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 19^th-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.