CBS news on the cons of medical tourism


CBS published a refreshing take on medical tourism – an article reviewing the pros and cons of traveling for medical care along with an interview with an American orthopedic surgeon,  Dr. Claudette Lajam from New York University Langone Medical Center.

Video interview with Orthopedic Surgeon

While Dr. Lajam pretty much rejects any form of medical tourism – she made some excellent points in her interview.  In the discussion, she stressed the need for facility AND provider verification.  She also talked about the need for people to know specifics – and gives one of my favorite examples, “American trained”.

“American trained

As she points out in the interview, this is a loose term that can be applied (accurately) to a Stanford educated surgeon like Dr. Juan Pablo Umana in Bogotá  or in a more deceptive fashion to one of the many surgeons who have taken a short course, or attended a teaching conference within the United States. A three-day class doesn’t really equate, now does it?

The discussion (and the article) then turned to the need to ‘research’ providers.. Now, if only CBS news had talked to me..   That would have made for a more balanced, detailed and informative show for watchers/ readers.

(Telling people to ‘research’ their medical providers falls a bit short.  Showing people how – or providing them with resources would be more helpful.)

“Off-label medical travel”

In addition, the print article should have gone a bit further in discussing the pros and potential consequences/ harmful effects of traveling for ‘off-label’ treatments instead of merely quoting one patient.  Since the area of harm is actually far greater in this subsegment of the medical tourism population due to the amount of quackery as well as the sometimes fragile state of these potential patients  – a bit more discussion or even a separate segment on “off-label medical travel” would have been an excellent accompaniment.

Speaking of which, several weeks ago, I interviewed with NPR (National Public Radio) as part of a segment on medical tourism.  During that discussion we talked about all of the pluses and minuses mentioned on the CBS segment as well as the “Selling Hope” aspect of ‘off-label medical travel” and the potential harms of this practice, as well as some of the issues involved in transplant tourism.  I am not sure how much of my interview, Andrew Fishman, the producer for the segment, will use – or when it will air, but I’ll keep readers informed.

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Start here…


This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.

Why quality of anesthesia matters: who is administering your anesthesia?


Now that Colombia Moda is over – let’s get back to the stuff that really matters.. Let’s warm up but reviewing some older posts for our newer readers.

Guide to Surgery in Latin America

I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring.  But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.

There is a saying among medical professionals about our patients.. We want them all to be boring and routine.   That is what I strive for, for each and every one of my readers – safe, boring and routine.

Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas.  In real life, it means something has drastically and horribly gone awry.  Unlike many of its fictional counterparts – outcomes are not usually good.

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure.  While we don’t know the circumstances behind this case – (and don’t really want to…

View original post 1,047 more words

In the operating room with Dr. Meza at Hospital General de Medellin


Dr. Meza, closing the chest

Dr. Meza, closing the chest

I apologize for the wordiness of this post – but much of what we discuss below is covered in the Bogotá, Cartagena and Mexicali books – the essential mechanisms of cardiac surgery; how procedures work, what is off-pump surgery, when do we use the bypass pump and other explanatory information.  But since I have am not writing a full book on Medellin, I wanted to offer a bit of a primer for my new internet readers here.  

Dr. Luis Meza

Cardiac surgeon, Hospital General de Medellin

After interviewing Dr. Meza and meeting many of the staff at Hospital General de Medellin, it was a pleasure to be invited to observe Dr. Meza and Dr. Urequi , the head of the cardiac surgery department in the operating room. Despite the patient’s young age, the surgery (for me as an observer) was knuckle-biting.  While the surgery itself was a fast, straight-forward and uncomplicated repair of an interauricular septal defect – it was the patient’s fragile condition that had me on the edge of my seat.

Complex patients The case was typical of many of the cases they see at public hospitals.  It was a young patient with newly diagnosed right-sided heart failure due to an uncorrected congenital defect.  The patient had traveled from another part of Colombia (one of the poorer regions) to have surgery.  The patient had initially presented to a local doctor after a syncopal event (passing out) and was found to have an enlarged heart, with a moderate sized pericardial effusion (fluid in the sac around the heart.)  After arriving at HGM, the patient was also diagnosed with a serious acquired coagulopathy (bleeding disorder).

drawing courtesy of Wikipedia (Creative Commons licensing)

drawing courtesy of Wikipedia (Creative Commons licensing)

Since the patient had a hole between the left atrium leading into the right atrium, blood was being pushed from the left atrium (which is under higher pressure) to the low pressure right atrium.  Over the course of many years, this had caused the right atrium to enlarge massively.  As the right atrium was continuously being overfilled (from blood from the left side), the right side of the heart was being forced to work harder, and harder.  As the atrium continued to be overstretched, and enlarged – it also caused blood to be forced back into the pulmonary arteries – causing pulmonary hypertension.  While pre-surgical tests (echocardiogram, and cardiac catheterization) showed the patient to have (only) moderate pulmonary hypertension (with PA systolic pressures of 65mmHg).

Pre-operative testing is only part of the story

However, when we looked down, into the patient’s chest – it was obvious that the patient’s pulmonary vasculature was engorged and enlarged.  The patient’s heart was massive, and floppy (which is a sign the heart is working way too hard).  The patient also had peripheral edema which is another sign that the heart was not working well.

Potential for badness*

So even though, the surgery itself (described below) is not terribly technically challenging (‘like darning socks’ one surgeon used to say) – a lot can go wrong because the patient’s heart just doesn’t work that well to begin with.

* a not-so-scientific term to describe the likelihood of potential complications, problems or adverse outcomes.  These may be unavoidable circumstances in many cases – but the term is a reminder to remain vigilant even during so-called “simple” procedures.

Nitric oxide on hand

This OR does have nitric oxide  – (which we didn’t need), but was available nearby, just in case. Nitric oxide, milrinone and other medications are critical to have on hand in patients with pulmonary hypertension.  Some patients will never need it – others can’t survive without it – and sadly, (in patients with severe fixed pulmonary hypertension),  nothing – not even an assist device is going to make much difference.  While we can try to predict which patients are going to tolerate surgery, it’s not always clear-cut.  Tests (echocardiograms, right heart caths) can predict, tests can give probabilities – but sometimes tests are wrong, and patients who appear to have only ‘mild’ disease do very poorly (and visa versa). Sometimes, we just have to hold our breath as the patient comes off bypass and see.

canisters of nitric oxide in OR #1

canisters of nitric oxide in OR #1

As I mentioned in a previous post – cardiac surgery procedures can be a bit more complicated than many other surgical procedures, and while having something like nitric oxide on hand doesn’t seem like a big deal – it is.  (I have worked in several facilities without these capabilities).   It also speaks to the general preparedness of the staff. But despite the ‘potential for badness’ everything proceeded beautifully with  Drs. Urequi and Meza.  The case seemed to speed by despite the patient’s fragile health.  The entire CPB (cardiopulmonary bypass run) was just 26 minutes with a total cross-clamp time of 31 minutes.)

A little bit about cardiopulmonary bypass – the “heart-lung machine”

In comparison to the congenital repair above, average CPB times for valve replacement run around 100 minutes, 60 to 90 minutes for bypass surgery.  Patients have a higher risk of CPB related complications from hypo/ altered perfusion after long pump runs  .  As the clock begins to exceed 120 minutes, the risk of renal failure, cognitive changes and bleeding problems (as blood cells are continuous smashed/ broken / damaged within the pump) increase.

Perfusionist operating bypass pump aka "hart-lung machine"

Perfusionist operating bypass pump aka “heart-lung machine”

What is “Off-pump surgery”?  Nowadays, lots of people get real excited about “off-pump” surgery because they think that by not using the heart-lung machine, they can avoid a lot of the problems we mentioned above.  But that’s oversimplifying the entire scenario – and one that I find is often used to “sell” a particular surgeon or surgical program.  Off-pump can be safer than CPB cases, for some patients.  But these are usually not the patients that the surgery is sold to.. So it’s important to know what some of the terminology really means.  Just because Hospital X has billboards announcing that they now perform off pump surgery – doesn’t mean that it’s something you may even need or want.

Off pump is not for everyone

Patients have to be fairly healthy to tolerate cardiac surgery without the pump.  People with a lot of the problems that we thought were worsened by the pump, actually fare worse when we try to do surgery without the heart-lung machine. For example, we initially thought that Off-pump surgery would be great for people with renal insufficiency or ‘bad kidneys’ – particularly people who have kidney problems but aren’t quite sick enough to be on dialysis yet. The hope was that by avoiding the bypass pump we could avoid any damage to the kidneys from artificial flow/hypoperfusion because one of the biggest risks of cardiac surgery in patients with bad kidneys is that surgery will cause their kidneys to fail entirely, and make patients dialysis dependent.  Unfortunately, the research from all of the off-pump surgeries being done hasn’t really shown the benefits that we thought it would. So like most things in medicine, it’s not quite the panacea we had hoped it was.  But we did learn an incredible amount  of information once surgeons started trying off pump surgeries for coronary bypass.   Surprisingly, we learned that many of the complications, and conditions that we had long blamed on the CPB pump – weren’t related to the machine at all. But much of this is still being argued by cardiac surgeons every single day – each with different research studies giving different results..

More importantly, Off-pump not possible for many types of cardiac surgery

It’s technically impossible to do some types of cases without the bypass pump.  Coronary bypass surgery (CABG) is very different from other types of surgery, for example.  During bypass, the surgeon is only operating on the outside of the heart – attaching new conduit (arteries and veins) to arteries on the surface of the heart.  So – it isn’t absolutely essential to have the pump circulating blood for him while he’s operating – in some patients – we can let their body do it for us during surgery.

But replacing diseased heart valves, or the great vessels (aortic aneurysms etc) is a completely different entity.  In those surgeries – the surgeon is cutting into the heart or great vessels themselves.  It’s not possible to lop off the top of the aorta, operate on the aortic valve and not have blood being re-directed mechanically during this process.   Otherwise blood would just literally spill out into the chest and never oxygenate the brain and the rest of the body. (The only time we ever do this kind of procedure without a pump is during organ retrieval – for obvious reasons). It’s important to know these distinctions so people understand how the surgery actually proceeds.

For the case today – the surgeon has to make an incision through the side of the atria (wall of the heart chamber) to get to the hole on the inside wall of the heart.)  The surgeon then closes the hole with suture (and a patch, in some cases).  Some doctors do this in the cath lab without surgery – but that’s also controversal because the patch used in the cath procedures in the past has caused a high incidence of stroke.  In a young patient like the one here – you certainly wouldn’t want to risk it – particularly since we don’t know how well those patches hold up in the long term.

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Overall evaluation of today’s case:

Safety checklists, and all pre-operative procedures were completed.  Patient was prepped and draped in an appropriate sterile fashion.  Antibiotics were administered within the recommended window (of time).  Appropriate records were maintained during the case.

Surgery proceeded normally and without incident.

Due to an underlying coagulopathy the patient did require administration of nonautologous blood products (4 units of packed red blood cells, 3 packets of platelets, and abumin) while on pump.  While the facility does not have a ‘cell-saver’ for washing and re-infusing shed blood, patient did receive autologous(their own) transfusion from the CPB pump. This blood, from the CPB circuit was returned to the patient to limit the amount of blood needed after surgery.  Hemoglobin at the conclusion of surgery was 9.6mg/dl, which is within acceptable parameters.

Hemostasis was obtained prior to chest closure, with only a small amount of chest tube drainage in the collection chamber at the time of transfer to the intensive care unit.

Surgical Apgarsdo not apply for cardiac cases due to the nature of the case, and use of CPB.  Mean pressure while on CPB was within an acceptable range.  Patient’s urinary output was less than anticipated during the case (150cc) despite the use of mannitol while on pump, but the patient responded well  (1000+) with volume infusion and the addition of furosemide.

The patient was hemodynamically stable during the entire case.  The was a very brief transitory period of hypotension (less than 5 minutes) near the conclusion of the case, which was immediately noted by anesthesia and treated with no recurrence.

On transfer to the unit, the patient was accompanied by several members of the OR staff, including Dr. Meza, the anesthesiologist, and the perfusionist, each of which did a face-to-face “hand-off” report of the patient (and medical history) including the course of the surgical procedure (including medications given, lab values, procedural details) to the Intensivist (physician), with ICU nursing staff attending to the patient.

Transesophageal echo (TEE) was not performed during this case, but was available if needed.

Also, I am happy to report there were no smartphones or “facebooking” in sight.  No one appeared engaged in anything other than the surgery at hand.

The cardiac OR


If you’ve never been to the cardiac operating room – it’s a completely different world, and not what most people expect.  For starters, unlike many areas of health care (particularly in the USA), the cardiac operating room is usually very well staffed.

 OR

Just a few of the people working in the OR. (photo edited to preserve patient privacy)

For example, there were eight people working in the operating room today:

Dr. Luis Fernando Meza, cardiac surgeon

Dr. Bernando Leon Urequi O., cardiac surgeon

Dra. Elaine Suarez Gomez, cardiac anesthesiologist

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient's privacy)

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient’s privacy)

Ms. Catherine Cardona, “Jefe”/ Nurse who supervises the operating room

Ms. Diana Isobel Lopez,  Perfusionist (In Colombia, all perfusionists have an undergraduate degree in nursing, before obtaining a postgraduate degree in Perfusion).  The perfusionist is the person who ‘runs’ the cardiac bypass machine.

Ms. Laura Garcia, Instrumentadora (First Assist)

Angel, circulating nurse

Olga, another instrumentadora, who is training to work in the cardiac OR.

This is fairly typical for most institutions.

Secondly – it’s always a regimented, and checklist kind of place.  (I wish I could say that about every operating room – but it just wouldn’t be true.)  But cardiac ORs (without exception) always follow a very strict set of accounting procedures..

For starters – there are labels.. For the patient (arm bands), for the equipment (medications, blood products etc..)  even the room is labeled.

Sign on operating room door (edited for patient privacy)

Sign on operating room door (edited for patient privacy)

Then come the checklists..

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

The general (WHO) operating room checklist.  The perfusionist’s checklist.. The anesthesiologist’s checklist.. and the big white cardiac checklist.

by then end of the case, this board will be full..

by the end of the case, this board will be full..

The staff attempts to anticipate every possible need and have it on hand ahead of time.  Whether it’s nitric oxide, blood, defibrillation equipment, or special medications – it’s already stocked and ready before the patient is ever wheeled in.

Most of these things are universal:

such as the principles of asepsis (preventing infection), patient safety and preventing intra-operative errors – no matter what hospital or country you are visiting (and when it comes to surgery – that’s the way it should be.)

Today was no exception..

In health care, we talk about “OR people” and “ER people”.. ER people are the MacGyvers of the world – people who thrive on adrenaline, excitement and the unexpected.  They are at their best when a tractor-trailer skids into a gas station, ignites and sets of a five-alarm fire that decimates a kindergarden, sending screaming children racing into the streets.. And God love them for having that talent..

But the OR.. that’s my personal area of tranquility.

This orderly, prepared environments is one of the reasons I love what I do.. (I am not a screaming, “by the seat-of-your-pants”/ ‘skin of your teeth’ kind of gal).  I don’t want to encounter surprises when it comes to my patient’s health – and I never ever want to be caught unprepared.   That’s not to say that I can’t handle an emergent cardiac patient crashing in the cath lab – it just means I’ve considered the scenarios before, (and have a couple of tricks up my sleeve) to make sure my patient is well taken care of (and expedite the process).

That logical, critical-thinking component of my personality is one of the reasons I am able to provide valuable and objective information when visiting hospitals and surgeons like Dr.  Urequi’s and Dr. Meza’s operating room at Hospital General de Medellin.

In OR #1 – cardiothoracic suite

As I mentioned in a previous post on Hospital General de Medellin, operating room suite #1 has been designated for cardiac and thoracic surgeries.  This works out well since the operating room itself, is modern and spacious (which is important because of the area needed when adding specialized cardiac surgery equipment like the CPB pump (aka heart-lung machine).  There are muliple monitors, which is important for the video-assisted thoracoscopy (VATS) thoracic cases but also helpful for the cardiac cases.  The surgeon is able to project the case as he’s performing it on a spare monitor, which allows everyone involved to see what’s going on during the case (and anticipate what he will need next) without shouting or crowding the operating room table.

Coordinating care by watching surgery

For instance, if the circulator looks up at the monitor and sees he is finishing (the bypasses for example), she can make sure both the instrumentadora and the anesthesiologist have the paddles and cables ready to gently defibrillate the heart if it needs a little ‘jump start’ back into normal rhythm..or collect lab samples, or double check medications, blood products or whatever else is needed at specific points during the surgery.

More on today’s case in our next post.

“Chose Colombia” campaign for medical tourism


As Colombia’s profile continues to rise as a medical tourism destination, Proexport is launching a new campaign which will air on international media such as the Discovery Health channel.  As reported in the Curacao Chronicle, Colombia is becoming a destination of choice for high complexity medical procedures, and expanding to include visitors from a myriad of destinations, including North America.

 

Historically, patients from the Caribbean have come to Colombia for medical tourism due to the lack of even basic services in most Caribbean nations – which is something travelers should keep in mind now that Barbados, and several other islands have launched their own medical tourism campaigns.

The growing role of Planet Hospital in Colombia

The only alarming part – appears to be the heavy participation of Planet Hospital in the world marketing of Colombian medical services.  Planet Hospital, a massively successful medical tourism company, which proudly exists in a ‘no mans’ land” of ethics (according to founder, Rudy Rupak).   The company also prides itself on its global forays into surrogacy and transplant tourism, both of which are highly controversal.

Selling babies… and organs

While people can continue to argue the ethics of the surrogacy baby trade, the murder of Chinese and other citizens for organ transplantation should give anyone pause.  Or the fact, that companies like Planet Hospital will send potential patients to someone who isn’t even trained in transplant

But that hasn’t stopped Planet Hospital in their quest, the ever-expanding global tourism empire has seemingly become more bulletproof in the last few months.  Multiple websites, blogs and news articles that detailed corruption and casualities (as well as problems behind the scenes) at Planet Hospital have seemingly disappeared.

Now it appears Planet Hospital will be adding  Colombia to it’s stables and laughing all the way to the bank.

Sunday lunch: the food of Antioquia


So, my talent runs short when photographing food..

tipico

As I may have mentioned before, the regional cooking of Colombia varies quite a bit.  Cartagena and the other Atlantic coastal areas, are famous for the Caribbean influence of the local cuisine which is heavy on fried plantanos, fish and a caribbean (caribe) curry type flavor.

Bogota, as a more mountainous but cosmopolitan area boasts a ready mix of flavors, but also have delicious traditional dishes such as Ajiaco, and  my personal favorite, morcilla.

We’ve talked about the tamals of Tolima.. and the vast array of fruits and vegetables, many of which only exist here (or in very specific areas of Colombia).  I have an intense love for chonteduro, feijoa and uchuva myself.. There is another blog, by a fellow traveler – who documents his delicious encounters with numerous varieties of Colombian fruit.

found mainly around Cali (and some parts of Panama)

found mainly around Cali (and some parts of Panama)

While I mainly write about surgery and such, I think it’s important that visitors to Colombia have a chance to experience the rich abundance of this country – and no where is it more evident than in the streets, fruit markets and grocery stores due to the readily availability of fruit.  No visitor to Colombia should ever leave thinking Colombian cuisine is just arepas, empanadas and frijoles.

concord grapes, uchuva, mangos, brevas, strawberries, guava and mangostinos are just a few of the delicious (and cheap!) fruit grown in Colombia

concord grapes, uchuva, mangos, brevas, strawberries, guava and mangostinos are just a few of the delicious (and cheap!) fruit grown in Colombia

Mangostinos are a particular delight – with an inedible hard shell, but a creamy, smooth and amazingly rich/ sweet interior.

Mangostinos (and brevas) with rich creamy interior of mangostino visible.

Mangostinos (and brevas) with rich creamy interior of mangostino visible.

But the food of Medellin, the food of the ‘paisa’ has its own flavors.. Hard to know where to start – and you don’t want to get locked into thinking ‘bandeja paisa’ is all Medellin has to contribute to Colombia’s culinary culture.

But I am fortunate enough to live with a native Medellinesa, Diana, who (among other things) is an excellent cook, so I can pretty much label “Authentic Cuisine of Antioquia” to most of what comes out of the kitchen, with the exception of the few paltry and miserable offering of my own.  (I am not a good cook.)

DeAna, with Olle Petersson

Diana, with Olle Petersson

So for Father’s Day lunch, we had grilled pork with a grape sauce, rice and a ‘green salad’ made of green tomatos, mild onions, avocados and a light dressing along with a creamy vegetable soup.  (Sorry I don’t know all the foodie terms like compotes and such – but it was delicious all the same.)

creme of vegetable soup, pork with grape sauce, green salad and rice

creme of vegetable soup, pork with grape sauce, green salad and rice