Friday, August 25, 2017

Buenos Aires, Argentina

By: Michelle Gosselin, MD, Class of 2018

With the support of the Department of Orthopedic Surgery at Washington University School of Medicine, I was fortunate to spend two weeks in Buenos Aires, Argentina for my international rotation. This experience was set up in part thanks to Dr. Cecilia Pascual-Garrido who is from Argentina and trained at the Hospital Italiano in Buenos Aires.

Buenos Aires is the capital city and also the largest city in the country with 3 million people living within the city limits and another 10 million in the surrounding areas.  It was founded by Spanish explorers in 1536 and later declared independence from Spain on the 9 de Julio in 1816. The city has a very European feel due to the significant Italian and Spanish influence here, both in city design and culture.  

My time was spent at the Hospital Italiano, which is largely a private hospital with about 500 beds.  I spent the majority of my time with the Trauma team. The team had many residents across all years with responsibilities varying by day. They welcomed me right in as part of the team and even did conference in English twice for me. Often, the acute trauma was treated elsewhere but the sequela of surgery performed in less developed parts of the country was the norm here across all subspecialties.

Much like in the United States, there is a huge emphasis on resident education.  There are ten residents per class. Many residents stay at the hospital after their fifth year to serve as “Chiefs”. Additionally, if they choose to pursue fellowship, it's usually done at the Hospital Italiano.  Their rotation schedule has a lot of flexibility so most residents get to spend additional time in their specialty of choice or some time in the United States observing. Tuesday was the big Trauma academic day with pre and post op review, lecture and journal club. This was followed by the big weekly trauma clinic.  Clinic was also very interesting, with 60+ patients that needed to be seen. The big difference was that the patients were not usually scheduled, but rather showed up with a folder of their imaging, hoping to be seen. They treat a lot of sequela from malreduced or infected fractures from all over the country at this hospital which was fantastic to see.

The residents in Buenos Aires start their day much like we do. Conference is at 0700 with review of consults from the previous 24 hours, followed by a Chief or attending lecture. After conference, everyone makes their way to the OR where we were lucky if cases started before 0900.  The OR set up is very similar to ours with a pre-op area, electronic OR board and similar implants.  However, I was shocked to see that the radiolucent table was made of wood and was not adjustable so the surgeon must either squat down or get up on a couple steps to be at the appropriate height depending on the case.  There were limited power drills so the majority of the cases were completed by hand. Their methods of fracture fixation were often predicated on cost and implant availability.  They had limited nail and screw sizes and lengths as well as plate selections and only one implant company was available.  This made me incredibly grateful and appreciative of the wide variety of implant brands and constructs available to us.  I was very impressed with what the surgeons were able to do with the resources they had. 

One of the most striking cases was a 77-year-old male who had suffered an open distal femur fracture five years prior which subsequently got infected. He was initially managed at a remote hospital in the Northern part of the country. When he arrived to Hospital Italiano, he had a significant bony defect with residual deformity, a 7 cm leg length discrepancy and hadn’t walked in years.  Unfortunately, it took 2 years for surgery to be approved. After confirming there was no residual infection, he underwent a corrective osteotomy with a plan for lengthening by external fixation.

After a couple days in their general trauma clinic, I quickly realized cases like this were normal.  Neglected open fractures.  Chronic open wounds.  Limb deformity.  Leg length discrepancy.  The residents here were impressed with the acute trauma that we are accustomed to in Saint Louis while I was equally amazed at the sequela of those same injuries that they managed on a day to day basis. 

I spent every free minute exploring the city and taking in as much of the food and culture that I possibly could. I used running as my main mode of exploration and did several long runs to see all the famous sites in the city.  I was able to participate in two traditional asados (similar to our BBQs) with the residents and the trauma team. I ate empanadas, noqui, pizza, helado and enough dulce de leche alfajores to last a lifetime. Argentina is also known for their wines and I was fortunate to learn all about the different kinds they are famous for through a wine tasting event.

Of course, no trip of mine would be complete without a race. Less than 24 hours after landing in BsAs, I hopped in the car with my Argentinian Sherpa, Jorge and drove 9 hours northwest up to the mountains of Córdoba. Much of the drive was similar to Missouri with flat plains and farmland. But once we hit Córdoba we were rewarded with some amazing mountain views that seemingly came out of nowhere. The race was in the tiny dirt road town of Villa Yacanto de Calamuchita. This race drew runners from all over South America and is one of the bigger trail runs in the area. We ran up and down mountains, across rivers and through vastly wide-open fields with wild horses and cattle roaming. This race was a huge reminder why I do these crazy events. There is no better way to see a new place than exploring on foot. Trail races particularly teach you so much about perseverance and perspective. I'm often taught whatever lesson I need to learn at that time. This race’s theme was to slow down and enjoy the journey, a lesson that I need to repeatedly be reminded of on a daily basis, but particularly at that time with all the responsibility of Chief year looming ahead. Additionally, it was a reminder of the truly incredible community of runners that I am a part of. Despite not speaking the same language, I ran the majority of the race with a couple from Uruguay.  We finished within minutes of each other and shared a very emotional group hug at the end.  It was a great reminder that the bonds formed on the trails through shared suffering defy all language barriers.

Muchas gracias to the Department of Orthopaedic Surgery at Washington University School of Medicine for allowing me to have this great opportunity. I will be forever grateful for the experience, perspective, memories and new colleagues that this trip granted me.

Monday, December 5, 2016

Manila, Philippines

By: KJ Hippensteel


Intramuros
Thanks to the assistance of the Washington University Department of Orthopedic Surgery, I was able to spend two weeks rotating at Philippine General Hospital in Manila, Philippines as part of my international rotation. The Philippines are composed of 7,107 islands, of which only about 2,000 are inhabited. Manila is the capital, is located on the eastern shore of the Manila Bay, and was founded on June 24th, 1571 by the Spaniards starting out as a fortified city named Intramuros where it stayed under colonial rule for many centuries. As a result of Spanish cultural influence, the Philippines are predominantly a Roman Catholic country. After the Philippine revolution against Spain in 1898, the United States took control and switched the language from Spanish to English and emphasized education to the native Filipinos. It fell under Japanese rule during World War II in 1942 and was the site of the bloodiest battle in the Pacific region of World War II in 1945 before being recaptured by American and Filipino troops. In 1946, it finally gained its independence as its own republic on July 4th. Manila is currently home to almost 2 million people and is the second largest city in the Philippines after Quezon City. It is also the most densely populated city in the world with over 41,000 people per square kilometer and the people in the Philippines speak a mixture of English and Tagalog.

My contact with the Philippine General Hospital (PGH) was made through the help of a Washington University anesthesiologist, Dr. Necita Roa, and one of our current orthopedic sports medicine attendings who was a former resident here and who did her chief resident international rotation at this same hospital, Dr. Lily Bogunovic. They helped coordinate my rotation there with Dr. Edward Wang, the chair of the Orthopedic department at PGH. Lily spoke very fondly of her time at PGH and given this feedback and the fact that my mother in-law is from the Panay island in the Philippines, this location strongly appealed to me when I was researching possibilities for my international rotation.

PGH is a public hospital affiliated with the University of Philippines that relies on government funding under direct control by the President of the country, President Rodrigo Duterte. This is unique because other public hospitals rely on government funding controlled by the Department of Health. It is the biggest hospital in the country and the largest training hospital with a 1,500 bed capacity, of which 1,000 beds are for indigent patients and 500 beds are for private patients. The Orthopedic department has 29 attendings, 5 sections (Adult, Trauma, Spine, Pediatrics, and Hand), and 5 services (Tumor, Ilizarov and Limb Deformity, Microvascular and Replantation Service, Sports Medicine, and Arthroplasty). Their residency program has 5 residents per year and is 4 years in length. Our internship year is replaced by a 5th year of medical school where they rotate through various specialties acting in the same fashion as interns here in the United States do and this year is when they apply to residency programs. Their department also has a fellowship in Hand and Microvascular Surgery, Ilizarov and Limb Deformity, and Tumor.


With residents and Dr. Wang
on residual clubfoot and
giant cell tumor cases.
Besides clinic and OR duties throughout the week, they have two formal conferences on Friday and Monday. On Friday, residents in each section present their cases from that week and cases from clinic or ER consults that are planned for the OR for the following week to the consultants (attendings). They are expected to present literature to support their plans as well as a detailed approach on how they will perform the procedure and are given feedback on what to change, add, or improve before their final presentation at Grand Rounds on Monday in front of the entire department. Based on their presentation at Grand Rounds, they are either given approval to perform that upcoming case or if their knowledge/plan is not deemed adequate, the case is transferred to the more senior resident, then fellow, then consultant if necessary to do that week. If the resident would prefer consultant assistance due to this being the first time they have done this type of case, if the case is significantly complex, or if the patient has private insurance, consultants will attend the case and assist the resident. Otherwise, a senior and junior resident perform the case and these are reviewed in the Friday conference. Due to the low salaries given to consultants at the public hospital, all are forced to work additionally at private hospitals which the residents do not help cover.


Distal radius fracture
with K wire fixation.
Volar locking plates are
usually not an option due
to financial restraints.
I was able to see a wide variety of cases and work with a large number of residents and consultants which included various ORIF cases, massive tumor excisions/amputations, pelvis iliac crest external fixation, first dorsal metacarpal artery flap for a thumb tip degloving injury, and foot reconstruction for residual clubfoot deformity. The keyword in treatment of orthopedic injuries in the Philippines that the residents used often is “improvise”. No equipment is stored in the hospital and choice in sizing of screws/plates is not often complete. As government insurance only pays for 25% of implant costs, patients with unstable spine or extremity fractures often will lie in traction or in splints/casts until their family can gather up the money to pay for the implants. Non-radiolucent non-modular external fixators are used frequently as temporary or definitive fixation as they only cost $30 US dollars compared to Asian manufactured IM nails which cost $500 US dollars. Volar locking plates for distal radius fractures are rarely used due to cost and K wire fixation is frequently used. Different staple or screw sizes are not readily available and thus, improvising with whatever size is available, is needed.

Standard presentation of patients
to tumor clinic (Osteosarcoma).
Another noticeable difference in patient presentation was in regards to musculoskeletal tumor pathology which I saw firsthand attending Tumor clinic. Patients started lining up outside the clinic at 2-3AM in hopes that they could be seen that day and patients brought their entire medical records and imaging in a plastic bag. Due to financial difficulties in obtaining transportation from provinces to Manila and due to initially being treated by village doctors with herbal medicine, patients present with tumor masses much larger than what I have seen here in the United States.

Often, limb salvage is not an option due to the size of the tumor or due to the financial constraints in affording an endoprosthesis. Allograft availability is much more difficult to obtain, but this is a current priority in improving access to allografts with a national tissue bank with the Filipino government.

3 generations of my Filipino
family outside restaurant in San Juan.
I was very fortunate to have family that lives in Quezon City, which is very close to Manila. They were able to generously house me one weekend, teach me Tagalog and Filipino history, introduce me to a wide variety of Filipino food, take me to various museums, tour Intramuros (the Spanish fort city from the 1500s), and visit Tagaytay where Taal Volcano is located. At the end of my two-week hospital rotation, my mother and aunt joined me in Manila after they had finished touring Vietnam, Cambodia, Thailand, Singapore, and Hong Kong on a cruise and we flew to El Nido in the Palawan province and took a boat to a secluded resort island where we stayed in a villa right on the beach.




View from our villa in El Nido (Maganda!)
My initial plan was to bring my wife, Rachel, here to the Philippines at the end of my rotation and to have her see her mother’s homeland for the first time, but after our rotation schedule for the year had been set up, we found out she was pregnant and her due date was too close to my planned travel to the Philippines. El Nido was truly paradise on earth with its crystal blue waters and white sand beaches as these pictures attest to and I enjoyed various activities ranging from snorkeling, hiking, island hopping, scuba diving, and laying on the beach. I only wish Rachel could have joined me, but we are incredibly thankful that I made it back before her delivery and that we have a healthy baby boy, JJ! We definitely plan to go back in the future and show Rachel and JJ the beauty of the Philippines and meet their family! I am so incredibly thankful for the opportunity to take this trip. This would not have been possible without the assistance and approval from the faculty here at Washington University as well as the faculty and residents at PGH. This truly opened my eyes as to the stark differences in medical care experienced by patients in developing countries when compared to here in the United States. This medical outreach experience is something I found so rewarding and I strongly desire to continue to participate in these types of trips in the future as an attending.