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.

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 familiar...my 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.

Cambodia

By: Maggie Kuhn, MD

Medicine does not exist in a vacuum. It’s a simple enough concept, and statement for that matter. There are probably hundreds of essays written with this premise every year, by college students eager for medical school acceptance. And how we practice medicine is reflective of our priorities: not only as physicians, but as a society and a culture. I know that I understood this at one time, and I know that I even contemplated in the past. But life gets busy: we get up early, we round early, we see patients and put out fires and attend conference all before a 7:30 am start. We go, go, go, we complain that anesthesia is slow, that the nurses are slow, that the patients aren’t compliant, that the other services don’t really care—and before we know it, we’ve been at this five years.

This experience for me, going somewhere completely foreign and seeing medicine in a completely new context, has been one that has required me to slow down. And slowing down, for me, has proven immensely difficult. Kossimak Hospital has an 80 bed orthopedic trauma unit. But things at Kossimak are different now than they were 2 years ago. Two years ago, the 80 beds were filled—so much so that two visiting surgeons contributed over £150,000 to build a new unit. But two years ago the government changed the compensation structure for surgeons and hospitals. For reasons unclear to me, prices for patient care went up and physician compensation went down. Now, the ward is at least half empty—patients cannot afford the $280 surgery fee, or the $30 a day to stay in the hospital. Most of them go to traditional healers or ‘bonesetters’ for their initial care. Otherwise, they go to the less expensive and closer provincial hospitals. This poses two problems. First, their care is not as good: resources are even more limited and physicians are less trained. Secondly, appropriate care is delayed—when the patients finally do present, it is months or years later, and fractures have become nonunions or, worse, malunions, elbows are stiff, joints are contracted, and the patients have lost their jobs.

Despite this, the dedicated surgeons at Kossimak continue to operate as much as they can. Four of the five operating rooms on the campus are dedicated orthopedic rooms, treating almost exclusively trauma patients. The crowdedness of city streets, the prominence of “motos” or scooters, and the lack of traffic laws (or, at least, their enforcement) make for plenty of business. The surgeons at Kossimack, and especially their dedicated chief of staff, Dr. Bunn, have done more SIGN nails than any other institution worldwide: over 1,300. The nail itself allows for long bone fractures, which are by far the most common orthopedic injuries seen in Cambodia, to be treated with intramedullary fixation. In the US, this fixation technique is frequently utilized in order to stabilize fractures internally and to allow patients to ambulate early after surgery. The alternative is the time tested and reliable “traction” technique, whereby patients with lower extremity fractures are maintained in bed, with traction applied to the affected extremity, until they heal—often upwards of 8 weeks.

Conditions in the operating rooms are sparse. There is air conditioning, but no running water in the rooms. Drapes are cloth and, often, rattled with holes that require multiple adjustments to maintain a sterile field. The surgical trays are sparse: one drill, but otherwise without power tools. There is one needle-driver and one knife blade per set, and generally very little uniformity to the trays themselves. All bone reaming and screw placement is done by hand, and all screws have to be hand tapped. Probably the most glaring difference with respect to the operating room setup is the fact that fluoroscopy is notably absent from nearly all procedures. Of all the frustrations I encountered trying to acclimate to a different system of operating and of administering health care, this was likely them frustrating. Lack of fluoroscopy, or intraoperative x-rays, is not uncommon in the developing world. In fact, the SIGN nail was developed expressedly to avoid the need for fluorography in the OR. But Kossimack hospital has two fluoroscopic machines, one in each of 2 operating rooms, which have been donated. Despite having the machines, the surgeons are exceedingly reluctant to use it, as many believe its use will make them impotent.

It is the care before and after surgery, however, that was most disparate from my own experience. If you were to sustain a femur fracture in Cambodia, say from a moto accident, your family would drive you to the hospital—in a car if you had one, but more likely on the back of a moto or a bicycle. If you had insurance, you could stay in the air conditioned rooms, but if not, if you’re like most Cambodians, you would be escorted to a room with 8 beds, a fan and no linens. For $30 a day, you could stay in the hospital and be provided IV drips, medications and dressings for your wounds. Your family would have to pay this daily fee on a daily basis—actually to the physicians themselves. Food and water, of course, are not covered, and families provide these for patients. Similarly, while nursing care is available for dressing changes and medication administration, family members bear the burden of moving patients to and from bed, changing bed pans and getting the patients up on their feet and beginning basic physical therapy. Not food, of course.. If you needed surgery and could afford the $280 surgical cost in addition to the cost of the implant used, your surgery would be scheduled two or three days after your admission. Your chance of contracting a post-operative wound infection would probably approach 10% if you were young and healthy, and your hospital stay would be about 5 to 7 days (or, as many days at you could pay for.) While these costs seem dramatically low, they are relatively high for Cambodian citizens, many of whom make less than $1,000 annually. Surgical orthopedic care is prohibitively expensive, and many patients simply cannot afford to come to the hospital, at least not initially.

The concept of outpatient care, both pre and post-operatively is a relatively new one at Kossimack. The surgeons there, with the help of World Orthopedic Concern, have recently established an outpatient clinic where patients can be seen. The concept, however, has not yet caught on with patients, many of whom have difficulties returning to the hospital due to lack of transport or job/family requirements during the day.

There are a host of things that I’ve taken away from this experience that I found profound, particularly as I reflect upon them having returned to my comfortable, efficient, wealthy hospital. The first is that it’s very difficult for me, as a surgeon, as one trained to be productive and to fix problems, to work in an environment in which efficiency is not optimized. I found myself, in Cambodia, constantly looking for the next case, trying to find more to do. The pathology is plentiful, but the resources and infrastructure are not: both on the patient side and on that of the hospital. The reality of this, however, was that I had to slow down and observe, think, talk to people and try to get the slightest sense of what it means to be Cambodian. More so even that operating, my favorite part of the day was board rounds with the staff surgeons, residents and medical students, the time each morning when we all gathered to review the week’s cases and discuss treatment plans. This was the time of day when I was most aware of just how much these well trained surgeons are forced to make medical decisions based on non-medical considerations: patients who cannot afford surgery with distal radius fractures get percutaneous fixation under regional anesthesia, patients who I would recommend for operative fixation with plates receive ex-fixes because no plates are available, anywhere in the country. It becomes difficult to define “standard of care”—that standard is so dependent, on patient finances and resource availability.

In the five years since I became a physician, I have, for the most part, stopped noticing just how profoundly our culture is intertwined with the way we practice medicine. The American medical infrastructure is enormous: it is legislative, administrative, medical, financial, intellectual, judicial and even religious. But what would medicine be if there were no government, no legal system, no money, no laws, no religion, no family? And how would you practice it outside of these entities?

When Pol Pot’s regime crushed Cambodia, it crushed not only a people, but an entire infrastructure. And now, thirty years later, the surgeons at Kossimak Hospital are desperately trying to practice medicine with an infantile infrastructure. There are patients, and there is pathology everywhere, and there are physicians who want to fight it. And in this situation, particularly as a surgeon, it is tempting to start formulating a plan—figuring out how we, as Americans or as western surgeons, can show these people how to succeed. But that is a delicate and dangerous thing. It is tempting to see the world in black and white, with good or bad fixation, with good or bad results—but this experience is teaching me that even those are relative.

Pune, India and Kathmandu, Nepal

By: Ravi Bashyal

As part of our residency training experience, we have the privilege of taking part in an international experience that allows us to participate in orthopaedic care overseas. I was fortunate enough to spend time with wonderful orthopaedic surgeons in India and Nepal.

The first week of my experience took me to the Sancheti Institute for Orthopaedics & Rehabilitation (SIOR) in Pune, India. Pune is a vibrant city of about 5 million people about 163 km (101 miles) east of Mumbai. I had the pleasure of spending much of my time with Dr. Parag Sancheti, the current chairman of SIOR.

SIOR has made a strong commitment to orthopaedic resident and fellow education, and many of my experiences there paralleled my training experiences at Washington University. Just as we do here in St. Louis, we began each morning at 6:30am with a morning conference on a specific educational topic, followed by an interactive "board rounds" where ER admissions, pre-operative cases for the day, and post-operative cases from the day before were presented by residents and discussed by the entire group. During my time there, we had a lot of interesting case discussions on treatment options of fairly common orthopaedic injuries. I found that in my situations, our thoughts and algorithms were almost identical. However, in some cases, we found that treatment philosophies, hardware availability, and even differences in patients' cultural/social standards led us down varied treatment paths. This all made for very lively debate, and I learned a great deal from participating.

I was able to participate in the OR and clinic as well. Most of my time was spent observing and assisting in various total joint arthroplasty cases. I enjoyed my time at SIOR, and remain thankful for the gracious hospitality extended to me by everyone there.

From India, I made a short 2 hour flight to Nepal, the rooftop of the world, and home of Mount Everest. The flight itself was spectacular, with amazing Himalayan vistas in every direction. Upon arrival in Kathmandu, I was greeted by Dr. Binod Bijukchhe, who was my main host during my time in Nepal. I had arranged my trip with Dr. Ashok Banskota, one of the co-founders of B&B Hospital in Kathmandu. In addition to founding one of the leading teaching hospitals in Nepal, Dr. Banskota spearheaded the creation of the Hospital and Rehabilitation Center for Disabled Children (HRDC) in nearby Banepa. Established in 1992, HRDC is a unique collaboration between Nepali physicians, the Nepalese Government, and domestic and international donors to provide care to Nepali children while also training future orthopaedic surgeons.

Nepal ranks 115th in the world for adjusted GDP, and the economic hardships faced by many of its rural citizens are extreme. For children, this translates into limited access and availability to adequate medical care, including orthopaedic treatment. HRDC attempts to address these issues by offering access to low or no-cost quality orthopaedic care for Nepali children.

During my time in Nepal, I was able to spend tie at HRDC as well as B&B Hospital. At HRDC, I was able to observe and participate in the pediatric orthopaedic care of indigent Nepali children. At B&B, I was able to work with orthopaedic surgeons in a high volume acute trauma setting. Both provided me with valuable insight into the similarities in education and dedication of the residents and staff, as well as the disparities in resources between the US and Nepal.

The most striking memories I took from my experience in Nepal were from HRDC. Everyday, I interacted with patients with orthopaedic issues that are rarely, if ever, seen in America. The lack of access to care can result in neglected injuries that present significant challenges to both surgeon and patient. Though the hurdles to proper treatment may have seemed insurmountable, I found that both the physicians and patients had boundless enthusiasm, patience, and dedication to help them achieve their goals.

My entire international experience was enriched by the fact that my hosts in both countries were so welcoming and hospitable. The lessons learned from my interactions with patients, staff, and residents were one of a kind, and could only be gained by spending a significant amount of time with them. It also became clear to me how much more can and should be done to help advance orthopaedic care for patients in less advanced health care settings. I am grateful that I had the support to be able to participate in such a program during my residency, and I am sure that I will be returning overseas numerous times in my career.