Monday, February 29, 2016

Buenos Aires, Argentina

By Sami Mardam-Bey, MD

For my international trip, I had the opportunity to travel south of the equator for the first time in my
life to the Garrahan Pediatrics Hospital in Buenos Aires, Argentina. Buenos Aires is the largest city in Argentina and the 2nd largest metro area in South American (behind Sãu Paulo, Brazil) with a population of 13 million. Approximately 3 million of these people live within the city limits, with another 10 million in the surrounding areas. Residents of the city are referred to as porteños, a nod to the city’s busy seaport. The city was founded in the 16th century by Spanish explorers, and formally declared independence from Spain in 1816. The 19th century saw a large influx of European immigrants, predominantly from Italy and Spain, giving the city a very European feel. The city is most well-known for its steak and tango.

I took several years of Spanish in college, but unfortunately do not have the opportunity to practice much in St Louis. I arrived in Buenos Aires (BsAs) on a warm Sunday in January ready to hone my skills. While “Spanish” is the predominant language of the country, there are several unique features that make the porteño dialect unique, and therefore a bit difficult to understand. The first is the use of vos in place of tú, and its alternate verb conjugation, in the 2nd person singular. Second, the ll and y sounds are pronounced not like the y in “yellow” but rather like the s in “measure” (I actually found this the most disorienting). Finally, owing to the large population of Italian migrants, the prosody of their speech sounds more like Italian than Central American Spanish. This made daily communication much more difficult than I anticipated.

I worked for two weeks at the Garrahan Hospital, a large, public, pediatric hospital. There are approximately 500 beds, and 20 operating rooms. The health care system is tiered in Argentina. The public system is free for all patients that walk through the door, not only those from Argentina. Many patients travel from as far as Chile, Bolivia, and Paraguay for care. The private system is paid for mostly through health insurance, which is provided through many jobs similar to the US. The public education system is free as well, though private universities do exist. The Facultad de Medicina is the public medical university (6 years after high school), and is the most well regarded. Orthopaedics residency is 4 years, with most programs only experiencing 2-3 months of pediatric orthopaedics. The pediatric orthopaedic fellowship at the Garrahan Hospital is 2 years.

I traveled from my hotel in San Telmo (in the “old town” of BsAs) to work each day by the collectivos, a large system of buses that actually functioned very well. A typical ride cost between 20 and 50 cents. My time at the Garrahan Hospital was divided between the operating room and cast room. Cast room visits were varied, between routine postoperative follow up, fracture care, and clubfoot visits. There are 9 pediatric orthopaedic fellows at the hospital and 12 staff. Similar to what one may expect at a pediatrics hospital of this size in the States, each of the faculty members had their own interest within pediatric orthopaedics – foot, deformity, hip, oncology, neuromuscular – and most people tended to do a bit of everything. While on the surface things seemed very different – older buildings, less shiny equipment, fewer resources – the more time I spent there the more I appreciated the similarities. A crowded cast room with patients and families making jokes to one another, a surgeon complaining about not having the correct screw driver, and improvised tractions apparatuses (see right) were all standard fare. And of course, when applying a clubfoot cast, always first correct the cavus.
Wednesday was their educational day. The day would begin with journal club, where three articles (typically from the American literature) were presented by one of the fellows. While only a few people spoke English well, everyone seemed fairly adept at reading and processing scientific articles in English. Next, the whole department would round on the inpatients in the hospital. Patients were presented by the fellows, and faculty would typically offer up a few teaching points. The most interesting part of the day was their case presentation session. Patients that had been identified the week prior as difficult, interesting cases were presented to the whole department, including their history and relevant imaging. The patient was brought into the room, and staff members would examine the patient and ask further questions. The patient would then leave and discussion would continue. The group was very animated and there was excellent back-and-forth between the staff members regarding their thoughts on treatment. Often they would turn to me to ask what I thought the St Louis recommendation might be. After only understanding 50-75% of the discussion I’m not sure my answers were always the most insightful, but by and large the principles I had learned were the same ones being taught.

I was able to participate in the care of a variety of patients during my 2 weeks at the Garrahan Hospital. The spectrum of pathology was similar to that which we might see in the United States, though there was a bit of a dichotomy in the patients that I saw. On one hand there were the patients that had been appropriately referred through the free public health system, and were seen and evaluated in a timely manner. Unfortunately, access to appropriate care is still limited in some of the less developed parts of the country, as well as those referred in from neighboring countries. I saw several infants that were referred in from their primary care providers for clubfoot, and received treatment with the Ponsetti method just as they would have received here in the states (though their care was entirely free). On the other hand, I saw patients with late sequelae of osteomyelitis that was missed and went untreated for several months, with resultant bone loss and deformity. Their surgeons at the Garrahan Hospital were attempted the Masquelet technique (a technique of delayed bone grafting aimed at filling large bone defects) with deformity correction, though they were admittedly cautiously optimistic. The use of external fixation when possible was more common, as these components could be reused and were more adaptable than the plates and screws towards which we tend to gravitate in the States. Implants that were removed from patients were often sterilized to be reused later. I was continually humbled by the ability of the surgeons as the Garrahan to perform cutting edge surgery without the luxury of many of the modern implants we often take for granted.

 After my 2 weeks at the Garrahan Hospital, my wife was able to make the trip down to join up with me. After a few days of sightseeing in the city, we traveled south to Patagonia. We arrived at the Torres del Paine National Park after a 3-hour flight to southern Argentina and an 8-hour car trip over to Chile (including a 3 hour stop at immigrations at the boarder). We spend 4 days at a hotel near the park, hiking and doing other excursions during the day, exploring the plains, glaciers, and granite massif. I can honestly say this was the most visually stunning place I have ever been.

I am extremely grateful for the opportunity to spend time with a fantastic group of pediatric orthopaedic surgeons doing excellent work in Buenos Aires. The team was extremely welcoming, and I made some great friends that I hope to keep in touch with through the rest of my career.

Monday, February 22, 2016

Kumasi, Ghana

By: R. Bruce Canham, MD

In August 2015, thanks to the support of the Washington University Department of Orthopedics, I traveled to Kumasi, Ghana in West Africa to work with the surgeons in the Directorate of Trauma and Orthopaedics at Komfo Anochie Teaching Hospital (KATH). I was especially fortunate to be accompanied by my brother, Colin, who is also a chief resident in orthopedic surgery in Rochester, New York.

Kumasi is a city of over 2 million people, approximately 120 miles north of the Atlantic coast. It is the second largest city in Ghana. KATH is the second largest hospital in Ghana. Originally built in the 1950's, it consists of 1000 beds, though most of these are situated in large open wards holding 20-80 patients as well as a new Accident and Emergency center (A&E) built in 2009. Given its location and size it is a major referral center for the entire northern region of Ghana.

Ghana is better off than many of the other nations in Africa, however it is still a developing country, and as a result it must struggle with providing healthcare for its citizens in the face of limited resources. It was in this setting that my brother and I found ourselves arriving in the middle of a doctors' strike. The doctors whose main source of income was from the government including those at KATH were striking with the goal of obtaining "conditions of service" which included things similar to workman's compensation, pension and reimbursement for work expenses. As an example, under the current situation if they contract a disease such as HIV or Tuberculosis while on the job they are on their own to pay for the costs of treatment and disability. The strike was very unpopular with many of the rest of the population as obtaining health care was very difficult. However the doctors' situation was also a difficult one as they did not have any alternative constructive avenues for advocating for themselves. It was certainly a thought provoking situation. While I couldn't fathom the notion of doctors in the United States going on strike, we are also much better reimbursed compared to our Ghanaian colleagues. In fact, it is not uncommon for the government not to pay the doctors for many months at a time.

The doctors were still working in a limited capacity, though were not taking new patients. Similarly we were able to be involved in the care of some patients that had come to the hospital prior to the strike, or that somehow got admitted despite the strike. We were however, grateful when the doctors voted to return to work at the end of our first week despite not receiving the conditions of service from the government.

Our second week at KATH was much different. Many patients returned to the hospital seeking care. The orthopaedics teams frequently see 50-60 patients daily in the OPD (outpatient department). Also there are many patients who arrive daily in the A&E. The orthopedic surgeons at KATH are swamped with trauma patients to care for, mostly from motorcycle and automobile accidents as well as pedestrians who are struck by moving vehicles. The volume of trauma is at times overwhelming, but the orthopaedic surgeons take it in stride. We saw and treated many open fractures while at KATH. Large open wounds are a significant problem.

While they have limited resources, I was impressed by the things that they are able to do there to care for their patients. The A&E is a new and relatively modern facility, similar to a level one trauma center in the United States, also with 4 operating theaters. The equipment that they have to work with in the OR's however is quite old, often making treating patients challenging. Problem solving and creativity are constantly required in order to treat the patients. The trauma and orthopaedics directive consists of 5 attending orthopaedic surgeons, 4 orthopaedics residents as well as other surgery residents and house officers. I worked most closely with Dr. Victor Ativor and Dr. Ralph Kumah, as well as with some of the residents such as Godwin and Robert, pictured with my brother Colin and myself. They do an incredible job caring for the people of Ghana. It was invaluable being able to work together with them, sharing some of my knowledge but also learning so much more from them as well.

My trip to Ghana gave me a new appreciation for how orthopaedics can be practiced with far less resources than we have in the United States while still striving to provide the best possible care for patients given the situation. The individuals that I encountered there are an inspiration to me to provide the best care that I can to my patients now and in the future. The Washington University Department of Orthopedic Surgery in St. Louis made this experience possible for me in so many ways, and I will always be grateful for this life-changing experience.

Monday, February 1, 2016

Panamá City, Panama

By: Jeffrey Stambough, MD
My trip to Central America was a first for me, having never been south of Mexico. Panamá City holds a unique place in the world primarily because of its geography. The country of Panamá is a large isthmus and it functions as a gateway from the Pacific to the Atlantic, thanks in part to the development of the Panamá Canal. Although this modern marvel of sheer engineering brings in over 5 billion dollars to the economy, this only accounts for 6% of their GDP.  The canal is currently in the final phases of a massive expansion that will create a second, larger channel lane to allow larger ships with more cargo to embark on the ten-hour bypass. Needless to say, this will further contribute to expand Panamá’s role in the global trade economy.

Hospital Santo Tomás
Panamanian healthcare in reality is a three-tiered system.  Private hospitals are the desired destination, but can be costly for the average Panamanian whose monthly wage is around $500.  There are social security hospitals, to which all citizen’s taxes contribute, but these facilities often don’t provide the breadth of care most people seek.  Finally, there are public hospitals in the National healthcare service (“Salud), which accept typical fee for service. Hospital Santo Tomás (HST) is the largest of such public hospital in the country and exemplifies this pay for service credo. It was massively expanded in the 1920’s to it’s current 5-acre plot and was originally called the “white elephant” for it’s grandiose size and thought that it was too big to deal with healthcare needs.  Almost, a century later, it’s a 600+ bed hospital that routinely runs a full capacity. 

I traveled with a group, Operation Walk, and we were granted access to a wing of this hospital for a little over a week. Our group consisted of 5 surgeons, 3 anesthesia providers, 4 PAs, a collection of floor/PACU/scrub nurses, physical therapists and volunteers to help with sterile processing, patient transport and other tasks.   We worked exclusively at HST under the direction of our coordinating orthopaedic physician, Karla Morales, MD, who helped recruit patients over the past year as potential candidates for joint replacement. 

Our first day in Panamá was spent conducting an all-day screening clinic for nearly sixty patients. After a thorough pre-operative review, we declined some people for surgery given our limited resources with implants and/or undue surgical risk factors. As a team, we agreed upon 56 patients who we’d then perform the various knee and hip arthroplasty procedures over the course of our week there.

Operating in a foreign country can be a daunting experience if one fears the unknown. Will they have the necessary equipment to properly sterilize the surgical equipment? Will there be enough modern equipment to safely perform anesthesia? Will the rehabilitation equipment be safe? Luckily, we quickly found the answer to these questions was a resounding yes.  HST is a very advanced hospital in terms of available resources and manpower. They have modern anesthetic monitors, fluoroscopy (although not always someone to run it), and portable x-ray that is nicer than most hospitals in the US! The only real problem we ran into during our time there was that the water shut down to the sterile processor after our 3rd day of cases, so we had to all pitch in to scrub down instruments and “flash” trays. And when we ran into issues trying to assess preoperative leg lengths, we got creative and used books old books and journals to act as “blocks.”

As for my interactions with the Panamanian orthopedic doctors, there were 3-4 orthopaedic residents per class who take rotating trauma call and are responsible for covering urgent cases.  Due to the healthcare structure, however, almost all fractures are initially managed with external fixation until the patient can raise the funds to pay for an intramedullary nail or periarticular plate and screws. One PGY-2 resident with whom I had the most contact, Eduardo Camino, was extremely helpful when it came to translating during the clinical interviews and inpatient rounds. His baseline understanding of orthopaedics made it easy for him to navigate those waters, and in turn, made me realize even more that knowing how to speak Spanish would have been huge advantage in my profession.

They use the same text books that we do – Campbell’s Operative Orthopaedics and Green’s Operative Hand Surgey – as well as read the same journals – JBJS, Journal of Arthroplasty, etc. Eduardo and my time together really allowed me to reflect on all of the perks that we have not only with training in the states, but specifically at Washington University.  Our scheduled didactics would be considered a luxury in Panama, as the students I talked with were yearning to learn the breadth of orthopaedics through case-based learning (instead of seeing photos in a textbook).  

In our time at HST, we were able to complete 48 hip and knee replacements in 56 patients. I either led or was directly involved with 15 of the cases. It was an eye-opening experience from beginning to end because we saw people who had such advanced arthritic disease that they often required substantial releases to achieve a balanced knee, for instance. However, using the tools which we had available combined with the perseverance of the patients, all patients were up and walking the day after surgery. One of the physicians brought 100 vials an antifibrinolytic drug, tranexemic acid, which was a Godsend in that in drastically cut down on the need for post-operative blood transfusions, even though most patients started with some baseline anemia (Hgb ~ 10) due to the rampant malnutrition in the country.

What I will take away the most from the mission experience was the seeing the gratitude from the individual patients from the pre-op through the rehabilitation process. Most patients had significant dysfunction preoperatively and had limited access to conservative treatment, such as anti-inflammatory medications. Some patients had fashioned a cane out a piece of wood to help offload the affected extremity. One patient in particular made an indelible impression. The last patient we treated was a 4’4” Franciscan nun who had advanced degeneration of her knee.  Although she was  
in extreme pain and wasn’t able to kneel for the past five years, she was extremely vivacious and happy throughout the entire process. Every morning on rounds, she greeted the team with a smile and hug, which turned out to be infectious in that it served as a constant reminder of the great things that come from our endeavors. While her surgery proved difficult given the amount of fixed deformity and bone quality, we were able to give her a solid, stable new knee. She was so happy she wept the day after surgery. It was a moment that I will take with me throughout my professional career.

Participating with a group like Operation Walk provided me insight into all the good that can come from medical mission trips. It is definitely something that I will look to make time for as part of my professional practice as a joint surgeon.