"winter"

Have I mentioned that it is winter here...igual (equal) que 29 de Diciembre.  It is 8 at night and dark out.  I was just too warm walking a block in jeans, a t-shirt and a blazer.  In fact, it was warmer than many summer nights in Connecticut.  Mild winter.

Pediatric Surgeries

Ok, so where was I?   Tuesday night I went to dinner with some very cool people who own property in Cafayate. Wednesday morning I went to a pediatric cardiovascular surgery.  Wednesday night I went to dinner again with some of the same people and two Argentines.  Then yesterday morning I went back to the clinic 8-2 then class 2-6 and I completely crashed last night.  Dinner is a late affair and went from about 8:30-11:30 both nights.  The days have been long but action packed.  Now I am going to try to catch up on what I saw in the surgeries. 

Two days ago I went with Rene to a different hospital: Hospital Publico Maternal infantil. It is a massive new pediatric hospital that is really nice. We went there to do a cardiac surgery on an infant.  As far as I can understand, the surgical team (Rene as the anesthesiologist, and the two surgeons) contains the only people capable of doing this surgery in Salta, Cordoba and Mendoza  (provinces).  

The surgery was quite incredible and went perfectly smoothly.  The baby girl (37days old) was born with a decending aorta that was nearly occluded.  That means that the blood vessel off of her heart gave off branches to each arm and to her head but then the blood supply to the rest of her body, her abdomen and legs, was barely existent. The surgery required clamping the aorta closed after it gave off the supply to the right arm and head (brachiocephalic trunk for my med friends); cutting out the narrow part; and reconnecting the wide part from below to the aortic arch.  This had to be done in less than 20 minutes in order that the baby not be paraplegic. 

It was amazing to see how they did this surgery.  I was expecting that they would have to violently crack open her chest from the front, but that is not how they did it.  They layed the baby on her side and made a cut between two ribs.  Since our ribs are supposed to move up and down it was not difficult to gently move them apart (easy because they were no longer yoked together).  The opening for the surgery was only a couple inches tall and wide.  Then they collapsed the left lung (her right one is enough to do all the work) and they could access the blood vessels.  

The surgeons were great at explaining to me what they were doing and pointing out things like the recurrently laryngeal nerve and the ductus arteriosis. They spoke only in Spanish but slowly and most of the technical language is the same in English and Spanish.  They completed the detatchment/ reattachment in 15minutes seemingly without effort. 

The important aspect from the anesthesiological perspective is that blood pressure in the brain rises when the aorta is clamped off.  The heart slows in response to the pressure change and returns to normal.  However, this can be dangerous when the aorta is unclamped because the blood pressure can drop dramatically sending the baby into a sort of shock.  Therefore, right before the aorta is unclamped it is necessary to increase adrenaline and add blood plasma quickly.  This transition went quite smoothly. 

After the aorta was repaired there was another part of the surgery.  Because the baby’s blood was backed up, the lungs were getting too much blood.  This caused a change in the way her blood vessels to her lungs grew and needed to be corrected so that the pressure in the rest of her body and in her lungs would have the right balance. Until this point the surgery was completely outside of the cavity where her heart is. You could see the beat, but not the heart, only the lung and blood vessels.

It was amazing to see them open up the sack where her heart was (carefully avoiding the phrenic nerve).  Her heart was about the size of the tip of my thumb to the first knuckle.  It was unbelievable. 

The bottom line is, the surgery was amazing and the baby did very well.

The drawing that one of the surgeons, Juan, drew for me.  They had to clamp at C; cut out A; and reattach to the part near B.

Yesterday there was another infant surgery, this time at Clinica Guemes.  Normally they do not do infant surgeries there but the night before a woman had a c-section and her baby was born with some of her intestines outside her abdomen (basically it looked like there was a bundle of intestines sticking out of her belly button.)  This surgery also went very smoothly but Rene told me that these children often have to have more surgery later in life because their intestines do not develop quite right. 

We also talked a little bit about the payment system for surgeries. One problem that doctors face is that they are paid pretty similarly for each surgery, though not exactly the same.  So the insurance pays Rene a little more to do the pediatric cardiac surgery but it takes the entire morning (most of the time is prep and finishing).  At Clinica Guemes he might do six surgeries in the morning.  This is certainly a disincentive to do the complicated surgeries which I find interesting to contemplate, but he really loves to do the peds-CV so he does them anyway.  

Today in the clinic I successfully started my first IV. (!!) and with some assistance I did my first spinal tap.  Very cool, I think.   

There were no surgeries scheduled in the late morning so I left the clinic, dropped off my laundry, and I am at a café.  After I publish this I am going to pull out my Spanish notes and study until class starts. I was completely exhausted last night (veged out infront of the Spanish food network ElGourmet).  I am glad to have a day to catch up a little.  I was so tired for class yesterday that I could barely focus.

Have I mentioned that there is a rooster in my neighborhood? I hear it every morning and I keep forgetting to mention it.  Did you also see the picture out of my window, pretty much straight out (not the sunset, the other one).  I live in an urban neighborhood.

That is why I love Salta, a city with roosters.

pictures

 The convent on the plaza.

 The plaza on a quiet Sunday.  Ill get one on the week day when it floods with kids after school.

 The view straight north out of my apartment.

The view to the northwest of sunset!

I love my life.

That pretty much sums it up.

I feel so lucky to be doing this and to have such good people here.

I am still enjoying my spanish class enormously but it doesn't change much so there is not a lot to discuss.  We have covered present, future, ser/estar, comparisons, time, numbers, reflexive, questions, the basics.  Tomorrow we start past tense which I have seen before but only very briefly (2hours of the class I took in Farmington.)

Then I went to el Quirofano, the OR, for the afternoon.  There I saw a tonsilectomy, partially saw a prostate removal laporoscopically (with a camera and only three small cuts in the patients skin), a hemorrhoid surgery, and a cesarian-section!  The C-section was clearly the coolest!  It was kind of crazy but totally cool to see them pull the baby out.  He was super cute and healthy.
I also tried to start an IV but failed, not terribly though...better luck next time. 

I am starting to get to know everyone a little better in the department and they are clearly getting to know me better.  They are very patient with me and were helping me by speaking slowly and listening patiently while I formulated my answers.  They were also directing me to better spots for watching the surgeries and introducing me to people who don't know me yet.  I shared mate with them, tried bread with anise (yum) and I might even go dancing on Saturday.  They make me feel very welcome.

Just to top it off, the weather was very mild again today and it was lovely to walk home in the fresh but not chilly air.  I also discovered that if I move my seat closer to the window, I have a gorgeous view of the mountains aka the Andes.  Me gustan mucho.

Surgery is cool and I have a great teacher.

Friday morning started like the day before focusing on the anesthesia.  Except Rene was more determined to speak to me in Spanish only even though he loves speaking in English.  After a couple hours, he had some free time in his schedule (which is rare) so he went to run errands.  I elected to stay at the clinic and follow his partner around, Juan Lopez who is affectionately referred to as JLo :) Since the morning was "quiet" I ended up staying in the surgeries and watching.

It is pretty unbelievable what can be done to the body and it made me appreciate how the human body is much less fragile than I tend to think. We are designed to repair ourselves very well.  And when we need surgical help to do it, we can heal from that too.  

The coolest thing about watching the surgeries was how it made anatomy come to life.  I loved anatomy this year and to see it in action was awesome! 
I saw a tubal ligation (illegal unless there is a medical reason for the woman's saftey), a meniscus repair (in the knee joint), both done laporoscopically.  I also saw a knee repair where the gracilis tendon was irritated, swollen and weak and the man's knee had become dramatically knock-kneed, this was fixed.  There was also a "cyst" in a mans wrist that needed to be removed and yesterday (Saturday) I saw a laporoscopic gallbladder removal.

All in all I would say that Surgery is amazing. 


On another note, I would also like to say that Rene is a phenomenal teacher.  Perhaps because he has been in my shoes when he learned English, but I think there is more to it than that.  He is wonderful at explaining to me in Spanish what is going on.  He speaks slowly and uses limited vocabulary which I know or can figure out. When someone else says something that I do not understand, he re-says it, in Spanish, in a way that I can, often just by slowing down.  I can understand a lot of the medicine too, which he clearly wants to teach me.  He checks often to see if I am comfortable with what I am doing and repeatedly tells me to let him know if I need anything at all. I am very grateful for having him as a cornerstone of my experience here.

First day in the OR

Estoy muy cansada. En la manana, me fui a la Clinica Guemes donde Dr. Rene Cadillo esta trabajando esta semana. Es un anestesiologo... (mas en espanol un otro tiempo.)
  
(I am very tired. In the morning I went to the Clinica Guemes where Dr. Rene Cadillo is working this week.  He is an anesthesiologist.) We went back and forth between four OR's all morning.  I saw some of the surgeries but not much.  More later.  Today I tried to focus on using as little English as possible (although Rene speaks wonderful English).  And started to learn about anesthesia. The surgeries included a carpal tunnel surgery, one for large nodules on a mans hand caused by gout, a hysterectomy and more. 

**(NERD ALERT) The coolest thing was the way they do the nerve block (stop the nerve from transmitting anything) for the hand surgery.  Dr. Cadillo uses an insulated needle except the tip is exposed.  He puts it into the arm with some voltage and can tell when he is close to the nerve because the arm starts to move.  Depending on which muscles move he can tell which part of the brachial plexus (nerves to the arm) he is near!  I thought this was very cool.  Then he can block only the nerves that he needs too!**

All in all it was a great experience and it is clear there will be more to come. After the OR I figured out how to buy a bus card because otherwise you have to pay with peso coins and these are nearly impossible to find. I found a great lunch spot where I successfully ordered a Quiche like thing and a salad with beets, eggs, and carrots.  Yum!  I successfully rode the bus to class and made it home too.
 
I am off to clean up for dinner at Rene's house with his family!  And to figure out how to get a taxi there. Chau.

Day 1

This morning I hung around here, made breakfast, organized a little, then got some empanadas (YUM) for lunch and went to meet my teacher, Patricia.  We took a cab to her place where she has a great classroom set up.

Patricia is great. Native to Salta, her mom teaches English which is how she started to learn.  She used to work for a company in Buenos Aires that wanted a "branch" in Salta, but a few years ago she quit working for them and now does it on her own.  I can tell it is going to be great to hear her and to have to communicate in spanish.  She will tell me the words if I say them in English and then I am supposed to continue in Spanish as much as possible.

It is great to have a personal instructor because we started at the beginning with basics and I am able to move through them quickly, but fill in gaps that I've missed with my self study; and get correction when needed. (For example, we didn't have to spend much time on numbers today because I know them pretty well, but she taught me some exceptions like 700 and 900 are slightly different from the normal pattern.)  She also taught me how to ride the bus home. 

Turns out it is winter here (as of tomorrow technically) and it was chilly on my walk from the bus stop.  I am warming up a bit and deciding what I want to do for dinner...?

arribo

34 hours after leaving, I am here.  Unfortunately tomorrow is a holiday so it isn't time for a shower and bed, it is time to grocery shop! Gonna sleep like a baby tonight.

Almost time!

So, I am mostly packed...I think and about to head to sleep.  Very excited for my trip! 

Just gchatted with the Dr. I am working with and was thrilled to find out that the clinic where he is working now is two blocks from my apartment!  And on the way to the grocery store and the center of everything!  It was especially good to connect with him because we have not connected lately.  It helped my excitement.

I am all set with my apartment and my Spanish lessons.  Finally feels like it is all coming together!  I had a lovely last day here and now I can have some sweet dreams!