The "blue screen of death" and other none non-sequiturs.

 The “blue screen of death” episodes are becoming more frequent on my computer. Soon it will be in hospice care. Fortunately everything is backed up. If I need new one it will be easy to find but Windows will be in Russian. Now I haven’t “learned” Russian beyond a limited, very limited, vocabulary so having Windows 7 (yes, 8 and I were not on speaking terms the last time I tried it), might facilitate some rapid learning, if not a lot of cussing. Of course I am in miserable shape, have been eating a lot of very fat meat with an extra helping of fat (the milk here is 2.5% butterfat although there is 1.5% if you can find it), and what with my well earned coronary just over the horizon and such, learning Russian through endless frustration might just tip me into myocardial mischief.

I’m back in Semey, a town I have come to love. Not sure why; it is a gritty, working class town of 300,000 hearty folks that have seen it all. From 500+ hydrogen bomb tests, up wind mind you, to the smoke and soot from local heating plants, to the Lada eating pot holes, somehow the place has really grown on me.

I am back giving master classes to interns and local colleagues and they seem to be well received. This represents a rather sizable change from my Almaty experience where the indifference can be palpable. Semey dates back 200+ years when there were seven sod and brick huts here. Seven is pronounce “seem” in one short syllable, hence the name Semipalatinsk or Semey. Many of the homes are constructed with logs and are air tight. I have included pictures of them in other blogs posts but just can’t seem to resist documenting this type of construction. So if you’ll bear with me here are some more.

The market (bazaar) here is a warren of shops that would give the average architect dyspepsia. Little if any obvious organization but everyone knows where everything is. All the public toilets in the bazaar are of the pay variety, generally for the equivalent of 18 cents. There are areas that are themed as it were; auto, home, food, even bikes. Again, everyone knows where things are, just not some taller American guy who is walking around in wonderment. I am only lost if I care. And why care? I think of all the things I would miss.

This year there are daily reminders of The War and its end 70 years ago. It is a source of enormous pride here and explains in part the large, dramatic, hirsute statuary dedicated to the warriors, male and female of that era. No one here didn’t know someone who died in the war and many are aware of the Battle of Stalingrad. Many of the TV stations will review what was happening on the same day in 1945. The grandiosity seems justified.

This herring bone theme seems to everywhere on older construction

Latch had to be as old as the home

 Rope used to make the home tight

Junk yard dog. Came up and wanted to be petted.

Hering bone facade on a log home

Apparently "Vlad and Natalia" are an item

It was COLD and gray in the bazaar unitl I saw these paper flowers

One of several bazaar bike shops

A sign celebrating 550 years of Kazakh statehood, 170 years since the birth of Abai (a revered poet and writer), 70 years since the end of WW II, and 20 years since the writing of the constitution of Kazakhstan

These signs are everywhere advertising invivo
facilitation of pregnancy

So here’s to a short post with lots of photos and no more blue screens.

Departing Aktobe

It has been awhile so let’s catch up…the hotel where I have been living has weak (assed) internet so rather than raise my blood pressure, cuss, and assure my place in eternal damnation I thought I would save this post for now. I have been in Aktobe for last three weeks where I have been teaching master classes on common problems in primary care. As is my style the classes are quite interactive. I have always disliked so called “eat your broccoli” lectures. Here the teaching is done by the true lecture method wherein a professor will typically sit at a desk and recite either the lesson or read slides verbatim. Historically that has always been a great way for me to catch up on sleep so I tend to wade into the group and ask for or, if you are with your head in your phone, demand participation.

The presentations (I really detest the word lectures) are clinically based and begin with a case designed to get the audience to think outside, in some cases way outside, their clinical comfort zone. I will often ask the class what they would do at a particular point in the management of the patient. There is generally an obvious answer to which they have been lead. So they will offer it up only to hear me say something like “The lab is in the next village” or “the C-T scanner just broke”. I tend to pick on the students but especially the interns (there aren’t any residents) as they are going to be lonely standalone physicians in three short months.

And woe unto you if you give me an ambivalent look, look down at your (damn) phone or are seen laughing with your homies during my presentations. Not sure why but that just washes all over me. The interns are the worst and they tend to sit in the back thinking they are protected. Nope, they just make the walk to them a little farther. Last week several guys were smirking as they looked at me, big mistake. I grabbed my interpreter, a bright 4^th year student and politely asked her to interpret as close to what I said as possible. I needn’t have asked.

I got one sentence into my dressing down when away she went, shaking her finger at them, cocking and shaking her head, talking so fast that I couldn’t make out a word. These guys were getting a monstrous lecture from what amounted to their little sister and 10 seconds into it they realized that they had better pay attention. One guy smirked and she blew a gasket. She climbed over the guys separating her from this poor schlep stood over him (she is about 5’-3’ in heels) and berated him into submission. Now I was smiling, where she couldn’t see me of course. These poor interns were getting dressed down by a 20 year old woman who had just plain had it. Now the faculty was into it. They made one of the guys stand and apologize. On the way out each one came and shook my hand, with the interpreter watching just in case they showed attitude. They left with their collective tails tucked and didn’t return, as a group anyway, thereafter.

A couple of funny vignettes: I am frequently asked about my family and I show them a picture of the outlaws and in-laws, and of course Lynne, from the reunion last summer. One student asked, “Dr. Mike how old are you?” I always give a straight answer to this. “How-old-do-you-think-I-am” is too loaded and doesn’t translate well across cultures. “Sixty three”.  Them (usually it’s a “them”), “We thought you are much younger!” “Really, how hold?” “Well, sixty”!

Another: “Dr. Mike, are you sick?” “Uh no. Do I look sick?” “No, but why aren’t you fat?” “Well I have been (and am) but I am eating different here and this is how I look.” “We (usually it’s a group of svelt women students) thought that all Americans are fat.” Oh the irony. There isn’t, yet, an American fast food outlet in Aktobe but of course it’s just a matter of time.

Aktobe is on the steppe. Those (both) of you that have been reading these threads might recall that I have been here once before, for a short time in October. It is a dusty town that rarely gets rain. It also is a good 15-20C colder than Almaty. But…it is on the steppe! And as I have said I feel I can breathe again.

I have been able to visit a rural polyclinic as well as the new teaching hospitals here where the faculty are rightfully proud of their new facilities.

A very sparse NICU and surgical recovery unit

I must admit I struggle as I have become too critical of the building as a finished product, I find I will examine these places for craftsmanship and the like. Again the corners might meet at 90 degrees, might not. The paint is on the object for which it was intended, but also on the floor. And somewhere along the line folks here have become enamored with faux marble floors. It makes for an attractive surface but of course is treacherous when wet, which is always, in this weather.

The rural clinic reminded me of some of the clinics in Albania. Dark, somber to a fault, much different than in Semey. But like in Semey the clinics here are staffed mostly by family docs. On the way back from the rural visit we stopped at a shrine to a treasured “batyr” (warrior). It is a touch out on the steppe and is, not surprisingly, very Muslin in theme. You enter into a small mausoleum and are greeted by an Imam. He sits on a masonry bench that surrounds the crypt that contains the remains of the warrior. He will then offer a prayer for you in Kazakh. This particular Imam was round and round faced. Many people here smile with their entire face and he was one of the better examples. After the blessing he invites you to tea and sweets at the building at the bottom of the walk. The shrine is on a small rise from which you can see the steppe stretching out in all directions. 

Last weekend I had finished my prep work for my presentations and thought I would arrange for a taxi to take me out onto the rural steppe. A kind English speaking man, Damir, working behind the hotel desk arranged for the taxi and then worried that the driver and I wouldn’t be able to communicate. I brushed it off, no worries I said, and it wasn’t. At 1pm we headed out. We drove south to a town called Alga. The plan was to head west onto a back road (my family is rolling their eyes at this very moment) to some small towns and then back to a road that would take us to Aktobe. The weather was <0C so the roads were nice and firm, that is until we were about 75km out when the sun started to get just high enough to cause some mischief. The roads quickly turned to mud. The driver was constantly looking for a reason to go back but there wasn’t room to turn around. Best just to look at the pictures….It was epic. He was truly shook and when we got back to Aktobe he told Damir how challenging it was and I started to feel guilty. He drove a Lada and these cars are bullet proof, a Russian rattle trap in most cases but very sturdy. His car was fine but he reminded me he had four kids. I tipped heavily. We were all happy.

Finally yesterday after I had given my last presentation I was invited to attend a university celebration of Nauryz, a Kazakh holiday that starts at the solstice and lasts for a week, punctuated by yurt building, eating and general carrying on. I went to an area on campus where there is a new university Family Medicine clinic.

There in the courtyard was a yurt with many students in traditional dress singing and dancing ancient songs. I was invited to see the inside of the yurt, went in, and was met by many senior faculty, all men, seated at a table covered in traditional Kazakh dishes. I was informed that a table during Nauryz must contain at least 45 different foods. I had horse, mutton, and beef, in various permutations, fermented camel’s milk, pastries, vegetables, fruits, it was amazing. All around the table were men and all were laughing, and doing as we do…joke about our wives (but I didn’t hon), our colleagues, and our kids. A boiled sheep's head is offered to the eldest of he guests and thankfully it wasn't me. The meat is carved and bones are given to honored guest

Items removed from a child's stomach.

"Clinica Family Medicine"

 I got the femur, an honor. One then picks it up and gnaws. Others got ribs and the eldest got the head. Again see the photos.

Today I leave for Almaty where I will add photos and up load. I will miss Aktobe; the town, the university, the students and faculty. I have been warmly welcomed (with the exception of three interns who will be all too happy to see the plane take off and know that I am on it) and showered with praise for my presentation style of case based approaches to medical discussions. I have been informed by students that some faculty are adopting that style even after seeing for just one presentation.

I leave in five days for Semey for a two week master class curriculum. Then home for ten days then off to Astana for two weeks then Lynne arrives (!). We will tour some of the most beautiful areas in KZ and should be able to see wild tulips. I told my Aktobe friends here about it to which they replied that I should bring her here because Western Kazakhstan has all five colors of tulips and the East had just two. Man I am three months from leaving and already missing this place.

An amber necklace given to me as a gift. 

Out on the steppe in the Northwest of KZ

I’m back on the steppe and feel like I can breathe again. I have been invited to teach in Aktobe, in Northwest KZ. The students and faculty here have a dedication to medicine in general and Family Medicine in particular that is refreshing and reassuring compared to the majority of experience I have had back in Almaty.

I have been giving case based master classes to medical audiences of 25-150 people over the last week. After a class I went to the cafeteria for some tea. As I entered all conversation stopped as all cafeterias are viewed as sanctums for students. Faculty rarely venture there and if they do they tread lightly. I got some tea and as I was scoping out which student occupied table I was going to join/harass I was invited to join some 1^st year, English speaking students. As is my habit I asked why they wanted to go into medicine and to a person stated that they had wanted to do so from childhood. There was one, the only guy in the group and an ethnic Korean who was sent here by his mother and upon arriving began to love medicine in its own right. Jack pot.

The presentations have been well received; lots of note taking, conversing (sometimes with animated undertones), and collegial back and forth. My hosts often apologize for the presumptuous manner in which my points are questioned as they are worried that not enough respect is being paid. I tell them that the way I know that the audience is taken in is when there is disagreement and that it is healthy for the students to see it.

The new medical center was built on the outskirts of Aktobe, surrounded by Kazakhstan’s equivalent of McMansions! Each looks like the other but for façade and the usual “ticky tacky”. Interesting all seem to be built with a craftsmanship that I haven’t seem elsewhere.

This is a three day weekend as Monday is International Women’s Day. I have always thought this was a much better day to celebrate women than Mother’s Day. So lots of chocolates and flowers in the magazines and bus stop kiosks.

To celebrate, West Kazakhstan Marat Ospanov State Medical University, where I currently teach had a huge talent show. And there is some serious talent here: a choir, three three person groups singing in Kazakh, Russian, and Turkish. (I am always reminded of the ancient Ottoman influence in this region). There were Kazakh dances and of course formal recognition of work well done for just about all of the faculty. Each was called up and given a flower and certificate. No men as medicine is virtually all female here. The masters of ceremonies were what I have taken to be the convention; a man speaking Kazakh and a woman speaking Russian. Both have the intonation of a ring announcer. Oh and in Kazakhstan, just like traffic wherein speed is either peddle to the floor or stop, volume is either ear splitting or off.

The weather here is more severe than Almaty. It hasn’t risen above 32F and there is thick ice everywhere. It is overcast most of the time and as things here are manufactured from concrete the overcast lends itself to an entirely new spectrum of white-gray-black.

It seems that most cities have at least one mall, here and in Almaty it is ‘MEGA”. All the signage is in English. The one here is about 5km from where I am staying so it is a nice walk, if not icy and cold. I walked into Mega and was immediately made for an American or at least a non-Russian speaker. Kids were walking up to me saying, “Hello. How are you?” then giggling and laughing as they skipped away.

Before I left Almaty I did a long walk that turned out to be a rather lengthy scavenger hunt. Almaty has some truly amazing graffiti. So what follows speaks for itself: