Medics2Mongolia

Our last day at the rural hospital was cut short due to an impromptu trip to the countryside of the countryside (Inception countryside). Our new friends in the form of: Dr Bhaa (Ophthalmologist), ‘Honey’ (Neurologist) and Togi (Interpreter) told us the clinic would finish at lunch time and they would take us for a picnic.

We stopped off at a Ger of Dr Bhaa’s family on the way. Airag was ‘forced’ down us, not a particular favourite but it is rude to refuse as well as point and pass with your right hand. After indulging with the family we went to the river beside a house that looked like it was from ‘Little House on the Prairie’, definitely out of place in Mongolia.

After delving into the picnic we were introduced to a drinking game involving the Mongolian equivalent of Rock, Paper, and Scissors but using all 5 digits of the hand (the one above beats the one below).  We were split into 2 adult teams of 4 members and the losers had to drink a bowl or Airag between them. Matt was lucky he had an experienced Mongolian on his side, which went through our entire team without losing. The losers (Sid and Ross) were soon hit with the punishment; you had to drink a full bowl by yourself. The tastes of this ‘speciality’ was highlighted by Sid taking a very long time to down, or sip, the Airag (3min.50) - Ross demonised it (27secs)

He soon paid the price and didn’t make it to the poker night arranged by the peace core, which involved using bottle caps, gambling a hefty £1.50 worth of Tugrog and enjoying the delightful snacks of Mongolia (peanuts and paprika crisps). All this said it was a very enjoyable night with American-English banter comparing the likes of baseball with cricket.

Before leaving we met another team that failed to complete the Rally, this Spanish team had broken down (unfixable) a mere 7 hours away from Ulaanbaatar. We felt their pain but at least they made it to Mongolia.

We wished we had arranged a longer time here.

Last week we packed our bags left the comfort of our apartment and took a 7 hour bus journey to Arkhaiveer in the countryside to finally meet Jo (if you remember form the post office in the first week). If you don’t remember: Jo is a nurse from England who been volunteering in Mongolia for a while, she got us our placement here. She has worked with peace core volunteers from America and medical professionals from England to help them settle them in and also tries to teach the doctors English, which they are all very eager to learn.

We checked into the Loving Hut which did exactly that to help us feel at home including taxiing us around the town. The vegan food was incredible after over a month of fatty mutton. The shower was interesting; you had to go outside to shower in a redundant modified Volkswagen. The experience was first dreaded but then fully enjoyable; the seats were an added perk.

After some questioning about the shower we soon realised that they had bought the vehicle from the Mongolian Rally (another charity that puts on the rally). Unfortunately he had lost the immobiliser and was unable to start the engine; we are currently in talks with Volkswagen trying to render the situation.

Everyone in the town welcomed us and the doctors were all equally friendly. We were divided into different departments, rotating daily. We were even supplied with a useful interpreter- Togi.

We spent time in many departments:

The majority of our time was in Ophthalmology with a doctor that happily took us under her wing. After a couple of days she was happy enough to leave us in charge of the clinic while she popped to more urgent cases around the hospital. We were diagnosing patients and writing prescriptions from the first day (mainly foreign bodies, allergic and bacterial conjuctivitis), even though these would have to be translated into Mongolian. During our time we tried to help her daughter apply for Dentistry in London, this is on-going.

Sid spent an afternoon in Neurology which involved him examining stroke (which took as many days for them to get a CT scan as it did hours in England) and schizophrenic patients. Most of the time was spent examining the patient and teaching the doctor the English terms for the medical conditions. Matt would say he spent in the gym after catching him mid work-out with who would soon become his Mongolian girlfriend, nicknamed Honey by Togi. Sid’s excuse was that he was told he was going to see the rehabilitation room.

Traditional medicine, from what Matt saw, involved a mixture of acupuncture and light therapy. The former you may know a little about:the placement of stainless steel wires in certain regions of the body to relieve pain and improve function of said parts. The latter is the use of either ultra violet light to improve anything from sore throats to headaches or normal halogen lights to relieve muscle pain…the legitimacy of which claims you can decide for yourselves.

Obs and gynae was fairly similar to what you’d expect in England; big women and little babies. Ross spent a couple of days here witnessing a delivery followed by a postpartum haemorrhage,a c-section and a variety of other operations. There were top quality doctors who, surprisingly, had really good medical equipment to rely on to look after the women in the 25 bed ward. Mongolian women didn’t seem too bothered about having a male English student in the room, made a nice change from standing awkwardly in the corner in England. That is if you are allowed precedence over the midwives or female medical students. This was after some time in maxillofacial surgery with the hospitals senior surgeon, only three years out of medical school. After watching some tooth pulling as the result of generally awful Mongolian hygiene Ross assisted on a surgery to repair a fractured zygomatic arch. His knowledge or lack thereof, of facial surgery was obvious when he congratulated the surgeon on a good operation only to be told it hadn’t fixed the problem. Embarrassing. 

After a few weeks in Mongolia we were eager to see what work the charity GoHelp did, and subsequently what work our Adrian could have done. The ever helpful Migah was happy to take us to one of the rural hospitals where the ambulances are used. The district the hospital supplied had a 90km radius encompassing 4000 residents (around 2000 in the town). The hospital itself consisted of a triage room with one bed and an upstairs ward separated into children, adult and a maternity wards but in total only had 25 beds. Outside the hospital facilities were clearly in need of development; one fast response ambulance and one large NHS donated ambulance from a previous rally. This seemed adequate until we were informed that firstly only the fast response was really used, due to the cost of running the large automatic petrol NHS ambulance, and secondly on closer inspection the fast response vehicle was in fact merely an aging family saloon it was clear the region badly needs the support GoHelp provides.

After a good look round we were provided with an unexpected gourmet Mongolian lunch in the director’s office and enjoyed the ride back to UB after being piled with mutton, vermouth and Airag. Migah also arranged for us to have a look round GoHelp’s garage with the mechanic preparing to receive this year’s new fleet to add to the 3 vehicles already in storage.  The garage could hold around 10 vehicles at a time to be worked on, usually for a few weeks before being designated to the regions hospitals. Seeing some of the vehicles already there was quite hard to take but just appreciating that the work still goes on is important. The money we’ve raised helps maintain other vehicles to improve the services for regions such as the one we had just visited.

We were picked up bright and early for our first trip in Mongolia after several weeks being cooped up in Ulaanbaatar working in the hospitals and trying to save the pennies after the pounds were spent on the unexpected flights. Matt unfortunately didn’t make it any further than the toilet seat and spent the rest of the weekend recovering on the sofa, after a dodgy khuushuur or twelve.

Our first stop was at a greasy spoon in a lay-by in the form of a Ger. It was located next to an impressive mountain that, because of tradition, couldn’t be named. A little like Voldermort. Here we learnt that Bobo’s (our tour guides) brother was competing in the Olympics. Turns out that he was the first Olympian to win Gold for Mongolia, winning a Gold at Beijing in Judo. A few days later we watched him win the silver medal in London after battling on through an injury in the semi-final.

Anyway, the next few hours was spent weaving our way through sights in the Mongolian countryside using nothing but the shapes of mountains and guesswork. We visited a cave used by Buddhist monks at a nearby secret monastery during Stalin’s rule over Mongolia when Buddhism was banned. Needless to say you can imagine the barbarity when the monastery was found. It’s a shame Matt missed the next location, a natural spring whose waters were fabled to improve eyesight. After a liberal splashing we made our way to the nearest Ger camp to be wined and dined on Mongolian fare listing to tales of the housecat fighting snakes. We awoke the next day excited at the prospect of visiting the Gobi desert only to end up at some sand dunes 20k down the road. Not quite what we had in mind. To make things worse we got a phone call from Matt telling us that our flights to Beijing  for a cheeky sightseeing trip had a ‘slight’ alteration…..a 17hr delay. This meant our trip would have to be cancelled unless we found an alternative way to get to China…

My first couple of weeks in the hospital have been spent mostly in surgery shadowing a young orthopaedic surgeon. The team has got me involved as much as possible scrubbing in to assist in the many femoral and tibial shaft fractures that the hospital sees, predominantly from the ridiculous numbers of road collisions that occur and horse riding accidents (especially around Naadam). There’s been plenty of hip replacements too which have a long waiting list as most patients have to buy their own prosthesis, from private companies, so whereas in the UK patients with hip fractures get fast-tracked to theatre within 2 days here the restraint is patients funds as well as waiting lists, so seeing patients who have waited 7 months for surgery with displaced fractures is not unusual.

As you can imagine surgery is a very different experience in Mongolia; most of the equipment is reused far more than should be hygienically possible, drill bits get replaced only after they have broken and a limited amount of tools make the job they do here that bit more impressive. I’m hoping to see the plastic surgeons in action next week, they have a large burns unit at the hospital holding about 90 patients (when we went to see people were sleeping on the floor in the corridors because there isn’t enough beds) and perform about 4 operations a day as there is only one theatre. Ill update you on that next week.

Ross and I also spent a night in A&E which I know he has told you a bit about so I’ll try not to repeat. On a Friday night the hospital expects to see 200-300 patients, there are two doctors who triage these patients and a third in another room but I didn’t see him often and can’t tell you what he actually did. The doctors we were with started at 4.30pm and finished at 8.30am. They kept the relentless queue of injuries moving at an impressive rate, no doubt partly due to their very brief patient assessments, and are very skilled in determining who needs more urgent care and sending them on. Patients were all seen in the one room regardless of their injury this lead to a very cramped room with probably a minimum of 4 people bleeding all over the place at any one time….it was quite hygienic though as a nurse came and towled the place down every so often.  As the night went on the hallways became a dormitory for the large number of inebriated patients, my supervisor seemed surprised to learn that it was a similar situation in the UK and that we sorted of expected this. It was an enjoyable experience though and the doctors were impressive to work with, in Mongolia as part of your training every doctor has to spend a year doing this job before they can go and specialise in surgery or medicine. I can definitely see why this is the case, you quickly learn to deal with high pressure situation and you become highly skilled in reading terrible xrays so when they occasionally get a good one I imagine it’s easy for them. Anyway after a long day starting at 8.30am I was pretty happy to get home in the early hours of the morning, did have to share the bed with Ross though…ups and downs.

Over the past couple of weeks I’ve divided my time between the intensive care unit (ICU), shadowing anaesthetists in theatre and a couple of shifts in A&E, including a Friday night.

My supervisors first stuttered words in ICU were, “I speak bad English” as he ushered me towards a reluctant looking doctor who soon palmed me off to another anaesthetist. This doctor, a friendly ex-wrestling champion, employed me as his English teacher in return for some lessons in putting patients to sleep. Using his basic translation books we started to get along and he explained the ins and outs of inserting a spinal anaesthetic, which all patients having lower limb orthopaedic operations at the hospital receive. The doctor’s love of wrestling soon became apparent as he spent the whole day watching live matches on the flat screen TV in the doctors lounge, leaving me in charge of a sedated patient’s airway with nothing but a piece of string to check she was still breathing and the mumbled word “watch” followed by a point to the vital signs monitor. No big deal. This went fairly smoothly apart from the patient basically waking up three of four times. In England we would use a continuous infusion pump to keep someone under but the lack of equipment here means they administer a little more anaesthetic when the patient starts to come round. Effective, but not ideal. 

After watching a few operations, that I’m sure Sid and Matt will give you the details of, we wandered back up to ICU. When you walk into Intensive Care in England you are confronted with a barrage of bleeps and buzzers, hand washing reminders and towering, expensive looking equipment operated by a dedicated nurse surrounding each vulnerable patient. Quite the opposite is true in Mongolia. The ICU has between ten and fifteen beds depending on who you ask (the actual number changes daily) and, from what I could gather, three nurses to operate two ventilators offered to the sickest patients on the ward at that time.  I’ve yet to see anyone wash their hands. Most patients have severe brain injuries with little to no chance of recovery. Perhaps the most shocking aspect of their care is the apparent lack of pain relief offered to most patients, something that would rightly not be tolerated in the UK, although this is more down to a lack of resources than a lack of moral responsibility. After several morning ward rounds where my main job was to usher flies away from prone patients while trying to understand their prognosis through hand gestures I realised there was little more I could learn or help with in ICU. I decided to try and spend some time in A&E.

Last night Matt and I worked in the triage department helping the only two doctors in A&E. On average they see around 250 patients a day between them; an epic task! This is reflected in the way they assess people. No matter what the injury, be it head injury after a car crash, suspected broken pelvis or a wound requiring stitching the patient is in and out within 5 minutes, all without a neck collar in sight (unless the patient brings their own). There’s no logical system to who’s seen next, more of a free for all in front of the only desk in the department. Although this sounds like a terrible system it’s surprisingly effective when run by incredibly experienced doctors. Within seconds they know the extent of an injury and whether a patient needs urgent assessment and referral or can wait to be seen. They can never match the standard of care people receive in the UK but they do a good job in difficult circumstances with limited resources. Even so, I don’t think I’ll ever complain about having to wait a few hours to be seen in A&E back home ever again. 

My second week in paediatrics saw me mainly in theatre with the paediatric orthopaedic surgeons. In the beginning I was mainly stood in the corner of the room, unscrubbed, trying to keep enough distance to prevent contamination whilst getting close enough to see- a little. During this time I was re-trained as a radiographer.

They had me operating the C-Arm (X Ray) in theatre as the room mainly comprised of two sometimes three surgeons, a scrub nurse, and occasionally an anaesthetist that spent her time dashing between multiple theatres as surgeons shouted her name. I was surprised by the role of the scrub nurse, in some instances she assisted a single surgeon in operations despite me and trainee Mongolian surgeons watching on, unscrubbed! When I was the only person unscrubbed I was given the task of operating the C-Arm as radiographers seemed inexistent or scarce at least.

Operating the C-Arm under Basic English explanations was easy enough, judging the duration they wanted the X-Rays for was difficult. The constant use of the X-Rays seemed unnecessary, especially considering the lack of protection.  You were lucky if you had a body protecting lead apron with a broken zip never mind a full length apron with a thyroid protector as implemented by many hospitals in England. I say you would have been lucky because most of the time the X-Ray is used without prior warning. In these instances I found myself trying to keep my distance, covering my ‘exposed’ testicles with both hands, even though I knew it wouldn’t make a difference. I found comfort in the fact I was taking action to protect something so precious. The best strategy I implemented was fresh from the streets of Mongolia and involved using a blocker preferably choosing someone that had an apron on.

After a day or two I was asked to scrub in to assist in an operation on a 7 year old boy that had fell off his horse during the Naadam Festival and fractured his femur. The operation involved reducing the fracture and inserting an intramedullary nail (a nail that connects the two sides of the fracture through the middle of the long bone) to align the fractured femur and allow it to heal. This was surprisingly difficult in the heat as the surgeon and I attempted to reduce (align) the fracture and hold it in place. The Mongolian heat was amplified by a full length lead aprons, a surgical gown, mask, hat and double gloves. The difficulty reducing the fracture increased as I felt the boy elbowing me as I tried to reduce the fracture. All of the operations I have seen have been done under spinal with the patients awake; General Anaesthetics are rare. The sight of my surgical scrubs after the operation was not pleasant as it was difficult to see the lighter green colour that they started.

I assisted in many more operations in the week including fractured femurs, humeri and tibias secured by different methods depending on the case. This helped me gain a lot more experience in orthopaedics (a speciality I had little exposure to in England) whilst practising my suturing skills.

A particularly interesting operation involved a 12 boy with polydactyl of the foot.  An operation I thought would be quite uncommon in England, depending on where you are from.