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.

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