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.

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