Learning to cuss..

I have a new Russian teacher. She is the former instructor for the Peace Corps volunteers here and is an absolute character. She lives with her husband in a modest flat about 20min from here where I see her in the evening. She generally has tea and delicious home made pastry for me and we discuss various topics in both Russian and English. For some reason she reminds me of a female Yoda.

The other night she wondered what coffee I liked. I sheepishly explained that I drink coffee for the caffeine kick and have been known to take a spoon full of the freeze- dried stuff and wash it down with a gulp of water. After that I like any coffee that my connoisseur son makes, except that it takes too damn long what with all the ceremony and prayers of thanks to the coffee gods.

Then our conversation went something like this:
Her: "Do you like Starbucks?"
Me:"Not really. But, like I said, I'll drink it if I need a caffeine hit."
Her, spitting: "Starbucks..."
Her: "Do you know where the best coffee in the world is from?"
Me, thinking that this was a gimme: "Ethiopia!"
Her: "No Mike, Vietnam."

Coffee excrement in the wild. Apparently there is lots of debate about whether this is real.

She then went on to explain how there is a variety in Vietnam wherein a civet will eat a coffee berry, husking it inside his gullet, then excrete is out as a coffee bean, what..., well you get the point. The beans are cleaned (she assured me) and then roasted. Now they have these critters on farms and it is done there. It costs 6000USD per kilo and it is very contoversial. Still, I had to come to KZ, and take Russian lessons from this character out of a movie to find out about it. Cool. An yet something tells me that I am the last guy in my circle to know about this and for some reason I can hear Eli's eyes rolling,

Then onto the lesson.
Her: "Mike do you know how to swear in Russian?" (I just knew I was going to like this teacher!)
Me, seizing on the moment: "No!"
Her: "Well we Russians love to curse, I teach you." The two principle ones are transliterated as "Fack" also "b`lyad'! and "Sheyst" also "derr`mo" and now I am armed and dangerous.

The group of interns I have been teaching are for the most part attentive although they would be more so if they didn't have their blasted cell phones. On Friday I followed them to a small cafeteria where I got a cup of tea and sat at a table thinking I could get lost in some thought for a few minutes, only to have a group join me. As is my habit I asked each one if they saw themselves in medicine in 5 years and if they did, what did they think they would be doing? Two of them were going into peds, another was going to be an ultrasound tech, another adult medicine and the last, "Stand up comedy!"

Absent a white coat one isn't taken
seriously

The interns present on Friday,
six out of thirty.

I said that in my country when we hear something as outrageous as this we call "BS" on it. He said what is this "BS"? I said that he knew good and well what it meant. We all laughed although the irony in the moment was thick.

Can I get an "amen"?

I received a care package from one of my homies on my cycling "team", Team Bag Balm, wherein the motto is "I think y'all is crazy!" I do love Payday bars as they are the best bonk proof substance out there and you already know how I feel about peanut butter. When cycling if I feel a major bonk headed my way I indulge in a Mountain Dew, a bottle of water, and a Payday and I'm good. Apparently a couple of riding buddies observed me eating one and I might have had a grin on my face that was termed "post coital". Not even close my brothers. But when they heard Ian was sending a care package they insisted they include these.

When I went to the post office to pick up the package I was confronted with a crowd in a room a quarter of the size of an average class room. I gently hip checked and shoulder butted my way to the front (ain't no lines over here), and found out I needed to fill out some more items on a claim form. This was  done with the help of friendly bystanders who are abundant and very indulging of a "white beard".

We left the city where it had been raining for three days and gained 500m. Look what we found.

 A wild apple (almaty)

More almaty

5 km to the top of Koke Zhalau

Guess where the gas tank is on this classic Soviet rattle trap

Random thoughts randomly

In no particular order:

• The people here are beautiful. All are svelt and appear fit and no one carries around a 750 cc soda as we see at home. But its out there, and in time...
• I live in the downtown area that is the most well established. According to the expats here it is the "Golden Rectangle" for bars and eateries, and where for the right price one can buy love. I haven't crossed the threshold of a bar here as it seems either too intimidating, not my scene, or somehow not, what, genuine perhaps. The expats often live in a bit of a bubble. I really enjoy the integration into the culture that I have been able to achieve. It's cut down on the beer consumption however. Oh and no "love", ever.
• In this part of town are all the high end shops you would find in Chicago, NYC, maybe in the 'ville but I doubt it. 
• It seems that women measure their status with shoes and bags. Even in the snow they seem to navigate in unbelievbaly high heeled and platformed shoes while dangling some insanely expensive bag on an extended arm. A member of this club usually drives a high end SUV (Mercedes seems to be the rig of choice) and speeds around like she owns the road. Of course men do this as well but aren't quite as pretensous. I was nearly hit by one of the above and slammed my palm into the rear quarter panel in protest. She pulled over a block later and looked at the car, not to see if she had hit anyone. Not my finest hour. Still pissed.
• I have started to play a game when I am on the bus. I look out the window at shoes only and decide based on that who "owns" them and how she is dressed. The consistancy is remarkable. With men it isn't the shoes it seems to be the tie; the pattern and qualith of the knot. The pretension is the same. 
• Out in the near-in areas where there are homes, not the apartment complexes like the one I live in, all gas piping is above ground,

  

  A "yellow pipe" arcade. Note the smog....

  
  which of course begs the obvious. What happens when an intoxicated and speeding Kazakh hits one? I guess it interrupts flow to all homes down line. At least it is easier to fix when ruptured.
• I take a bus to and from Polyclinic 3 

Bus 65, driven by a rural born Kazakh who takes pride in his work, and likes purple.

where I teach interns in their second year. They, too, are under prepared by US standards but are eager to learn and very welcoming. 

Here we are discussing percussing the chest and chest expansion with respirations. (I think I may have lost some weight now that I look at this picture. Found a scale, 5kgs, all from my frontal cortex)

• We had a class on examining the chest where I always advocate beginning with inspection. Our volunteer was an intern who happened to have undiagnosed scoliosis. It was a great opportunity to discuss how scoliosis can affect ventilation and how to break news like this to a patient. She was very sweet, accommodating, and had very slight deformity but in retrospect had had some back pain.She and I discussed her situation at some length during a break. We had two pregnant women in the class so I was able to demonstrate the changes in diaphragmatic excursion with gestational age.
• Two great illustrative cases this week. And for those of you not inclined to med-speak, please accept my apologies. This blog serves as a journal for me so I don't have to write it down twice. All the patients are consults to me and are interviewed in front of the interns so they can participate in care.
• The first was a woman who was an unfortunate example of what can happen in the absence of horizontal and vertical integration in care. People can self refer here. She saw an orthopedist with knee pain. Now in medicine if all you have is a hammer everything else looks like a nail. So naturally she had her knees injected and promptly had some variety of allergic reaction. She saw an allergist and was placed on a steroid iv. All "serious" medication here is given iv. She then was placed on more steroid. The last 9 mos have been marked by continuous steroid administration, two hospitalization and visits to no less than 8 docs for "who the hell knowsosis". And now she is having severe side effects from the medication she is on for a "systemic disease". We haven't done her any favors and she is Cushinoid with cardiomyopathy and osteoporosis. Oh, and her knees are fine. As I tell the interns, it is always the last doc who is the smartest. Far from the brightest bulb in the box, I was able to tell her to wean very slowly off steroid and to come back in two weeks to see us, making this the first time she has seen the same doc in this idiopathic exercise in morbid pathology.
• Our second was a delightful woman who was 37 weeks pregnant and having some routine palpitations while in bed. Interestingly as I was relating this case to B she stopped me right there, and began with a "don't tell me let me guess" litany, and was pretty spot on. She had an EKG and was told she had some ischemia of her heart and should have an ECHO. Over to me for consult. I deterimined that she was having ususal symptoms of late pregnancy. The EKGs here are a source of real annoyance to me as they are run at 50mm/sec and usually have all of 4 complexes with which to analyse. I asked that another on be run at 25mm/s and it came back fine, a good example of unnecessary lab ordered after an inadequate evaluation, To be sure this happens in the US and there is simply no excuse for it there. Here it will take a generation to work out. 
• I've already related this to my extended family but it is a funny anecdote none the less: 

I have been taking Russian lessons with another gent, Peter Malone.  We meet in a local cafe where we are taught by Xaniya, a lovely and thankfully very patient Kazakh woman. After the lesson last night I found myself walking the same direction as Peter. Until then we had known each other only by our first names. Peter is a Malone from Ipswich by way of Liverpool, with a light Irish intonation to his speech. He has a broken wrist and admits that, while it is embarrassing, it had to do with some vodka shots. In turn I introduced myself as Mike Pendleton. The conversation went something like what follows:

"Really, I've been to Pendle, you?" (Pendle is in England from whence the surname)

"Nope"

"How the hell did you make to Kazakhstan but not to Pendle?"

"Uhh, OK you got me."

"You know my first summer job was with three Pendleton brothers. Yeah, I was sixteen. They made ice cream and I helped them for the summer. Learned a lot about business from them, I did."

"Really, what? "

"They were brilliant! They made one style of ice cream but packaged it differently for different markets. They sold the high end stuff for several pounds more than the regular stuff and it came out of the same damn spigot! Bugger me blue if know why I went into mathematics. (He teaches math at a local expat high school). The numbers I study are after an equals sign, not at the bottom of a spread sheet. Damn but they were sharp! How about you, are you in business as well?"

"Nope, I'm a physician."

"A doc? Too bad....Want to go to the Guinness House?"

Sunday afternoon

I just got back from a quick walk around the neighborhood. It was my intent to photograph some of the textures here but the results were rather cliched and underwhelming so I headed over to Panfilov Park. It seems that there is always something happening there. I'll let the photos speak for themselves.

People here love to dance and do so from a very young age. They have no inhibitions about it so at any function they will get out of their chairs and dance! For someone like me who can't keep a beat and can't dance it is a touch intimidating for some reason. But every now and then you get to see this and I wish I would just lose the silly self consciousness and dance like Snoopy!

It has been a beautiful sunny day that has slowly surrendered to the brilliant southern light of a late fall evening. I passed these two ladies signing their hearts out. I gave then the equivalent of $1.10 USD and took a few pictures. 
                                                                           The music was, well, who cres because they didn't!
The woman on the left thought I was French (me?!) and between my bad French and Russian and her French, Russian, and Kazakh we laughed and had a delightful interlude. As I walked away she yelled, "Bon voyage!".
 

At the learning center of Kazakhstan National Medical University

I generally follow "my" San Francisco Giants from about from March through April and Mid -August to whenever the season ends. As a kid I have fond memories of my dad listening to the game on his transistor radio (about the size of "War and Peace" in hardback) and if memory serves he even snuck it into church on a Sunday afternoon to listen on the ear phone as the Giants played the hated Dodgers. My mom blew a major gasket which of course made it even more worth it to him. So over the years I have casually followed the Giants from a distance, sometimes great distance. I knew they were in the wild card game then lost touch as I am 13 time zones away from the left coast. So what follows is an editied narrative to my family about the last day of the World Series.

Students in the entryway of the hall

"Here's how it went down over here in A'town. I awoke and knew the last game was on so tuned into TuneIn and listened as long as I could before Ieaving for the university. As it is about a 45min walk and I wanted to continue listening I thought, "OK I can do this", and loaded TuneIn onto my piece of shit phone. (It's a Samsung, by way of who knows where, so the outside says "Samsung" but the inside says "bugger off!")

Download to POS phone: check

Listen to game via Internet on walk over: check. Me saying to myself, "Man this is so cool. Me, in Almaty, listening to the freakin' World Series being played last night in the morning!"

Now just the day before I gave a group of women medical students a monstrous dressing down as they were in the back of the class gossiping, giggling, and playing with their cell phones, like it was bloody high school. You might say I lost it. Bear with me here, the point will become evident. I informed them that while they were adults, what they were doing was considered rude in my country. So they could stay, or leave, but please stop talking (shut up already!)  and please turn off the (effing!) phones. You get the gist. I think they figured they could do so as I was the guest and what did I care? Suffice it to say, I cared, a lot. But I digress.

same

So in I walk on the morning of the last game to an empty class room but for two students of the same group from yesterday. It's now the bottom of the 9th, no outs, MB on the hill throwing heat, scary good. I SO wanted to listen as I was thinking myself so very clever to have downloaded TuneIn and then signed into the university WiFi, in Russian no less!  I had unplugged my ear phones before entering but had left the phone and at very low volume so I could check. But I didn't want to get busted by the very same students I had just given hell to the day before. 

So, and I'm not ashamed to admit this, I stated that since there were only two students in the class let's just start in half an hour! Brilliant no?! I caught the last out, well not me, The Panda did. I silently raised my arms in celebration, and in walked a student. He asked what I was doing. I told him that my team had just won the World Series of Baseball! He high fived me and then walked past with a look of "dude its not the World Cup, chill."

Screw it, WE WON!!!"

Lately I have been working at the University with a group of students who are in their sixth course (the last year before internship). We have been discussing common cardiac arrhythmias, acute coronary syndrome, heart murmurs and the like. Students here get very little real time experience with humans so they are reduced to using manikins. This is not unlike other schools in the US where student learning is truncated due to lack of exposure to or patient unwillingness to be the subject of a learning experience. I'm old enough (and my kids would say crusty) to recall that I would simply walk in and take a history and physical after introducing myself and most patients were glad for the time. Like I tell my students, it like playing piano. You can't get proficient unless you practice. But for practice there is now a huge industry that tries to mimic human encounters with manikins. I'm talking manikins for rectal, pelvic, pediatric, thoracic, ear, and eye exams. Never mind that you can't find gloves, speculae, otoscopes and certainly not ophthalmoscopes in an exam room.

Not sure why but many want their picture with me

So as part of the week we spent some time watching presentations on heart sounds from the University of Miami. The speech was fast and of course meant for US audiences and it was done by the driest Casper Milquetoast'iest professor I have ever heard so even I was bored.

Jeez I look much older than I feel

Next we met "Harvey", half the man(ikin) he used to be. One can dial in forty different murmurs, feel pulses, and the like. It was a mess. Few got it, so the next day I downloaded a bunch of murmurs (clever, no?) took them to the class room and went over them one at a time with case based presentations. Much more effective. Next (Friday) we discussed and listened to breath sounds at their request. We listened on each other, they were introduced to Dr. Mike's distaste for the word "normal", and in general it was a great learning experience.

"He's dead Jim"

Finally, we have a close friend living in the same town as where two of our kids attended college. She is one of those amazing people you can trust to listen to your kids complaints of how they have a Neanderthal for a father and how "my (insert gender)friend is..." and know that the truly important stuff will get to us. She is tall and beautiful. We met in the OB dressing room at residency when I was trying to swipe some scubs after a tough delivery. Yesterday I got on a bus and there she was. Or someone who had to be her clone. Then it occurred to me that we have always known her by a contraction of her name that is properly a common Russian appellation. Her father was a Russian sea captain no less, and she looks like she could be from the CIS. So no, it wasn't her but it was freaky-amazing.