets it quickly as well.

Fue su primer ictus isquémico. Ha tenido uno más isquémico y otro más hemorrágico. Su vida previa ha sido robada. No tiene memoria a largo plazo. Es completamente dependiente y vive en una residencia. Vamos a verla cada día desde que está allí. Aún así, cada vez que se da cuenta de dónde está su tristeza es absoluta. Lo bueno es que también lo olvida rápidamente.

I’ve just come home to see her today. It breaks my heart any time I see her sad. It really does. 

Acabo de llegar a casa de verla hoy. Me parte el alma cada vez que la veo triste. De verdad que lo sí.

In the last times many people ask me why a general surgeon is interested in strokes. Do you know why? Because I would like to avoid an independent person becomes completely dependent. I can’t revert my grandma situation but if only I could improve the prognosis of someone it would be worthy…

Últimamente mucha gente me pregunta porque un cirujano general está interesado en ictus. ¿Queréis saber por qué? Por que me gustaría evitar que una persona independiente se vuelva completamente dependiente. No puedo revertir la situación de mi abuela, pero si pudiera, simplemente, mejorar el pronóstico de alguien, merecería la pena.

paper blog