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.

Bangkok, Thiland

Rounds at King Chulalongkorn Hospital
Bangkok, Thiland

By: Ben Gray

In July of my chief year, I traveled to Bangkok, Thailand for my international elective. Having taken off at 10AM on Saturday morning, I finally landed around midnight Sunday night losing roughly half a day to the time change. I was greeted by the staggering heat and humidity of the monsoon season and would only find out later that these temperatures paled in comparison to their “hot season” in April. When I told the surgeons at the hospital that I walked to work on the first day, they asked if I brought two shirts. I quickly learned the vast size of the city. Roughly 14 million people live within the metropolitan area of Bangkok. Of these, 98% are Buddhist in religion.

 I spent my two weeks working at the King Chulalongkorn Hospital, which is a public hospital that is run by the Thai Red Cross. I was fortunate enough to be hosted by Dr. Noppachart Limpaphayom who completed his pediatric orthopedic fellowship at St. Louis Children’s Hospital with Drs. Dobbs, Schoenecker, Gordon, and Luhmann. His practice in Thailand is a combination of pediatrics as well as general orthopedics. While the Department of Orthopedics at the hospital is robust with several departments, he has inherited all of his previous mentors patients on top of his new patients. Thus, he will perform revision joint arthroplasties and adult spinal fusions in addition to his treatment of pediatric foot conditions.

Administration building, King Chulalongkorn
Hospital, Bangkok, Thiland

The hospital was primarily open air but with air-conditioned operating rooms and clinic rooms. They are transitioning from a multitude of smaller subspecialty buildings (GI, orthopedics, cardiology) to a massive, multicenter facility that should be completed in the next several years. Patient rooms vary from the open wards with 8-12 patients to the private floor dedicated entirely to the Queen of Thailand. If patients do not have private insurance or government insurance, the Thai Red Cross will cover their expenses. The medical training in Thailand is quite different from the United States. Students take a national exam in high school that determines their profession more or less. The highest scores are eligible to apply for medicine. They then complete 6 years of medical school followed by 3 years of obligatory public service in which they serve as a primary care physician in a rural community. They then apply for a residency program, which for orthopedics is 4 years. Whereas in the United States all residents are paid by the hospital in which they are working, this made up only a minority of the residents. Most of the residents were being paid during their residency by a hospital that they had promised to return to practice upon completion. Likewise, they would need sponsors to complete fellowships beyond their residency training. Another contrast was that their third year residents served as their chief resident. They were responsible for calling patients, scheduling cases, and running the services. The fourth year was dedicated to reading and learning the finer points of operating.

 In Thailand, the feet are considered very lowly and you would never touch anyone else with your feet. Your toes thus are never supposed to point at the Buddha as it would be disrespectful. I found out that this is one reason that their hand surgeons do not perform pollicization of the toes for children with congenital hand deformities. Families would not want their children to have toes on their hands as it would be disrespectful. They would however do transfers of the proximal phalanxes from the toes to the hand for lengthening purposes. Somehow this was considered different. In the operating room, infection control was very important. If you entered a room with an infected wound or an open fracture, you were required to change your scrubs, hat, mask…and sandals before entering another operating room. It was striking to me that shoes were not allowed. When you entered the locker room, there was a wall of sandals that you would change in to. I quickly learned that there were separate sandals for the bathroom as well.

One of the interesting cases that I saw was of a young boy with a myelomeningocele and neuromuscular clubfeet. It was explained to me that families traveled a great distance to come to the hospital and most wanted one surgery to fix their child’s problem rather than returning for multiple casting or multiple procedures. Thus, they have adopted the practice of performing talectomies in order to accomplish the correction with one surgery. In the clinics, I was able to see a plethora of diseases that we rarely see in the United States. The residents explained that tuberculosis always has to be in their differential as it can be an atypical presentation of joint pain. Likewise, they are seeing a resurgence of polio. I was surprised to see a large number of patients with osteogenesis imperfecta. I greatly enjoyed interacting with the residents and attendings, discussing the varying ways in which we would treat cases in the United States. English is fortunately taught starting in elementary school and thus they were all quite proficient.

During my time in Thailand, I was able to explore the city and saw several of the beautiful Wats (temples) and experience the amazing food that Thailand has to offer. Dr. Noppochart as well as other residents treated me to several excellent meals and helped me find my way around the city. Overall it was an incredible experience to see a world that is far different from my own. I am extremely grateful to the department for allowing me this opportunity to see how orthopedic surgery is conducted in Thailand.