An example of cool people.

Another quick fun thing to share about why people are so nice and friendly here!


This afternoon, as I finished my jamon y queso tostado,  I was glancing at foodgawker.com (check it out!) and the waiter/manager/chef walked by and said "que rico" (how delicious). To which I responded, "Si, me gusta cocinar. Y esto ayuda encontrar..." "Yes, I like to cook and this helps me find recipes (which I didn't know the word for.)

We then discussed tamales and humitas and what the difference was.  Turns out that tamales are made with maiz and humitas with choclo, which is I think like saying that tamales are made with corn meal or the type of corn that goes in corn meal and humitas are made with a sweeter fresh, corn on the cob.

After this conversation and a bit more he invited me to come back, when I want to come.  Yup he invited me to the kitchen of his restaurant because I like to cook and because cooking is like medicine, it is very different to study it and read it, than it is to have someone show you.

Stitches and stuff.

I have been completely enjoying Cafayate. In all ways: food, atmosphere, weather, company, etc.  I am recovering from Dave's departure as well. Monday we had a fabulous lunch and I got some wicked tan lines (winter sure is rough here).  We had a tasty dinner too.  Then he left on a bus at 5:00am for Salta, and his subsequent return to the US. He is currently in Miami, in the middle of a 15hr layover.  Ugh.

Yesterday morning I went with Dr. Vargas to the hospital in San Carlos, a small town of a few thousand people, 22km north of here. It functions as a kind of walk-in clinic with a few beds for inpatient and one labor and delivery room. It is tiny. There was a single patient staying in the hospital.  She was there for significant stomach pain, and a classical Murphy's sign. (This indicates that she has an inflamed gallbladder and means that when you press on her stomach near her ribs on the right, she pauses during inhalation because it hurts when he diaphragm pushes her gallbladder to close to your hands.)  Otherwise, we saw about 10 patients there several post-op and a few others.

Today at the hospital in Cafayate, I did my first stitches.  I stitched closed the cuts for a laporoscopic surgery. (aka a total of about 8 stitches.) Of course I felt pretty good about this.  Also, the surgeon taught me how to gracefully make knots which I practiced for about 20min after using thread tied around the arm of a chair.  Everyone got a good laugh out me sitting there tying knot after knot, myself included, and now I am also much more graceful at knot tying.

Later on I assisted in a hemorrhoid surgery. (After doing the spinal block.) The assistance the surgeon needed was more simple that for some surgeries so the second surgeon did another small procedure while I helped the first.  It is interesting to get the perspective of the surgeon now, in addition to the anesthesiologist.

I also went to the consultario (clinic) after the surgeries and saw how several of the appointments go. The practice with my Spanish is constant and applying it really helps.  I even read a little of a textbook on OR nursing (in Spanish) and could pretty much understand it. 

When the appointments were over, I returned home and Skyped with some fam for a while which was lovely.  Then I dropped off my laundry, just finished a ham and cheese sandwich at Fabiola's and am going to go exercise.
 I made the mistake of starting "Game of Thrones" yesterday after the hospital since Dave had left and I was alone. I read about 1/4 of the book before bed.  Hopefully I can finish all of them before school starts again.  I have a feeling it wont be a problem.

Back at it.

(A rare winter cloudy sky Sunday, when we arrived in Cafayate.  Hasn't been a cloud since.)

We arrived happily in Cafayate Sunday evening and have been enjoying sleeping late and relaxing.  This is the start of a two week school winter vacation so Cafayate is buzzing with Argentinian tourists and others as well.

Feeling a bit back to normal today. After a few days of pure vacation and practice with castallano (more common here than espanol). I am back in the swing of things. I started this morning at the hospital in Cafayate, under the guidance of Dr. Carlos Vargas, general surgeon.

My walk to work at sunrise.

This morning when I arrived, Dr. Vargas was doing diagnostic ultrasound. Here, gallbladder problems are very common, so mostly, that is what he looks at. I saw two normal gallbladders before we continued to rounds. From about 8-9 all of the doctors (and I think head nurses) round on all the patients in the hospital. I would estimate that there are about 10 beds for children and 10 for adults with an additional 4 each for intensive care. There is also a labor and delivery area that is pretty small, but has space for about 8 newborns. During rounds I was introduced to everyone and especially to Norma, the head doctor (I think).

Next we went to the quirofano (OR) I had a little more chance to get to know the other doctor, intrumentador y enfermera (nurse) there. They all complimented my spanish, especially once they found out that I haven't taken classes before. I of course appreciated that and then continued to miss half of what they said. It was really good to be back to speaking spanish. And while some of the other doctors (on rounds) clearly speak some english, they know I want to learn spanish and the folks in the quirofano seem pretty limited to spanish. I am very happy about this.

There was a laporoscopic cholycystectomia first this morning (have I mentioned that they are very common). They were unable to simply pull the gallbladder out when it was detached because it was so full of stones. I knotw this because they needed to remove the stones. If I had to esimate I would say that there were a good 3 tablespoons of stones before they successfully removed it.

After the first surgery there was a little down time so Dr. Vargas gave me a tour of the rest of the hospital, did an ultrasound on an ER patient and introduced me to the director of the hospital. Everyone gave me warm welcomes and invited me to do whatever I want while I am here.

For the second surgery, I scrubbed in! (first time) (means I got totally washed and dressed in sterile garb, and got to help (kinda). The surgery was a hernia repair and they debated on whether it was an old direct hernia or a new one, but I didn't understand the resolution. I held a retractor and was able to feel the hernia before repair. It was great to be as close as I was because it was a lot easier to see how careful and deliberate every movement and cut was. They nicely explained all of the layers of fascia (connective tissue) and exactly what they were doing. Again, all in castallano.

That was it for the surgeries today. Tomorrow is c-section day.

I left the hospital and got a cab to La Estancia for a nice late lunch with Dave, however, power is out here so I am blogging and waiting to see if it comes back on.

My walk home.

Don't worry Dan, there is a place for visitors to play futbol while they wait (v. the neighborhood kids.)

Too much fun

As happened last time we were here, I/we started having too much fun and then our blog dropped off the face of the earth... more or less.

There is no way that I can possibly describe in appropriate detail all of the things that happened after last Sunday morning so here is a laundry list of what has passed:

Tilcara- went with Daniela, her niece and two daughters, bought veggies at a market, took lots of pictures of the drive.
Asado- Daniela's family and Rene's friend Dr.Carlos, and his family came up for an asado (giant BBQ) Sunday afternoon.
Salt Flats- Monday after leaving the house, we drove up to the salt flats which required crossing the Tropic of Capricorn (for those interested in latitude).
Jujuy- stopped at Daniela's family's home in Jujuy on our way back to Salta, had some more amazing food and celebrated Rene's bday- complete with birthday cake firework!
Made it back to Salta after 10 on Monday night.

Dave started his journey here about 5 hours later!  Made it seamlessly here for lunch on Wednesday.
We have been enjoying eating here together.

I finished up my classes in Espanol and continued in the OR.  Yesterday was my last day it was an interesting one too.  I successfully did an entire lumbar puncture by my self.  In fact I performed all of the anesthesia (supervised of course) for an indirect inguinal hernia surgery.

After the OR yesterday we went back to Juan's (La Cordobesa @ Leguizamon y Martin Conejo).  We shared a fabulous wine with Rene and a bit of food.  We spent the afternoon wandering around Salta a bit more.  Had some coffee, a fabulous burger (complete with corn, an egg and some awesome tomato, egg, mayo type sauce).

                                                          Rene (left) and Dr. Carlos

Then we got to do the coolest thing!  Rene's family, Dave and I were invited to join Dr.Carlos at a very special asado.  He has a friend who is a gastroenterologist but owns a farm about 20minutes south/southeast of the city. Once a year, for decades, his family slaughters pigs.  Then they have a massive asado.  Rene said that even for his family, it was a special event.  The food (pork) was amazing.  The people were so welcoming and friendly. The hosts kept pulling things off the fire and as they cut it, they specifically called out my name and gave me two pieces of whatever so that Dave and I would be sure to try it.  It was definitely a Spanish speaking event, and while I know I missed things, I was far from mute the evening.  Dave talked with one of the farmers about his tobacco crops and the difference in Argentine and Brazilian tobacco.  They talked quality, oils, burn and minerals.  They talked about the difference in shade tobacco in CT and what is grown here.  It was fabulous as well.

In an hour we will be packing up and heading to Cafayate!  I am so excited to continue this adventure.

Big Four Days

 

Well its been a big few days.  I am have been having too much fun so I haven’t been writing.  As it is I am sneaking in a quiet few minutes to start this post. Friday was a quiet morning at Clinica Guemes but that meant it was a good time to learn.  I have been pretty consistent in starting IVs which is awesome.  I also tried to do a lumbar puncture again, but needed help. The most exciting part was that I learned to intubate!  I mostly intubated two patients, with Rene’s close guidance. It makes so much more sense now…pretty cool. I have also finally figured out manual ventilation with a mask where I can manage the mask with one hand instead of two.

After class Friday afternoon I went to La Cordobesa, the almacen that Rene’s friend Juan owns (corner of Leguizamon and Martin Conejo).  I enjoyed a bunch of wine, some picada and some hot dogs.

Now (Sunday morning) I am in Purmamarca with Rene and his family.  He rented a house outside of town for the long holiday (Independencia, 9 de Julio) and his birthday (9 de Julio).  

I took the bus here, it was easier than I thought.  Platforma10 is the best website for looking at some major bus routes, like Salta to Jujuy.  Otherwise, the internet is not the way to go.  I took the bus to Jujuy (San Salvador de Jujuy) and at the bus terminal there, just walked around to the dozen or more bus companies that had signs indicating a bus to Purmamara. One had a bus leaving 2hours after I arrived, which would have been fine, I could have wandered Jujuy a bit, but I asked “hay un collective mas temprano”  “is there a bus earlier” and she directed me to Evelia.  They had a direct bus to Purmamarca leaving in about 10 minutes.  Perfect.

Purmamarca is (as described in Lonely Planet) more than anything, in the most beautiful location. It is clearly very touristy, but it is nice to get to be a tourist a little.  The place the Cadillo’s rented is 1-2km outside of town and it was a warm sunny afternoon, perfect for a walk. (Saturday)

It is incredible here.  Beautiful and empty.  There are many trucks that come by on their way from Chile to the rest of Argentina and to Bolivia.  Especially common are truckloads of used cars on their way to be sold in Bolivia. However, when the trucks are not passing, which is still pretty often, it is completely silent here. I haven’t been somewhere this quiet in a very long time.

Today, I am going to go with Daniela and anyone else to Tilcala. 

I was very lucky to be invited to join the Cadillo’s here for this trip. I do not know how to express my gratitude for their welcome.  Hopefully I can repay it someday.

(this is incomplete as I wrote it Sunday Morning and it is now Monday night, but I will edit this post later with more info)

Just a view from the bus window.

The center of Purmamarca

A shot from my walk up to the house. 

 Los ninos y los chanchitos.

 Just a view from the car.

 Yup.

 Oh and a picture of me!

 Some vicuna, wild on the side of the road.

Las Salinas (the salt flats)

cell phone in Argentina

I wanted to take a minute to describe how I easily and painlessly got a cell phone in Argentina for cheap. In general cell phones are expensive in Argentina so when I say cheap, I mean I use it infrequently, but easily.

I have a Droid2Global phone by Motorola.  It has a SIM card and is global ready.  It is possible to simply pay to use (Verizon or other) service in Argentina but it is insanely expensive (like $5/min).

Instead, I unlocked my phone and got a prepaid-SIM card from a local cell phone company.Here's how:

1.  First I called Verizon, before I left the states and I asked them to please tell me the unlock code.  It was not perfectly easy to get the right person on the phone, but it wasn't terrible.
For Verizon Call : Global Customer Support Team at (908) 559-4899.  I think I needed to speak with technical support. I said something to the effect of "I am travelling abroad where I will not be able to use Verizon service.  I would like the code to unlock my phone. I am prepared to aggree to the terms and conditions," (such as, I can't call Verizon for help when I have another SIM card in my phone, duh?!)

2. I showed up at the main Movistar branch in Salta (I expect that this would work at Personal or Claro as well)  I went to reception and asked for a prepago chip (aka a prepaid SIM card).   With a little bumbled spanish and english, but plenty of smiles, the woman got me a chip an a phone number. We put the chip in my phone, turned it on, it asked me for the unlock code (make sure you have your unlock code available) and I was all set.  It cost me nothing.

3. Next I went next door to the telefonico (or something close to that) and I handed her a piece of paper with my number on it and I said I wanted to recharge it (recarga).  It was possible to charge either 30pesos or 60pesos.  Be warned that the charge does expire after about a month.


So for about 30min of time or less, and 30pesos ($6.67USD) I have a cell phone that I can use to get in touch with people here.  Calling is still much more expensive, although I think it is free to receive calls, and texts are about 0.60pesos.

los colectivos (the bus in Salta)

In Argentina the buses are referred to as colectivos, not autobuses.

I must say, I love the buses in Salta.  (Once I had a bus card). 

There are a lot of bus routes in Salta, they are not perfect, but they are pretty darn good.  There are 8 general routes that the buses take, but most numbers have more than one route i.e. 7A, 7B, etc. The buses are most useful for exiting the center of Salta, such as going to Spanish class for me. 

The bus that I take every day to and from class picks me up 2 blocks from my house and half a block from Clinica Guemes, where I have been spending most of my clinic time.  I was nervous about learning how to get my stop the first time because I had no idea how to figure it out, but the city is laid out well so I knew I had to get off the bus at Tomayo, which I am pretty sure is not labled, but I also knew that the address I was going to is 2240.  It is a block over from the bus route, but the blocks are numbered the same, so I could just watch the numbers climb as we passed houses and businesses and when we hit 2100, I hit the button to stop and viola, I did it.

The bus comes frequently and is way more convenient than any subway system, even than DC. It works because traffic is never really bad in Salta, many people walk and take the bus system so a "slow ride home" might take 15-20minutes instead of 10-15 in good traffic.

Another thing I like about the bus system is the courtesy that continues from other parts of this country.  If a child or an elderly adult gets on the bus, immediately, a person in a seat gets up to give it to them.  Many times during rush hour the buses get very crowded so it is even more helpful, and more of a sacrifice, but this is the norm. It is also the norm in places like banks to let elderly adults and adults with young children or pregnant women to the front of the line. It makes perfect sense but never happens in the US outside of some public transport and I haven't noticed it in other countries.


Some tips for anyone who wants to ride the bus:

Another thing to know is that there are specific bus stops within "el centro" but after that a bus will pretty much stop on any corner, so if you want to take the bus back, just lift up your arm when you see it and it will stop for you.  Likewise, just press the button to stop at any block you want.

You must pay for the bus with coins in exact change but it is difficult to get a hold of coins here. So with a card, just like a metrocard at a major US city, you hold your card near the machine and it prints you a receipt so that if "an authority" comes on the bus, you can prove you paid.  There are signs at many kioscos "SAETA RECARGA" at any of these kiosks you can buy a card (6 pesos right now) and recharge it as needed.  These locations are more or less listed on the bus company website as well.

If you need to find a specific stop within the city, google: saeta nuevas paradas and the PDF you find has a map of the stops in the center. Easy.
 
www.saetasalta.com.ar/

a little about life

So it is high time that I wrote about more than medicine, although it has been consuming a lot of my time and thought...

The lifestyle in Argentina is similar to Spain (as I understand it). In general there is siesta every day and dinner is late at night.  There are often four meals a day.  The "fourth meal" is often called "tea" and is a light snack eaten around the hours that most people eat dinner in the US.  Dinner is usually started later than 9.  Also, no one shows up on time (almost no one)  For example, last night I was invited to dinner at the Cadillo's again and invited to come at 8.  I showed up at 8:30 and I still felt early (although totally welcome).

I want to mention that Rene and Daniela's children are completely adorable.  I love the sound of Antonella's laugh, a sweet constant giggle.  I love practicing my Spanish with Paula. Last night they were excited to find out that used to teach dance.

Last night for dinner we had picada y postre.
Picada is like antipasto, complete with:

 olives, homemade pork pate, pickles, and pickled onions and garlic.  Yum

and ham, mortadella and prosciutto (I had to look up the word because all I could come up with was jamon crudo.)

and homemade empanadas!!!  With diced beef, eggs and herbs; or cheese. In Salta empanadas are always baked, not fried.  Love them.

For dessert we had a strawberry and cream tart and a bunch of different types of cookies (most containing dulce de leche). 
Of course dinner was also served with agua mineral con gas and wine from the area.

Tonight I am invited out again to return to the almacen (where I went Saturday afternoon) to enjoy more wine, picada and conversation.  It is great practice for me to go out and I enjoy the company but my alarm certainly comes early every morning and siesta does not exist for medicine. (Surprise surprise)

otra cirugia (another surgery)

Today I returned to the Hospital Publico Maternal Infantil for another cardiovascular surgery.  This time the surgery was for a 13 year old girl who had an atrial-septal defect, that means a hole between two sides of her heart that serve as a kind of reservoir for blood. (Not the ventricles which do most of the pumping.) 

Unlike last week, this girl had a nearly fully grown heart.  I was blown away by what it looked like while it was moving.  When we are taught about the heart we are taught that the electrical impulses that cause contraction, move through the muscle in a particular pattern, but then when we talk about the heart pumping we almost describe it as a uniform stiff strong contraction.  For me this is not what it looked like at all.  For me her heart wiggled and danced with waves of motion that were so soft and elegantly coordinated.

The surgery required temporarily bypassing her heart using a blood pump.  As soon as the bypass was complete her heart almost looked deflated.  The heart is meant to be dynamic in size so it can effectively pump what ever blood comes its way.  With out blood flowing through her heart, it shrunk to less than half the size from before.

Next, in order to operate, they use a special "blood substitute" into the coronary arteries. This literally stopped her heart. They were then able to open her heart (by cutting into the right atrium) and sew closed the hole between the atria.  I was taking turns in the good viewing spot at the patient's head with the anesthesiologist.  At first when I saw them sewing the defect closed it looked like they were sewing up a valve.  I was not expecting the tissue to look like that, although it makes sense. (Sorry non-med people, you'll just have to trust me on this.)

The actual repair of the girls heart took, maybe, 5 minutes.  It was over so quickly I could barely comprehend.   After they finished and her blood was successfully returned to her own circulation, they continued to clean up and close up.  The thing that struck me during this process is that the free edge of her right lung kept moving in and out of the scene.  The way it moved reminded me of waves lapping at the shore.  It expanded into view and part way over the heart and then receded again with each breath. 


In case you haven't noticed I am trying to capture things that I find amazing and beautiful that I am sure I will loose sight of in in time.  The intimacy and trust in the OR and the view that it gives me of our bodies is something special. I am sure I will continue to appreciate this at some level, but I am also sure the novelty will wear off and I might forget how beautiful a heart beat is.

Parade!

Despite asking several people and googling a bit, I still do not understand why there was a MASSIVE "procesion" (relgious parade) yesterday.   There were at least two kilometers of roads in Salta filled with gauchos and their horses.  It was incredible.  Many others also marched the parade. All I know is that it had something to do with the Virgin Mary.  Other than that, your guess is as good as mine.  I was out in the morning yesterday (Sunday) for a bit, then I came home and was studying for a couple hours with the windows open and I could just hear loud projections of something over a city wide speaker system.  I decided to check out what all the noise was about (besides, I wanted to go out anyway to enjoy the sunshine and move some more).

 Typical gaucho clothing for the region.  I learned that the red is to represent blood and the black stripes to represent mourning.

 This is three lane road plus there a usually cars parked on both sides.

 The horses are on the shady side of the (four lane plus parking) street.  The horses continue past the second tall building in the photo.

 And they keep going!

 This is the crowed by the square where the main announcements were happening, however there is a speaker system throughout the city (V for vendetta style) so you could hear the announcements and singing everywhere.

 Many of the groups carried pictures of Mary with gorgeous floral arrangements.