Monday, October 28, 2013

Coimbatore, India and Jakarta, Indonesia

By: Ameila Sorensen

Coimbatore, India

Ganga Hospital provides world-class orthopedic and plastic surgery care using ingenuity to overcome the difficulties with obtaining resources. Cost is central with the best care provided for the minimum cost. A free flap can be done with two small pans of instruments. The specialized paper drapes used in America are replaced with elegantly draped sterile sheets that are washed at the end of each case. Each suture opened only after requested and then used to the fullest extent. Even the air conditioner is only turned on when the room becomes too hot and then when the room is cool it is turned off. Dr. Hari said the hand / microsurgeons have to do 30 surgeries a day to meet their cost of operation. Orthopedics does around 50. They are hoping to keep expanding until 100 surgeries a day are done at the hospital.

Every patient is told how much their treatment will cost when they arrive. It is even on the consent. A surgery including preop admission, anesthesia, OR, recovery time in an ICU like specialized monitoring unit as well as on the general floor costs a few hundred dollars. While each patient got the same level of care in the OR, several levels of postoperative care were available. There was a general ward with 25 beds separated only by curtains or smaller rooms up to a private room with a TV.

A sense of family and family responsibility is very strong in India. I was in an elevator when a stretcher came in with at least 7 other people crowded around.
The family members provide the majority of perioperative care. One person is allowed to stay and if more stay then they pay the hospital extra. The entire family or even community helps to pay if someone needs surgery. There a few homeless people in India because a family no matter how cramped will make room for one more.

The majority of what I saw was trauma: crush injuries, closed and open fractures, amputated fingers/hands/limbs, burns, and degloving injuries all came through the door. The doctors said when there is an accident in Coimbatore people thank god they are alive and then tell the ambulance to take them to Ganga. The system for dealing with the traumas if one of well timed efficiency. When the hospital started there were 3 doctors – an orthopedic surgeon, a plastic surgeon and an anesthesiologist. When traumas came in often the surgeons couldn't leave the OR, so the anesthesiologist would go evaluate the patient and prepare them for the OR. This system has stayed in place. If the patient has a severe injury they are taken to a room just outside the plastic surgery OR and there an entire trauma code can be run. The doctors said it is the room in which the most lives have been saved in Coimbatore. If the patients have a mangled extremity a nerve block is immediately performed, so that the patient can be comfortable while waiting for the OR. If it is something that does not require emergency treatment then they are admitted and taken the next day. It is the same if a patient is seen in clinic and needs operative treatment, since many travel long distances. No one but the surgeons can say who is admitted or discharged and when.

 In the OR since almost all patients have a peripheral nerve block which makes their extremity numb they are usually awake. Somehow the patients just lie still for however long it takes for their surgery, sometimes watching, sometimes sleeping. I never saw anyone talk or move unless asked. Dr. Sabapathy said all he needs to do is tell the patients to lie still and be quite and they will do it. My attempts to explain why this would be difficult in America were met with disbelief.

However, I spent most of my time with my only patient being a rat who I knew would not survive the day. We watched Dr. Ackland's video from Louisville in the 70s/80s on which this course is based. My favorite part had to be the bluegrass interlude while he stitched a vessel. It started with the principles of microsurgery. Beginning with how to sit and hold the needle and place your hands. Practice on rubber gloves progressed to chicken legs the first day. The next day we started on the rat femoral arteries, which at first seemed hard, but then we tried veins, then a vein graft and finally a vein end to arterial side. By the last day my hands which could not even find themselves under the scope the first day were moving with a sort of quickness and confidence as I sutured 1mm vessels with needles smaller than a finger nail and suture thinner than my own strands of hair. After the course ended each day we would go watch Dr. Hari and Dr. Sabapathy operate seeing complex reconstructions, replants and free functioning muscle transfers. They seemed to be on fast-forward compared with my own pace.

During the course we took plenty of breaks as beginning microsurgeons must and spoke with two orthopedic surgeons from Bangladesh who were also there for the course over cups of Indian tea. They also did mostly trauma but wanted to be able to repair their own vessels since someone who could was not always available or came too late to save their patient’s limb. This realization helped to put in perspective how lucky I was to be coming to learn not because I had to do it, but because I wanted to do it.

The week at Ganga probably improved my skills and thought process as a surgeon more than any week since that first one as the trauma intern. Truly an amazing time.

Jakarta, Indonesia 

After the week at Ganga I took a series of small planes across the Bay of Bengal to Jakarta. Jakarta has a population of 10 million people and 28 million within the metro area. Nearly 40,000 people live in each square mile and they have exactly two pediatric orthopedics surgeons, one of which calls pediatrics his hobby since what he really does most of the time is joint replacement. The entire country with a population of 238 million has only 7 fulltime pediatric orthopedic surgeons. There are more pediatric orthopedic surgeons than that in St. Louis, which has population 1/100th the size.

However, they were not as overwhelmed as I thought they would be. Most Indonesians received their orthopedic care from “bonesetters.” They seemed to do everything from treating fractures to scoliosis. National Health Care is coming to Indonesia in 2014 and no one is sure what is going to happen then. For now the ability to pay had to be guaranteed before surgical care was delivered. Even patients who had insurance had to wait until the insurance carrier agreed. I spent one day in a private clinic that functioned much like a western hospital and another in their public hospital that had a packed waiting room.

Again the hospital rooms were leveled with general rooms of around 10 down to private rooms and the ICU was a massive room with people separated by sheets. There was a patient with spinal TB in the general ward. The residents said they saw so many patients with TB it wasn't possible to separate them. A patient with a tibial shaft fracture was being treated in cast because he could not afford the cost of a nail or even a plate. Patients were always admitted prior to surgery both for the logistical reasons of transport and OR time and also to make sure they were stable for sugery.

There were only 3 or 4 orthopedic operating rooms that could run each day at their main hospita
Even with surgeons and staff available for more there simply wasn't enough equipment. During a free fibula case they could not start the two portions simultaneously because they only had two tourniquets for all the ORs and one was already being used. The hospital did not own a power driver and one had to be rented if it was needed. Anesthesia was again primarily blocks. A pelvic fracture patient was given a spinal. As I watched him rolled on to his widened SI joint for the spinal I thought again of how no American patient would tolerate it. This patient had been waiting 9 days for his surgery, so made no complaints.
The 3rd year resident templated out what he or she thought would be needed and that was what they had to do the surgery. For a complex DDH case which would have had a whole series of plate choices and jigs at St. Louis Children’s, they had 4 LCP plates to choose from. I learned in Indoneisa that almost anything can be fixed with an LCP plate. They knew what the books said could be used and how to do that operation as well, but they also knew what they had and how to do what needed to be done.

The residents paid slightly more than $1000 a year to work at the hospital. They were all very well read, frequently quoting the main orthopedic textbook and reviewing it on their smart phones (they all had two since this was how the communicated with each other) before the surgery. The last 6 months they are free from clinical duties and spend it studying for boards and in teaching sessions with the attendings. Since pediatrics is not seen everywhere several residents from other programs where in Jakarta at the same time as me to learn from their head surgeon. They made a point of having me at these sessions and I was able to offer insight into our management of general orthopedic trauma, hand trauma and pediatrics. I gave a presentation on Slipped Capital Femoral Epiphysis which is seen more commonly in overweight children, something none of the residents had seen, but judging by all the McDonald’s in Jakarta and even a Dunkin Doughnuts inside the hospital I think they will be soon. It was incredibly rewarding to be able to teach as well as learn from the residents there.

The residents also had vast knowledge and skills as general surgeons. They spend an entire year doing general surgery procedures and continue to do some at night throughout their training. Even the interns had done appendectomies. This part of their training was compulsory because like the surgeons from Bangladesh they did not know if where they en
ded up practicing would have another surgeon to care for patients.

There were no women surgeons in India or Indonesia. In Indonesia they kept telling me about an interesting bone lengthening case, but the head of the department was doing it and since he was “traditional” and did not think women could or should be orthopedic surgeons they did not send me into that surgery. There were a few female residents in Indonesia. One was assigned to “accompany me where ever I wished to go.” I gave her as much encouragement as I could during my stay and urged her to come visit our program.

In reading through what I have written I comment most on what they did not have which was in sharp contrast to everything we have here. However there was no lack of hardworking people who had joy in being surgeons. I was impressed by everyone in both places dedication and creativity from starting a free flap at 4pm to using their cell phone lights for bedside dressing changes. The whole trip made me feel lucky not only to live in America, but also to be a surgeon here who is treated as an equal to the male residents, can change her mind during surgery about implants, call for another driver or set if something is missing or broken, and operate on anyone who needs it.

Unlike some other countries I have visited where I am glad to have seen them, but have not made plans to return, I am already thinking of how I can come back to India and Indonesia and join these talented surgeons again.

Wednesday, September 4, 2013

Bangkok, Thiland

Rounds at King Chulalongkorn Hospital
Bangkok, Thiland

By: Ben Gray

In July of my chief year, I traveled to Bangkok, Thailand for my international elective. Having taken off at 10AM on Saturday morning, I finally landed around midnight Sunday night losing roughly half a day to the time change. I was greeted by the staggering heat and humidity of the monsoon season and would only find out later that these temperatures paled in comparison to their “hot season” in April. When I told the surgeons at the hospital that I walked to work on the first day, they asked if I brought two shirts. I quickly learned the vast size of the city. Roughly 14 million people live within the metropolitan area of Bangkok. Of these, 98% are Buddhist in religion.

 I spent my two weeks working at the King Chulalongkorn Hospital, which is a public hospital that is run by the Thai Red Cross. I was fortunate enough to be hosted by Dr. Noppachart Limpaphayom who completed his pediatric orthopedic fellowship at St. Louis Children’s Hospital with Drs. Dobbs, Schoenecker, Gordon, and Luhmann. His practice in Thailand is a combination of pediatrics as well as general orthopedics. While the Department of Orthopedics at the hospital is robust with several departments, he has inherited all of his previous mentors patients on top of his new patients. Thus, he will perform revision joint arthroplasties and adult spinal fusions in addition to his treatment of pediatric foot conditions.

Administration building, King Chulalongkorn
Hospital, Bangkok, Thiland
The hospital was primarily open air but with air-conditioned operating rooms and clinic rooms. They are transitioning from a multitude of smaller subspecialty buildings (GI, orthopedics, cardiology) to a massive, multicenter facility that should be completed in the next several years. Patient rooms vary from the open wards with 8-12 patients to the private floor dedicated entirely to the Queen of Thailand. If patients do not have private insurance or government insurance, the Thai Red Cross will cover their expenses. The medical training in Thailand is quite different from the United States. Students take a national exam in high school that determines their profession more or less. The highest scores are eligible to apply for medicine. They then complete 6 years of medical school followed by 3 years of obligatory public service in which they serve as a primary care physician in a rural community. They then apply for a residency program, which for orthopedics is 4 years. Whereas in the United States all residents are paid by the hospital in which they are working, this made up only a minority of the residents. Most of the residents were being paid during their residency by a hospital that they had promised to return to practice upon completion. Likewise, they would need sponsors to complete fellowships beyond their residency training. Another contrast was that their third year residents served as their chief resident. They were responsible for calling patients, scheduling cases, and running the services. The fourth year was dedicated to reading and learning the finer points of operating.

 In Thailand, the feet are considered very lowly and you would never touch anyone else with your feet. Your toes thus are never supposed to point at the Buddha as it would be disrespectful. I found out that this is one reason that their hand surgeons do not perform pollicization of the toes for children with congenital hand deformities. Families would not want their children to have toes on their hands as it would be disrespectful. They would however do transfers of the proximal phalanxes from the toes to the hand for lengthening purposes. Somehow this was considered different. In the operating room, infection control was very important. If you entered a room with an infected wound or an open fracture, you were required to change your scrubs, hat, mask…and sandals before entering another operating room. It was striking to me that shoes were not allowed. When you entered the locker room, there was a wall of sandals that you would change in to. I quickly learned that there were separate sandals for the bathroom as well.

One of the interesting cases that I saw was of a young boy with a myelomeningocele and neuromuscular clubfeet. It was explained to me that families traveled a great distance to come to the hospital and most wanted one surgery to fix their child’s problem rather than returning for multiple casting or multiple procedures. Thus, they have adopted the practice of performing talectomies in order to accomplish the correction with one surgery. In the clinics, I was able to see a plethora of diseases that we rarely see in the United States. The residents explained that tuberculosis always has to be in their differential as it can be an atypical presentation of joint pain. Likewise, they are seeing a resurgence of polio. I was surprised to see a large number of patients with osteogenesis imperfecta. I greatly enjoyed interacting with the residents and attendings, discussing the varying ways in which we would treat cases in the United States. English is fortunately taught starting in elementary school and thus they were all quite proficient.

During my time in Thailand, I was able to explore the city and saw several of the beautiful Wats (temples) and experience the amazing food that Thailand has to offer. Dr. Noppochart as well as other residents treated me to several excellent meals and helped me find my way around the city. Overall it was an incredible experience to see a world that is far different from my own. I am extremely grateful to the department for allowing me this opportunity to see how orthopedic surgery is conducted in Thailand.

Wednesday, May 29, 2013

Managua, Nicaragua

By: Drew Blackman

Prior to my trip to Managua, I had arranged for a hotel shuttle to pick me up at the airport. As I walked through customs and baggage claim, I saw numerous shuttle drivers with whiteboards emblazoned with hotel monograms and guests' names written in dry erase marker. None had my name on it. I continued through the airport and out into the muggy Nicaraguan night. Finally, I saw something name. Written in pencil on a piece of three hole paper ripped from a spiral notebook. I followed the driver, expecting to be led to a bus, or van, or car, or something with the words "Hotel Casa Naranja" on it to reassure me we were heading in the right direction. No such luck. Just a dented, scratched 1990's era Toyota hatchback. I got in and we drove through the night, through unfamiliar boulevards with no street signs. I had studied the city map briefly before my arrival, but as we wound through dark streets past residences made of corrugated sheet metal, I was admittedly lost...and nervous. Eventually, a small lit sign read "Casa Naranja", and I had arrived at my home for the next two weeks while I would experience orthopedic surgery in the capital of the poorest nation in Central America. Hotel transportation was only the beginning of the differences between my experience in Nicaragua and what I am used to in St. Louis.

I spent the majority of my time in Managua working at Hospital Antonio Lenin Fonseca, HALF for short, which is a public hospital that serves as the major referral center for uninsured patients throughout the nation of nearly six million people. In Nicaragua, there are three tiers of healthcare: privately insured, government insured, and uninsured. The gap between three is staggering, but that between those with insurance of any kind and those without is particularly chasmal. The private insurance-only hospitals were on par with most community hospitals in America in terms of resources, facilities and capabilities. The hospitals that accepted both private and government insurance seemed to be on par with smaller American community hospitals. HALF was different. The hospital itself was outdated and the interior lacked the cleanliness one typically associates with hospitals. Patients were housed eight per room, with no air conditioning in the 100 degree heat. Patients, or their families, brought many supplies from home, including sheets and fans. Family members provided much of the nursing care that did not involve administering medications, as well.

The majority of my clinical days spent at HALF were in the operating rooms, assisting primarily in fracture surgeries. Many of the Nicaraguan surgeons who operate at HALF also have a private practice at another hospital to supplement their income, as fulltime HALF surgeons are paid around $1400 per month…although the average income in Nicaragua is only around $2000 annually. On days they operated at HALF, these surgeons would bring most of the necessary equipment with them from their private hospital, including orthopedic implants, instrument trays, patient positioners, and scrub nurses. On days when these outside supplies were not available, the surgeons relied on the hospital’s inventory, which was severely limited. The hospital is unable to purchase many of the newer generation fracture fixation devices that we take for granted in the United States, and thus relies on older fixation devices as well as donations from international surgeons. As a result, options are limited. Issues with outdated sterilization equipment and poor organization within the sterile processing department serve to further limit surgeons’ options at the hospital. Despite all of these challenges, however, the surgeons are able to work with what is available to perform satisfactory operations for their patients. There were six operating rooms, with one or two being devoted to orthopedics per day. Two surgeries per room per day was average, which was hardly enough to keep up with the influx of new patients coming through the doors each night. As a result, on the orthopedic ward, patients with lower extremity fractures lied in bed for weeks, awaiting their turn in the operating room.La Hospital Escuela Antonio Lenin Fonseca, or HEALF, is one of the largest medical training programs in Nicaragua. Their orthopedic residency training programs is regarded as the best in Nicaragua. My trip to Managua was arranged through Health Volunteers Overseas, who has partnered with HEALF to bring international surgeons to HALF with the primary goal of provide training and education to the residents. Orthopedic residency at HEALF, and at other hospitals in Nicaragua, is much different than in the United States. Residency is only three years, although this has been changed to four starting in 2013. Residents are taught by their attendings primarily by observing in the operating room and during department-wide ward rounds, which occur once weekly. There is one hour per week devoted to didactic resident education, in the form of a basic orthopedic knowledge lecture given by one of the upper level residents. Given the lack of skilled ancillary staff in the hospital, the residents take on many additional duties, such as running the fluoroscopy machine, cleaning the operating room between cases, and making sure all the instruments for each case are available and ready for sterilization 48 hours before the surgery.

 During my time at HALF, I was able to interact with the residents on a daily basis and provide some teaching in the inpatient, outpatient, and surgical settings. They were all very eager to learn how different clinical scenarios would be handled in the United States.

A busy clinical schedule limited my time for sightseeing while in Nicaragua, but a surgical cancellation on Saturday and a day off on Sunday allowed me a weekend to experience the countryside. I spent an afternoon hiking on the Mombacho Volcano overlooking Lake Nicaragua. On my drive home, I was stuck for 90 minutes in traffic after I was detoured off the main highway on account of a huge street carnival that lasted well into the night. I also spent a day exploring the uncrowded, and largely undeveloped, beaches at the southern extent of the Pacific coast, eating ceviche and watching surfers prepare for the upcoming World Surfing Championships.I am grateful for the opportunity to have had this experience and grateful to those who made it possible, specifically the orthopedic department here at Washington University, Health Volunteers Overseas, and Dr Dino Aguilar in Managua.

These trips are an important tradition that can help inspire a sense of international stewardship and facilitate future overseas volunteering. I hope the relationships I formed during my two weeks in Nicaragua will help me with trips to HALF after I finish my orthopedic training.

Monday, May 20, 2013

Bomet, Kenya

By: Charles Lehmann

For my trip I elected to visit a mission hospital named Tenwek Hospital located about 10 kilometers outside of Bomet, Kenya.  Bomet is a small Kenyan village located about a four hour drive west of the capital Nairobi on the far side of the rift valley.  Tenwek serves as the primary hospital for approximately 600,000 people living in many small villages and farms within a 30 kilometer radius of the hospital.  It also serves as a referral center for a much larger radius.  The majority of the people in this area are a native Kenyan tribe called the Kipsigis.

I chose to travel to Tenwek Hospital because there is a United States trained orthopedic surgeon who works at this hospital as a full time missionary surgeon.  I wanted to experience not only what orthopedics is like in the third world, but also what the life of a missionary surgeon is like.  On Saturday, January, 26th I arrived at Jomo Kenyatta International Airport in Nairobi, Kenya.  It was already dark, but thankfully, the driver that Samaritan’s purse had arranged to pick me up was waiting for me immediately after I had obtained my luggage.  He drove me to the Mennonite missionary guest house where I was able to obtain a hot shower and get a reasonable night’s sleep before making the trek to Tenwek Hospital.

The next morning a driver met me and we departed for Tenwek Hospital.  It was a fairly smooth trip by third world standards complete with cattle crossing the highway at numerous points, police officers standing on the edge of the road with machine guns, and a few random roadside baboons and zebras.  After arriving at Tenwek I was given a warm welcome and tour of the hospital and grounds by the orthopedic surgeon that I was going to be working with named Dan Galat.  I quickly realized that it was going to be a busy two weeks since the orthopedic service had greater than 40 inpatients on it and ran 2-3 operating rooms every day during the week.  

Similar to the United States we started the day out with inpatient resident rounds at 6am.  However, prior to starting rounds we had a fairly quick devotional led by one of the residents.  Following resident inpatient rounds we met with the orthopedic attending surgeons and reviewed the x-rays of all of the consults that had come in over the weekend and cases that had been done.  This was performed on a small computer monitor.  (Yes, they do have digital x-rays in the third world.)  Then the entire team proceeded to make other set-of rounds on all of the orthopedic patients that were scattered throughout the hospital complex.  It was remarkably similar to rounds at Washington University other than that we stopped to pray for patients three different times throughout rounds.

After rounds we headed to the operating rooms to start our first case.  We had two operating rooms that were filled with cases.  The spinal’s had already been performed when we arrived and the patients were in the process of being positioned for surgery.  The majority of the OR staff were Kenyan natives, but thankfully all of them spoke reasonably good English making communication much easier.   In the room that I was placed, the first case was labeled AMP.  I assumed that we were going to be amputating somebody’s leg, however I was completely wrong.  AMP stood for Austin Moore Prosthesis (non-cemented, non-modular hip prosthesis – this was one of the original arthroplasty options used some 30-years ago in the United States).  Apparently, this is the cheapest hemiarthroplasty that one can buy (costs $80 from India).  Therefore, working with my mentor Dr. Galat I implanted my first ever AMP.  Another interesting part of my 1st case was that while removing the femoral head, I noticed tumor appearing material in the femoral canal suggesting a pathologic process.  I asked if we should send this to pathology to have it evaluated.  However, I was told not to because this patient was sick and elderly.  Apparently, even if we were able diagnose a specific cancer, the patient would not be able to afford chemotherapeutic medications nor would was their oncologic care that would be readily accessible to them.  Obviously, a very different perspective from how we practice in the United States.  

The second case was a type I open fracture of the tibia and fibula.  We fixed it with a special kind of nail called a SIGN nail.  This is a special stainless steel intramedullary nail designed by a guy in the United States specifically for use in third world countries.  The unique feature of this nail is that you can put the nail in without requiring a fluoroscopy machine.  One is able to do this by reducing the fracture through an open incision.  They also have an extra long jig that allows one to place the distal interlock screws along with several other creative tools that help to ensure that the distal screw is being successfully inserted into the nail.  Despite the lack of fluoroscopy the case went surprisingly well and we successfully placed the SIGN nail in about the same amount of time that it would have take to place an intramedullary nail in the United States.   Following this we did another SIGN nail to fix a closed femur fracture.  We finished in the OR at about 6pm.  Therefore, I didn't have time for much other than eating a little dinner, getting cleaned up, and relaxing for a few minutes before hitting the sack.

The next day I operated with Dr. Kiprono, who was a young Kenyan trained orthopedic surgeon in the 1st year of his practice.  Our 1st case was a SIGN nail on a nonunion of a prior segmental femur fracture.  It was rather tricky to find the femoral canal on both sides of the fracture, but non-the-less we were able to get a nail successfully placed in a reasonable amount of time.  The second case was one that I had never seen before – a chronic elbow fracture dislocation.  Dr. Kiprono let me take the lead operating and I was able to successfully open reduce the elbow.  It was quite challenging, but also quite rewarding at the same time.  Our final case of the day involved pinning an unstable fracture dislocation of a fourth metatarsal.

While the operating room conditions were comparable in many ways to the United States, the wards at Tenwek Hospital were strikingly different.  The wards at Tenwek are large rooms that contain anywhere from 5-25 patients and are separated based on sex and hospital service.  Patient fees for staying in the hospital are approximately 600 Kenyan shillings or a little over $7 dollars per day, plus the cost of any medications that they receive.  In addition, the hospital here has moved towards a payment system where patients are expected to make payment for their surgery prior to any elective procedure - fixing a fracture is considered elective.  For example, a common orthopedic surgery procedure such as fixing a femur fracture costs $50,000 Kenyan shillings ($570 US dollars), which is equal to the median monthly post tax income in Kenya.  In comparison to US healthcare this is extraordinarily cheap, but it is a significant amount of money for many people in this region of the country.  By charging this fee the hospital is able to stay mostly self sustainable, and is also to pay the salaries of the 600 local Kenyans that it employees.  Charging a fee also seems to make the patients much more invested in their care.  

During my two week stay at Tenwek Hospital I ended up performing over 30 cases.  I learned a lot of what it is like to be a missionary surgeon in the third world.  I also learned that sometimes you have to accept different treatment options as good enough based on the resources available to you.  If you are interested in reading more about my experience I wrote a more extensive blog along with my personal reflections during the trip that is outside the scope of this summary.  It can be found at

Thursday, January 24, 2013

Buenos Aires, Argentina

By: David Bumpass, MD

For my international rotation, I spent two weeks at the Juan P. Garrahan Pediatric Hospital in Buenos Aires, Argentina.  I left St. Louis on a cold winter night and arrived 12 hours later in the South American summer.  Driving into the city from the airport, I saw how huge this city of 12 million people really is.  I arrived at my small hotel in the neighborhood of San Telmo, grateful to have an afternoon to rest before starting my time at the hospital.  San Telmo was once one of the wealthy neighborhoods of 19th-century Buenos Aires, but a yellow fever epidemic in the 1890s caused many well-heeled residents to move to the northern city.  While the neighborhood is now an eclectic and slightly seedy area, it retains much of its intricate turn-of-the century architecture around the central plaza.

The Garrahan is one of Argentina’s biggest and best childrens’ hospitals.  It is government-funded, and is mandated to accept not only all Argentine children but also children from neighboring countries as well.  Many patients come from as far as Paraguay and Bolivia for care, all of which is free.  There are approximately 500 beds, as well as 20 operating rooms for all surgical specialties.  The orthopedic department consists of ten attending surgeons and eight fellows.  The fellows stay for two years after they complete their five-year orthopedic residencies at other hospitals.  Everyone was exceptionally nice and made a great effort to include me in clinic and cases.  I was surprised to learn that most of the attendings also ran their own private practices after work each day, in order to supplement their relatively small government salary.  Typically they conclude work at the Garrahan by 5PM and then see their private patients until 8PM or later.  Call consists of one fellow and one attending staying in-house each night; one night while I was there the call team completed ten operative cases, so they are very busy.

The attendings each have an area of subspecialty interest, including spine, neuromuscular orthopedics, trauma, knee, clubfoot, oncology, and hip preservation.  Hand care is provided by the plastic surgeons.  I attempted to spend time with each subspecialty.  The hospital, while sparse from the American point of view, is still able to provide high-level care and advanced surgical techniques, due in large part to the dedication and creativity of the physicians and nurses.

Each Wednesday the entire department gathers for a morning journal club.  Then everyone rounds together to see all the inpatient post-operative patients.  Afterwards, pre-operative patients with difficult problems who have been seen in the clinic are brought in to be examined by the all the faculty.  Imaging studies are reviewed for each of these patients, and then the attendings attempt to create a consensus plan for the patients’ treatment.  These discussions were often quite animated and lengthy.  Sometimes after 15-20 minutes of debate I would be asked, “What would you do in St. Louis?”  Of course, the entire preceding discussion was in Spanish, so I did my best to offer an educated opinion.  For one particularly difficult hip dysplasia case, I was able to provide some recent literature from the Washington University hip preservation group that prompted quite a bit of interest and was used as a journal club topic the following week.

Some of the interesting operative cases that I was able to see during my visit included a triple osteotomy for hip dysplasia, an occiput-to-C7 posterior spinal fusion on an 18-month-old child with incomplete quadriplegia, an above-knee amputation for a very large distal femur osteosarcoma in an adolescent patient, and a revision of a distal femur endoprosthesis that had been broken for 8 months while the patient underwent resection of a pulmonary metastasis and further chemotherapy.  In addition, there were numerous osteotomies for cerebral palsy and arthrogryposis children, as well as common pediatric fracture fixations.

I also spent time in the cast clinic, where post-operative patients as well as non-operatively treated fracture patients are seen.  There are 3-4 fellows in the clinic at any given time, and probably 15 or more patients are seen each hour.  The doctors attempt non-operative management for most extra-articular fractures, probably more often than we do in the United States.  It was beneficial for me to see this, as generally the children still had very good outcomes.

After work, I often took a few hours to walk through various parts of Buenos Aires.  Dinner is usually not eaten until nine or ten o’clock at night, and typically consists of beef or other meat dishes.  Notable sites include the Avenida 9 de Julio, the “widest street in the world” at 14 lanes across.  Also, the Plaza de Mayo with the presidential palace, the Casa Rosada, are important landmarks in Argentine history.  I was struck by the tremendous gulf between rich and poor in this city; there are incredible homes and luxurious high-rise condos built by Argentina’s powerful families, while just a mile away people live in small shacks and cardboard houses.  Nowhere is this better typified than La Recoleta cemetery, literally a small city of ornate mausoleums, some two or three stories tall topped with marble sculptures; here the wealthy have long been buried in family crypts.  As with many Latin American nations, corruption and the lack of a stable middle class continue to plague economic growth in Argentina.  The frustration caused by what is seen as inept government and skyrocketing inflation of 25% annually was readily apparent in talking with the doctors at the Garrahan.

I had several free days before returning to St. Louis, so I flew 3.5 hrs further south to Patagonia.  This is the region of the southern Andes straddling Argentina and Chile, just north of the tip of South America.  I visited the town of El Calafate and the nearby Parque Nacional de los Glaciares (Glacier National Park).  This is one of the largest icefields in the world, and I took an all-day trek onto one of the large glaciers.  The scenery and remoteness of this region and stunning, and I would very much like to return again in the future.

This was a tremendous opportunity, and I am appreciative for the chance to travel to Buenos Aires.  The experience was rich from both a medical and cultural standpoint, and many things I learned will stay with me throughout my surgical career.