Mongolia

 

Excerpts from a Mongolian Mission Journal - Final Part ...for now

Ivan Shulman, MD, FACS

October 26th, 2010 | Comments

Thursday, Sept. 17, 2010

The days have been full since we arrived, and while high-speed internet access has been easier than I expected at times, it is not always available when we might most like it.  The hospital has good connections most of the time, but it is usually late when we are finished with work, and somehow the lines are turned off by that time.

Since the main intent of this trip has been to continue the education of local surgeons in the use of laparoscopic cholecystectomy, that has been the primary aim of all our activities.  Where all of this technology fits into the big picture of medical care in Mongolia remains to be seen, and I have to be honest that there are more than a few times that I have my doubts.  The Russians were the main influence here since the 1920s and while they have left (rather abruptly, I was told, one morning in 1992), their teaching persists in the leadership, both for good and for not so good.  The main connection we have here, both as interpreter as well as for medical and logistical issues, is a very tall man, probably in his early fifties, who is an anesthesiologist and professor at the university in Ulaanbaator. He spent three years learning anesthesia in East Germany in the early 1980s, and later spent time in Arkansas doing additional training.  He is clearly a very bright and delightful person, and it is through his eyes that I get to interpret what I am seeing.  The cleanliness of the hospital, he says, is directly linked to Russian training.  Surgical journals may be available on the internet, but they are expensive and mostly in English.  Since only some of the younger individuals have learned basic English, it will always be a struggle for them to see what is going on outside of the country.  Thus, medical missions such as ours will be the only source of new information that they will get for some time.  Not surprisingly then, I found that the few words of Russian that I do know have gone a long way to bringing smiles to the faces of people around me. 

Food has always been a good reason for me to travel, and I would suggest that there should be no illusions that just because the local customs and traditions might be different from elsewhere, that does not necessarily translate into something that is easy or even pleasurable.  As one can imagine, this is not a very friendly terrain in terms of agriculture or of life in general, and so foods are quite limited.  This is a meat-eating culture, and while we declined the opportunity last night to feast on a freshly slaughtered sheep, to enjoy intestine soup, a meal without meat is not a meal at all.  Lamb and mutton are the most common of these, and while marmot seems to be the second most common of local meats, I actually did eat a stuffed cabbage yesterday for lunch that quite resembled beef and was really delicious.  Mutton soup with vegetables (mostly carrots, a turnip or two, and some potatoes), mutton with rice and potatoes, mutton balls (not the anatomic ones!) with broth, mutton dumplings and mutton soup with noodles have been the mainstay of what we have eaten so far – is there a consistency to this?  I hope that my coronary arteries do not start to complain.  I have not even seen anything resembling the “Mongolian barbeque” that we think of from home, but I do think I will look forward to a scorpion kebab or two at one of the stalls near Wangfujing when I return to Beijing next week.

It is fall here already, and the few leaves that there are, are starting to turn.  With very few trees around, even though they are mostly of the deciduous type, there is not a lot of autumnal color, and it seems that only the setting sun brings out a palette of visual variety to the landscape.  The temperature is still comfortable during day, but drops precipitously at night, and I have taken to wearing my long underwear to bed.  The streets are probably only half paved, and the sidewalks perhaps a third so.  As we were crossing the street the other day, I noted that there was a pipe that seemed to serve as a culvert, through which snaked thick electrical cables whose insulation seemed to suffer the effects of exposure and age.  Most of the people seem to live in compounds defined by five foot high walls made of concrete aggregate, within a combination of gers, frame houses, and housing composed of old, Russian railroad cars, derailed, and de-wheeled.  Probably not surprisingly then, because of the relatively low height of the walls, there are no “extended security means” such as glass shards, applied to the tops of the concrete blocks.  Extended families and resident dogs seem to complete the unit.  A pack of 13 dogs barking in pursuit of something just passed under my window.  Mostly people seem to dress in Western garb, and other than for height, look like everywhere else in Asia.  There must be something in Mongolian genes or nutrition that breeds tall people, for it is not uncommon to see six-footers here at all.  Occasionally, I see people dressed in dells, the traditional long coats with hats that bring a sense of difference to the area.  Lastly smoking, which is so common elsewhere in Asia, is not so common here, and seems mostly to be among the urban dwellers rather than those few I have seen from “the country.”

I have made a few telephone calls during my stay so far, and it never fails to amaze me as to the technologic changes that we have seen in the past few years.  ATM’s have completely replaced traveler’s checks, and internet, Skype or G-chat, and phone cards now are commonplace instead of aerogrammes or letters.  Who ever goes to a post office to find a postage stamp or even postcards?  There must be some who still do, but as a singular innovation, I think that email has changed the face of travel almost more than anything else. 

Breakfast awaits, and we have at least four surgeries to do today:  two pediatric hernias and two gallbladders. Let’s hope that all goes well for all.

73*,

Ivan

 * “Best Regards,” as defined in The National Telegraphic Review and Operators’ Guide, first published in April 1857.

Excerpts from a Mongolian Mission Journal - Part 3

Ivan Shulman, MD, FACS

October 21st, 2010 | Comments

Monday, Sept. 13, 2010

It seems unbelievable to me that I am actually writing from Khovd, in the western part of Mongolia, on my laptop, in a hotel, looking out over the unpaved, dusty streets as the sun starts to rise on another day.  A woman is herding her cow through what serves as a parking lot in front of the hotel, by throwing stones at its rump, as a pack of a dozen large dogs marches around the corner, off to do some damage someplace. From what I saw yesterday, these are not your sweet household pet type dogs, but serious animals who contend with all manner of abuse, from wolves to other animals, as well as competition within the pack.  We are told to grab some stones if we are out walking and come across the dogs.  Life is not easy here.

We arrived in Khovd after our three-hour flight on EZNIS airways, on a propeller driven SAAB 380, crossing a goodly portion of the Gobi desert.  Deserts are obviously not all the same, as the dunes of the Sahara barely resemble anything I have seen of the Mojave, and this one seems to be widely varied as viewed from the air.  There are dune-like areas, with undulating sand banks, to those with vaguely greenish tint which I suppose are grasslands, to lakes, to smooth, Santa Fe stucco-colored sandy flats without obvious changes in elevation.  I was told it was going to be like arriving on the moon when we got to Khovd, and in fact it was. But I now realize that there are many places on earth that must then look like the moon, because it reminded me of the area around Tuba City, Arizona, a lot closer to home than the moon.  Certainly, as the day breaks and I look at the faces of people, the similarities between Mongolian and Navajo visages is quite striking.  Linguistically, of course, there appear to be no similarities, and if anything, one hears syllables that sound vaguely Korean. 

Our hotel is across the street from the hospital where we are working, and of the many hospitals that I have seen in developing nations, this one is about the cleanest yet.  People are constantly washing the floors, and there is no stench that one smells in the tropics.  The only odor one perceives is that of mutton being cooked everywhere, and occasionally, a homeopathic dose of germicide, kept in an assortment of glass bottles everywhere.  The stuff feels and smells like plain water to me, but who really knows?  Ultraviolet lights are turned on in the operating room for example, to help sterilize things. I was told yesterday that the water within the10 liter bottles kept corked in the room becomes sterile through this mechanism.  Interesting.  Intravenous solutions are made in the hospital in on- liter bottles, which are covered with a type of canvas, secured by colorful orange string.

…The young doctor on call, who had been part of the group who had been trained in laparoscopic cholecystectomy last year here in Khovd, had a patient who had been in a truck accident, probably with some broken ribs.  Over the next few days, he developed subcutaneous emphysema.  An unlabeled, unnamed, unoriented CXR was shown to us, which indicated that the left lung had completely collapsed.  The doctor had proposed to take the patient to the operating room to suture the hole in the lung.  The other surgeon in our group, a wonderfully warm and cheery 64-year-old man, has had many years experience working with Italian relief groups in places as disparate as Peshawar, Kandahar, Sierra Leone and Malagasy Republic, looked at me, and it was all we could do to slow down our words to suggest that perhaps placement of a tube in the chest emptying into a water seal bottle might be a better and safer alternative.  Of course, no such chest tube exists in the hospital, and so with the assistance of our anesthesiologist we fashioned one out of an endotracheal tube.  Finding a suitable water seal apparatus was not easy, and we considered cutting apart some strange drainage bottle we found that had been left over by a Swiss team some time ago.  In the bowels of some storage place a single Russian-made thick glass bottle with an appropriate cap was located. With additional tubing rigged from what we had, my colleague directed the Mongolian doctor as he placed this chest tube into the patient’s chest.  Sterile conditions are a relative term here, and it is frequently said, I have learned, that “clean is good enough.”  Maybe, but we offered some antibiotics to go along with what had been done so far.  After some more bleeding than we might have liked, the tube was repositioned and the expected bubbling came from beneath the water seal.  The fellow tolerated this all well, but it remains to be seen as how long it will take for this to resolve. 

Last night, we were taken to the ger of the family of a Kazakh man who is a feldsher, or village medic, about 20 km northeast of Khovd.  I am slowly learning the etiquette of Mongolian traditions, and now understand that what we have been calling a “yurt” is the Russian word for the Mongolian “ger,” and so now, I too shall try to use ger in my vocabulary.  The campsite was on the banks of one of the numerous rivers that traverse the area, and was as colorful as one could imagine, with cashmere goats, sheep, yaks, and a few cattle outside, and inside a warm and toasty comfortable homestead.  It was remarkably warm inside, and with all the Kazakh and Mongolian carpets lining the walls, two beds, a dresser, a wall of medals for horseback riding and family photos, and a central stove vented out the top. I can easily see how the winter can be survived despite the environmental challenges.  The feldsher also captures eagles for training, and we saw at least one nearby, looking well fed and content.  While we were there, a man came up on horseback, complaining of a headache.  Some potion was dispensed, and off he went.  Warm goat’s milk, fried biscuits, fried yoghurt cheese, tallow and yak butter were served, along with local watermelon.  This is not a low fat, low carb diet at all, but if one considers what is available, it seems to work for them over many years.  On the way back, we saw a herd of Bactrian camels (two humpers), and seeing them outlined against the grasslands, the snow covered peaks in the distance, and just the entire sense of foreign, I really did feel that I was on the steppes of Central Asia.  Where was Borodin when we really needed him?

I am off to help with surgery this morning, and need to get going.  I have been served a bowl of hot butter tea with rice, so I had better get my dose of calories early this morning.  A long day awaits.

73*,

Ivan

* “Best Regards,” per The National Telegraphic Review and Operators’ Guide, first published in April 1857.

Excerpts from a Mongolian Mission Journal - Part 2

Ivan Shulman, MD, FACS

October 15th, 2010 | Comments

Saturday, Sept. 11, 2010

We flew out of Beijing Capital Airport yesterday morning. I was impressed at the incredible sprawl that has become Beijing, densely packed areas of industrialization, farming and housing all within short random locations scattered every which way.  For reasons unknown, the pilot flew east, then north, then east again, then north and finally more northwest, and so I used the view to try to see if I could identify the Great Wall, but to no avail.  One would think that if the astronauts could see it from space, I should be able to do the same from 36,000 feet.  With no such luck, I’ll look for it again on the way back next week.  Once over the mountains north of Beijing things settle down to lower level grasslands and finally parts of the Gobi desert become apparent.  It is hard for a non-geologist to characterize the Gobi from the Sahara or even the Mojave but there were certainly only a few manmade structures evident, with some roads and little signs of the presence of anything.  Strangely, as we flew north to Mongolia, the sand took on a vaguely green tint, and one could see that there were grasslands below, amid the bareness, and that must be a part of how the nomadic shepherds exist down there.  Again, I’ll see more today, and as we move on.

Flying into UB was fairly straight forward, and I was actually surprised to see how much air traffic there was in the morning.  It was probably about 75F and with a dry hot breeze, felt not so dissimilar from Arizona or New Mexico.  The hills nearby did remind me of areas in Southern Colorado or Sonoma.  Could they grown grapes for wine here?  Anyone for Mongolian Shiraz in a few years?  We were met by the local members of our team, and taken to the VIP lounge, where our passports were collected and baggage retrieved.  For the 15 or so of us, only one bag was missing, it apparently having been sent from Salt Lake City to Paris, rather than to Beijing – go figure.  That poor surgical resident spent yesterday shopping for new clothes for the trip, something that was not particularly onerous, she said.  We headed to the warehouse where the Swanson Foundation has collected a huge assortment of surgical tools, and equipment over the years, and we began to unpack what had been brought new on this trip, and repackage what we need for our current projects.  The Swansons have apparently done a lot of long-term planning (they have been in Mongolia for at least 11 years) and do understand the need to wean the local hospitals off the Swanson largess, and rather have them step up as equal purchasing partners, to help them develop self sufficiency over time.  It is curious to see what had been a very solidly Marxist-Leninist country now move so far towards a free market economy, and to observe, as we have done elsewhere, the growing pains that this entails. Apparently it was a horrible winter last year, and they lost many head of livestock, so the country is now economically stressed in additional ways. How the Swanson venture will work out for hospitals in Mongolia obviously is unknown now, but it seems like a valiant and fruitful effort to accomplish modern economic goals.

Having reassembled the requisite boxes and bags, I walked around UB for the rest of the afternoon, accompanied by a surgical colleague who is also going to Khovd. He is an absolutely delightful 64-year-old gentleman from Parma.  He is a remarkably kind and generous soul and I am sure that we will spend many hours solving the world’s problems together.  He had been to UB last year for a conference on world health, and together we marched around the somewhat dusty streets to the central plaza, where can be found the Parliament building, the museum, and yes, the opera house.  I’d like to visit the latter on my return here next week, and will try to see what is available.  I’m not into the tourist shopping program, but visited several stores selling beautifully made cashmere sweaters, yak wool goods, camel hair blankets – ah, but if I only felt that I “needed” something like that!  I stopped for a glass of KBAC (Cyrillic spelling)- otherwise known as kvass, a fermented cold brew of yeast, sugar and whatever sold from vats on the street.  I know that perhaps I should be more cautious about things like this, but I wanted to taste it and it was fine – no more, no less.  I know that fermented mare’s milk is on the menu once I get to Khovd, so the relative familiarity with yeast, sugar and water will be mild by comparison.  There are still statues of Lenin, but without a doubt Genghis Khan (Chinngis Khann) dominates everything.  While we in the West may have thought about him as a marauder, a dictator or whatever, here he is revered as the father of the country, and his Grandson Kublai Khan set out to create one of the largest empires ever known.  I am sure that I will get more about this as we go on.  It is an issue of looking at both sides, and there really are two sides to this puzzle, at least.

Its now 5:15 AM and I need to be downstairs to get ready to leave for the warehouse and the airport, so I’ll say 73* again, and try to see what I can learn about the next stage of this venture.  Something different.

Ivan

(to be continued)

* “Best Regards,” per The National Telegraphic Review and Operators’ Guide, first published in April 1857.

Excerpts from a Mongolian Mission Journal - Part 1

Ivan Shulman, MD, FACS

October 12th, 2010 | Comments

Sometimes-locum-tenens surgeon shares his first-hand impressions during surgical teaching mission to Ulaan Baator

Friday, Sept. 10, 2010

…in the few minutes before my plane takes off from Beijing, I’ll try to give you a quick overview of what I will be doing for the next few weeks.

As you know, I had been doing locum tenens work, covering general surgeons in rather rural and remote parts of the US (Ft. Kent and Houlton, Maine, Dansville, NY, Rock Springs, WY).  Last March, I got a call to cover the hospital in Los Alamos, New Mexico, and as you may know, that is very close to everything I have always enjoyed about Santa Fe.  Long story is that after a few visits, I was offered a job at the hospital in Los Alamos, and since November, I have been working there steadily, commuting to and from Los Angeles weekly as needed so that I can also continue my conducting at the Los Angeles Doctors Symphony Orchestra (www.ladso.org). 

During the summer, I got word of a surgical project that caught my interest.  Out of that, comes this email from Beijing.

I am on my way to join with three other surgeons to teach laparoscopic cholecystectomies (removal of the gall bladder through four little holes, rather than the older traditional long incision.)  We are part of a small team of surgeons, nurses, scrub techs and bio-technicians organized by the WC Swanson Foundation of Ogden, Utah, and are headed for Ulaan Baator, Mongolia.  Actually, once we get to UB, as it is more colloquially called, we will spend tonight in orientation with those who have been there before, and in the morning, I am heading with my team of one other surgeon and half the support staff to a town called Khovd, way in western Mongolia, near where Russia, Kazakhstan, China and Mongolia all meet – for me it is a different version of ‘the Four Corners area.”  If you go to Google maps or Google earth, and paste in these coordinates, you will see the hospital where I will be working.  

48.00385, 91.633288

The “kh” sound in Mongolian is pronounced very much like the Yiddish “ch” sound, so saying at least those things in Mongolian may not be so difficult for me.

The team was in Khovd last year, and we are told that over that time, they went from doing five gall bladder operations to 100.  Part of our job will be not only to continue the teaching process, but also to review what they did, and how they might be able to avoid some of the pitfalls of the learning curve which we all have experienced.  There is apparently a little hotel near the hospital where we will stay, and beyond that, I know almost nothing.  Here is a link to a recent TV item in Salt Lake City about the trip: 

http://www.ksl.com/?nid=148&sid=12129702

I am told that after the 3 ½ hour propeller driven plane flight from UB to Khovd, it looks like the moon when you arrive.  So be it.  Over the weekend, I hear tell that the local staff wants to take us on a four-day visit to the hinterlands, and so I suspect that we will go, forsaking two more days of teaching.  It all looks very remote, and I am looking forward to it, of course.  I am reading a wonderful book called “The Wolf Totem” by a Chinese writer Jiang Rong, who was sent to Inner Mongolia (a part of northeast China) during the Cultural Revolution.  He writes beautifully, and if his tales are anything like reality, I am in for something special.

I’m going to be in Mongolia for about two weeks, returning via Beijing for two nights, and then back to Los Angeles for a few days, and will be back in Los Alamos/Santa Fe after that, to begin my weekly commute again.

I had a good breakfast this morning at a Beijing version of quick food, and instead of burgers and other junk, I had congee with chicken, glutinous rice in tea leaves, and some actually not bad Shanghai pork dumplings (not anywhere as good as Hong Kong or Taipei but, hey for the price of one dollar, I was not at all unhappy!)  My tummy is full, and I am looking forward to taking off in less than an hour.

I like the idea of sustainability in medical missions, leaving something more tangible when we depart, rather than just scars and other short term benefits.  I hope this gets fulfilled for me.

73*,

Ivan

 * “Best Regards,” per The National Telegraphic Review and Operators’ Guide, first published in April 1857.

Subscribe to RSS - Mongolia