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Messages for Naj
My Introduction to Russian Healthcare- 10/22/05

Part I, Getting the News


Naj and his doctors.

"You have a hernia," said Dr. Badma Rinchinovua looking at me with a steely gaze.

"That's what I thought," I said, not that her bearing implied any other remote possibility.

"We can do other tests, but the result will be the same."

"I'm sure."

"In your case, there is only one solution. Surgery," she said.

"Yes," I said.

"You can spend time looking at other options, try seeing if it will heal itself. It won't. The longer you wait the greater chance it will rupture and then you'll be in real trouble. You need to have this surgery very soon," she said.

"OK."


Buryat banquet.

"The problem you are having digesting the Buryat diet is a separate matter. Both problems just hit you at once. These things happen."

"My having a sore throat being such an example," I said. "Not tied to the hernia at all."

"Maybe to the weddings," said Darima.

"Huh?"

"Two weddings in one day. And throat singing."

"You agree on next steps," said Dr. Rinchinovua in a statement, not a question.

"Surgery? Yes," I said. "What next?"

"You come back to my office tomorrow morning at 8:30," said Dr. Aleftima Vladimororvna, my original examining physician. "And bring a morning urine sample with you."

"If you give me a liter of water I can give you one in about a half hour."

"No, a first morning sample is required."

"Don't worry," said Darima. "Dr. Rinchinova is the best. She is held in high regard throughout Russia. You are lucky that you have her. You couldn't do better in Moscow. These things are normal. No problem."

"Please put your shirt back on," said Dr. Vladimororvna, "We will go down the hall to examine your stomach with ultrasound."

"Our friendship is developing a level of intimacy I'm sure you hadn't quite expected," I said to Darima while buttoning up."

"It's OK," she said. "Both of my parents are doctors. You get used to such things."

Darima is the daughter of my two friends Valentina and Ardan Batarov, both doctors and he Nicholi's cousin as well the person at the Orlik Children's Hospital who opened the doors to developing an arts program there. She met me at the Ulan Ude Children's Hospital to serve as my translator with the hospital's senior administration, who were waiting for me upstairs to conduct the second planning session of the week and, in so many days, develop an arts in healthcare program for the hospital. The previous day, while at the hospital for a meeting with the associate director, I told her mother I thought I had developed a hernia over the weekend, a result of having great difficulty digesting and passing food since I had been here. I asked her where I should go for professional advice. She arranged that I see a doctor at the hospital the next day, and, seeing how I was coming back, the senior administration arranged a follow up meeting. Thus I unexpectedly found myself experiencing the hospital from several points of view simultaneously - not far removed from attending a Russian and Buryat wedding the same day.

In this case my treatment on the first floor was being closely monitored, and thus sped through, from upstairs. After the stomach exam, which left my belly covered with a thin layer of goo, I buttoned up a second time, replaced my tie and attended a ninety minute meeting that resulted in my agreeing to giving a power point Grand Rounds presentation to two hundred of the hospital's medical leadership along with their architect and engineering firm, and an invitation to the Academy to bring over students and faculty that might be a part of the planning process. "We should get it in before your surgery," one said.


Naj's medical records and prescriptions.

Back down on the first floor I was handed my medical records, notes written by Dr. Vladimororvna on three sheets of 8.5 x 5.5 sheets of newsprint paper glued together, one 8.5 x 5.5 printed form with various items checked off (also newsprint), three forms 5.5 x 4.25 (one being the prescription), three handwritten notes each 2.5 x 4.25 and one 8.5 x 11 inch formed filled out and signed; these all on newsprint as well. With these in hand, I received my container for a urine sample and additional reassurances that all would be well, picked up my outer wear and hurried off to give a lecture on arts administration, gave a keynote address on a city conference on aging, beg off on the post conference reception and dinner, attended the opening of a major retrospective of the "dean" of Buryatia's painters, canceled a previous dinner invite that had slipped my mind, and got my prescriptions nearly filled. Looking at my piles of notes the next day, I could see that worries of identity theft or electronic medical records accidentally or deliberately sent to another would not be a problem. Rather their preservation rested squarely in my hands.

"Don't forget, no food or drink today and remember to fill that urine specimen first thing tomorrow. Not tonight, but tomorrow morning," said Olga, the department chair of academics after helping me with my purchases.

Part II, The Second Day

Dr. Valentina held out her hand and I passed over the urine specimen. She disappeared and was back shortly to lead me into a blood lab. Never a fan of seeing blood, especially my own, I took the black humor approach and wore a red Lands' End short sleeve shirt thinking if there was any splatter it wouldn't show. Going into the lab was a bit unnerving as there was a mother with her child, who was screaming full throttle giving voice to her unhappiness with whatever the technician was doing. It was deafening. I was plopped down in a seat next another technician, we but a few yards from the vibrating vocal cords; she seeming immune to the sound. I expected a needle in the arm. Instead I got a short sharp slice on the fingertip. 'Damn, if I was the kid, I'd scream,' I thought.

Using a long glass tube with a bulb on the end, blood was taken and placed in a number of tiny dishes, and a few last drops squeezed onto some glass slides. I was motioned up and out into the comparatively dead stillness of the hall where I could see several small pairs of eyes looking at me with a mixture of dread and relief that I was still alive. I thought, 'Well, that's over.'

Not so. Into another room I went. This woman had a needle. It seemed to grow larger every second. She whipped the rubber tube around my arm, gave a quick swab, with nary a thwap thwap on the arm to raise the vein, she had the needle in and the chamber half full of my blood before I had firmly settled in the seat. Without a doubt the fasted blood draw I've ever experienced. "You've done this before," I said while she put a cotton ball on the exit hole and bent my arm to hold it place.

Then it was back to Dr. Valentina's office. Going through the pile of notes scribed by my admitting doctor the day before, she said, "You need to drink at least a liter of water and, when you feel the urge to go the bathroom come back for the next test."

"Do you have any water I can drink now," I said. "Since we're here I'd just rather continue."

"Tea?" she said.

I nodded. That came and was soon followed by a liter of boiled water. As soon as it was cool enough down it went. I asked for another. Polished it off. Within an hour I was back in the ultrasound examine room for round two. This time I was asked lay on my back, stomach, sides, stand up facing and stand up facing away. I felt like I was being basted as I now had all goo on all sides. I also felt that they did not look far enough south when examining my groin as I now had a couple bulges not apparent five days earlier. It seemed to me they were looking there up.

Inessa, serving as my translator, said things seem calm - that they didn't notice anything and would take a wait and see approach. She also said they want to know if I had been eating, and I said no. I hadn't had anything since Monday morning. Why not? I was told not too eat or drink. That was just in the morning and evening, I should be eating at noon. OK, what should I eat? Fruit, vegetables, yogurt, no meat or fatty foods I was told. Had I taken my medicine? No, no one told me what to take starting when. 10 drops three times a day of one, and eat one packet of the other each evening. So we got that cleared up, but it left me feeling uncomfortable.

On the way home I decided I needed a second opinion. I wondered what happened to the "You have a hernia and must have surgery soon" to the now "wait and see approach." I was feeling very nervous. Since I had to go into the center of Ulan Ude to pick up a thank you gift and add my closing remarks to the conference on aging, I took the time to stop at an internet café to send a note to the Fulbright office and an update to Jerry in New York asking her to contact my family physician. Then I went over to Roberto and Justine's, where I had a bowl a curry ramen, my first meal in three days (a huge energy boost), filled them in, showed them the bulges in my groin and got her to call Dr. Valentina. I learned that Inessa had not communicated all they had said. They indeed felt I had a hernia and needed surgery, but it seemed calm and were trying to get a better read as to when. It also came clear that they didn't understand the bulges in my groin were not normal; that they were a new condition. Another appointment was scheduled for the next day, meanwhile they would also try to get another surgeon so I could benefit from two points of view.

I also heard back from the director of Fulbright Moscow their recommendation that I catch an early flight home, get tested and have the surgery in the U.S., and then come back. I was told first to discuss their recommendations with my surgeons and family physician. With so many projects being launched, leaving for at least month seemed like big step for something that I was learning to be a very common form of surgery. If I could do it here, I thought, I'd have the surgery sooner and be able to return to work sooner. I also knew the medical community was highly motivated to give me the best care possible; at the same time, it was a huge unknown with the danger of unclear translation leading to poor decisions and creating unnecessary anxiety.

That evening I took my medicines, ten drops of a clear liquid I washed down with juice, and a small dark chewy substance that looked grim but turned out to be a concentrate of dates, prunes and other natural relaxatives. It was both tasty, and, it turned out, kept things moving.

Third Day

Following my morning class, I returned to the Ulan Ude Children's Hospital where I met Justine at the entry. She told me that everyone was aware of who I was, "the American." Once it was sorted out that I was not there prematurely for the lecture I was to give in the afternoon, but to see Dr. Badma Rinchinova, a journey of discovery that took me the length of the hospital, up the stairs to the third floor administrative wing, across that to the far side, down the staircase and back to the entry where her office was located.

"You do have a hernia and you must have an operation," said Dr. Badma Rinchinovua. "It is not an immediate danger. There is no blockage to the flow of your intestines. Some people go for months, even years, without such an operation. I understand that you are going to Moscow in November. You can have it done there. We can do it. We do about 500 such operations each year. Or you can go to one of several fine hospitals for adults in Ulan Ude. Valentina and I can recommend some excellent surgeons. This operation is very common and can be handled as safely here as in the United States. The operation will last about two hours. We'd recommend keeping you in the hospital at least three days. Several clinics have one-day procedures where the patients recover at home, but you are single and have no family. I suggest you stay in the hospital."

The issues were discussed back and forth several times, including the Fulbright Office's initial recommendation that I be flown home. The thought of me being trapped on a plane anywhere from eight to twelve hours going from one long flight to another seemed to more likely to put me at risk than if I remained where I was. I said I would share their thoughts with my family physician and the Fulbright office and agreed to see a surgeon who specializes with adults the following week. They informed me of what warning signs would indicate a rupture, told me not to eat meat unless it had been boiled and free of fat, and said to stay on vegetables, fruits, breads and yogurt. I was also shown the stomach of a young man, lying in an adjourning room, who had recently had a similar operation. That's where the incision will be and what your stitches will look like, I was told. Not pretty, but effective I thought.

"One thing you can be sure of in Ulan Ude," said Justine as we left. "They will make sure you get the best possible treatment. They have a lot invested in you and Dr. Valentina will make sure everything possible will be done. I feel foolish giving an adult advice, (I wondering what adult she was thinking of) but you have to say no. They want to drag you to every possible event and feed you all these foods, which you can't eat. I can't eat. Their diet is tough on Americans. Santiago has been here a month and he still hasn't adjusted. I haven't even after a year. You have to say, I can't eat that, doctors orders."

"It's a challenge as I'm eating with Buryats near daily and am constantly at special events."

"I know. They take you everywhere. Food is an important part of their celebrations. You'll just have to be firm. How do you feel?"

"Relieved," I said. "The idea of the long flight to Moscow, where one is often stuck for hours sitting in a plane waiting for clearance to depart, the haul between airports in Moscow, the long flight to New York, the airports, dealing with luggage, places to stay and visas, trying to book flights back and what it would do to all these projects that have taken so long to get moving was starting to stress me out. I was feeling it would put me at greater risk."

"I think it would. What's next?"

"Back to the Academy to scan a bunch of photos for this afternoon's presentation, teach another class, meet a group of students, come back here and do the presentation, take a tour of the hospital and then go meet Betsy to interview a candidate for a Humphrey's Grant."

"When did you learn about that?"

"Just now in the doctor's office. The call I got - that was Betsy. The embassy emailed her and said they needed the evaluation of the candidate completed today. She called me, and we agreed to meet the candidate at five at the Marco Polo Cafe."

"Today?"

"Yes, I had no clue until a few minutes ago. And you?

"We're going to the ballet."

"I saw it last night. It was terrific."

"Get some rest."

The Buryat Diet


A lunch with fish.

Meat. The Buryat's eat meat at every meal. They like fatty meat, and indeed eating slices of fat is considered a highly sought delicacy. The ethnic Russians, living in Buryatia, are not far behind in their consumption of meat. If there is a national dish, it is posies. Ground sausage, with onions, seasonings and sometimes ground beef mixed in, is rolled into a ball, wrapped in dough and steamed. The result is a cocoon of pasta containing cooked sausage steaming in all its juices. "Very tasty," they say and it is. The trick in eating is to first bite a hole in a side, tilt your head back and suck all the juices, and then eat the remaining dough and meat. Some pour in a little soy sauce or mild hot sauce before finishing it off. Three is considered an acceptable minimum. Posies are eaten happily at any meal.

Sliced kielbasa accompanied by sliced cheese is a staple at most meals accompanied by sliced bread. Stuffed cabbages, cooked meat, mutton, chicken and fish are all popular at any time. Soups, Russians and Buryats make some of the best I've ever had, usually contain meat, as do salads. Whether you order a beet, carrot or cabbage salad julienne sliced meat is often combined with the other ingredients, the common binder and dressing usually being mayonnaise. A Romaine, Caesar or other leafy salad, even a wedge of lettuce, is as rare as a winter without snow. Cucumbers and tomatoes are popular in summer, hard to come by in the winter. The three most available vegetables are cabbages, carrots and potatoes, assuming one fits the later and onions in that category. Apples take care of the fruit division. There are other options, but they are expensive, as they have to be shipped in from long distances. I have often been served a fatty hot dog and pasta for breakfast. Ramen soups are popular, but not overly balanced.

People here, as seems true in most countries, love cakes and fried bread products. Fried dough that contains meat inside is popular. All this is washed down with gallons of tea served with milk. I love tea and have managed to get it served without milk. Russian style is with a slice of lemon and sugar. At a special event, such as a wedding, birthday, event to honor a person or reception after a tribute or concert the tables are filled with heaping platters of all the above with many more being added that ranges from fried meats with boiled or mashed potatoes, raw or steamed fish, and baked chickens to skewers of chicken and beef. Platters of thinly sliced apples, oranges and, in season, grapes and watermelon are included along with boxes of chocolates and wrapped candies. Bottled mineral water and fruit juice is often included, the latter drunken more by women then men as is the wine.

Health officials are aware of the importance of a balanced diet; indeed my friend and pediatric specialist Dr. Ardan points out that his biggest challenge is getting young mothers to eat a proper diet both during and after pregnancy - indeed that alone has done more to reduce deaths of babies and prevent many health problems than any other action he has implemented since coming to Orlik. For many the challenge is sheer cost and access. Olive oil costs twice what it does in the United States placing it way out of reach of most households. Simply free-range animals and their milk by-products, root vegetables, grains and fish from Baikal are most available, most affordable and most used. When a high consumption of vodka is added in, it is no wonder that heart disease is a high cause of death and the average male lifespan is 57, highway fatalities, smoking and industrial accidents contributing to the low number.

My Health Next Steps


Dr. Alxsey.

"What's next?" said Serge.

"I spoke with my family physician," I said. "He agreed with Dr. Alexsey."

"Who said?"

"No surgery. Massage therapy."

"My physician said I would need surgery at some point, there was no rush. He felt it could wait until I got back as I did not have a strangulated hernia. He felt that it was safe for me to stay where I am, get some massage to keep the intestine back in where it belongs, to take it easy and change my diet. He felt that I would be fine and that I should continue my work."

"Did Alexsey begin your treatment?

"He said he wanted to work on my emotional and physical healing, and would start with the emotional side. This morning he took me to a lama friend of his who was conducting a healing ceremony for a person with a gambling problem. The lama had a meditation corner set in a room of his home. It included a photo of His Holiness the Dalai Lama, many hadaks in red, yellow, blue, white and green, many bells, books, copper bowls, hanging banners and other objects. He sat behind a desk facing us and we gave him bottles of vodka, five in all. He took off the caps removing all the metal and poured some vodka in several small dishes. He then went through a long rhythmic chant that included the ringing of bells and placing some small seeds in a glass jar that contained some vodka. He then dipped a small piece of cloth into the vodka and used it to wash the hands and face of a young man with us. He then very slowly, to a chant, cut a piece of paper in half. Not a straight cut, but one with a half moon in the middle. The young man took the jar of vodka outside at his instructions and scattered it to the sky. Then we sat around a bowl, each with a bottle of vodka and the lama continued a chant with us pouring a little bit at a time into a large bowl. This continued until we had emptied the vodka bottles and filled the bowl. After some more chanting we took the large bowl and small dishes with vodka outside and threw them into the sky. After returning he gave the two pieces of paper to the mother of the young man. He had drawn a hand on one that was covered with numbers. He explained the significance to her.

Alexsey spoke to the lama a bit further about my situation giving him the date of my birth. He looked me over, said I would be fine, and that my karma is good. Then we left."

That afternoon Alexsey took me to a banya with a swimming pool where we spent two hours until I was very clean and very relaxed. Then, after a cup of tea and light refreshments, he took me to his office near the Datsan of Khambi Khure. Once inside, while waiting for it to warm up, he showed me various anatomical drawings of the body - the musculature - and explained that if I wanted my groin muscles to heal I had to get everything lined up. He had me take my clothes off and slowly do some deep bends - fingers to the toes - while he examined my body from the front, sides and back. For the next half hour, on his exam table, I was on my back, on my sides, on my stomach, back and forth, as well as up on a small high table while he manipulated nearly every joint, muscle and bone in my body. Near the end he had me do the touch my toes bend while he again examined me from all sides. Then he made several more adjustments. It was a combination massage and chiropractic treatment. About the only muscles not touched were those in my lower groin, although he did a bit of an internal exam at one point.

When he was finished he pointed to my groin and I was surprised to see it looked normal again.

He said, "See this? Now don't look there again. Look straight ahead. Stand straight. Breathe straight. If you want your groin to heal you need to keep your body in balance and not create additional strain. For the next three weeks, no heavy work or lifting. Every other day we will repeat this treatment. Your muscles have to remember where they belong. We must remind them and you must help them stay there. Do not look down. Look forward. OK? You have a problem, call me."

I said, "Da. bolshi spaseba."

"He said, OK."

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