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?"