Getting a handle on Russian medical practices

[promedglobal]

A plea for help:

I run a small clinic in the former soviet union. We take care of workers on a construction project, and as such, deal extensively with the local soviet-style medical system. From my experiences, I am trying to get a handle on the good, the bad, and the ugly of what I see done by the local medical system.

I would appreciate feedback by Russian-trained MDs on any or all of the following topics:

Beliefs:
Hypertension- Why do my local colleagues seem to think a BP of >140 needs immediate and drastic reduction? Especially if the patient has a BP of 148/90 and a headache. Does it occur to them that maybe the headache pain is the cause of the HTN, and not the other way around?

What IS this obsession with blood pressure all about?

Treatments:
Dimedrol (diphenhydramine) I understand. In the US it is benadryl, and we have been using it for years to treat allergic reaction. However it seems to have a much wider scope of use here. Sedative, pain killer(?) etc.

Metamizol- Seems to me very effective. However, as it is illegal in most of the world, I cannot allow it's use in my clinic. If an expat has an adverse reaction to it, they would crucify me in court. We use ketorol (ketorolac) instead.

Gentamicin: It's widespread use, esp in children, strikes fear into my heart. There is no monitoring of gent levels, of course. I see it prescribed to patients with chronic UTI's/pyelonephritis quite frequently. This seems unwise. Medicines such as ciprofloxacin are commonly available and relatively cheap.

Polypharmacy: I frequently refer patients for treatment, and they invariably come back with a LONG list of meds to take, most of which seem to have nothing to do with the diagnosis. Example: an uncomplicated UTI in a 40 year old woman gets daily injections of vitamins, aloe, iron, gentamicin, and a couple other meds. She brings all these medicines to me that she has bought and asks my opinion because she states the injections are very painful. I give her 500mg cipro bid and some vitamin tablets. She gets better.

I agree with the local practice of prescribing vitamins, and so we give vitamins much more often than in the US. The local population (central asia) eats an extremely poor diet and anemia is rampant. Vitamins are quite expensive in the local pharmacies, so our workers get them for just about any complaint.

I had no experience with brilliant green spirit (zelionka) prior to working here, as it is mainly a veterinary antiseptic in the west. I assume because western patients would object to being painted up like a Spetsnaz commando. However, according to a WHO study, it is quite effective, and has a longer duration of effect than some other antiseptic tinctures. We tend to paint up local infections with it, then slap some bactroban on top. This works well. It does not come off as quickly as iodine does.

Diagnostics:
Fingerstick CBC's. How accurate are these? The local laboraties simply refuse to do a CBC off of a vacutainer. They say they dont know how. It has to come from capillary blood or not at all. This is incovenient, as it is much easier to send a vacutainer than a patients finger. The patient tends to not want to be seperated from the finger.

I like antibiotikagrams, which seem to provide useful guide to best choice of antibiotics. These are done here more than in the west. I also note there is a lot of resistance to ampicillian and biseptol (SMZ-TMP) in the local population. People tend to take biseptol for everything. As a result, we find it is almost useless for treating UTI's.

Jim

[shrink]

Dear Jim!
You should understand that the level of health care in this region is far from perfect, some GP here are not well educated, because they had no need to go through tough exams like USMLE and postgraduate training like residencies in US, UK and other countries. Some are really bright,but many don't have an extensive knowledge. ( I don't mean to insult esteemed members of this forum who came to US from this region.)
If you have doubts use current guidlines, and standarts of care and that's it
Good luck.

[Dr. Mom]

From my experiences, I am trying to get a handle on the good, the bad, and the ugly of what I see done by the local medical system.

I would appreciate feedback by Russian-trained MDs...

Dear Jim:
Sure, I will be happy (and honored) to help with whatever I can. And thank you for great (and funny) insights about Soviet-type medicine.

Dimedrol (diphenhydramine) I understand. In the US it is benadryl, and we have been using it for years to treat allergic reaction. However it seems to have a much wider scope of use here. Sedative, pain killer(?) etc.

--- Dimedrol (benadryl) is used like this all over the world (at least in Russia and in the US). In my US-based practice parents of all origins and all colors are using it for any problem - from snifffles to fever to earaches to sleep problems and everything in between.

Gentamicin...
--- That is a great problem. Toxicity is horrible, resistance is huge, complications are too common, but old recommendations are dying hard...

Polypharmacy
---Oh, I can talk about it for hours... I would recommend just to accept it and to try to choose the lesser evils..

I agree with the local practice of prescribing vitamins, and so we give vitamins much more often than in the US.
--- Yes and no.
Yes, as a supplement vitamins are good.
No, vitamins are not a "silver bullet"

I had no experience with brilliant green spirit (zelionka) We tend to paint up local infections with it, then slap some bactroban on top. This works well. It does not come off as quickly as iodine does.
--- Zelyonka is a great drug but (as usual) with some limitations. FUKORZIN (Kastellyani dye) would work better on skin infections and eczema. Zelyonka is unsurpassed on chicken pox and as drying agent on an umbilical cord stump.
As a dermatologist in my previous life, I would warn you about using the iodine (even it is coming off the skin much quicker ;-)). Iodine (despite common belief in the Soviet medicine) is not such a good medication. It burns the skin more then heals and therefore should be used judiciously, if ever.

Fingerstick CBC's. How accurate are these? The local laboraties simply refuse to do a CBC off of a vacutainer. They say they dont know how. It has to come from capillary blood or not at all. This is incovenient, as it is much easier to send a vacutainer than a patients finger. The patient tends to not want to be seperated from the finger.
--- What a great description!!!! I do not share a common love to fingersticks, so common among amny docs here, in the US, who are still doing a lot of fingersticks in the office.
Yes, CBC's from fingerstics (the same as heelsticks) are pretty accurate. So let it be (we have to choose what we can change)

I like antibiotikagrams, which seem to provide useful guide to best choice of antibiotics. These are done here more than in the west.
--- Again, yes and no. We are getting into the "in vitro" vs. "in vivo" discussion, but in your situation, facing such a rate of antibiotic resistance, it can be the only way.

I also note there is a lot of resistance to ampicillian and biseptol (SMZ-TMP) in the local population. People tend to take biseptol for everything. As a result, we find it is almost useless for treating UTI's.
--- Oh, yes, my favorite "bactrimchik for diarrhea" and "ampioksik for fever" :-(... I am getting a lot of those here from my patients too.

How is your Russian? If it is fair or better , you can get a lot of help from the members of www.medico.ru

Let me know, how else I can be of service.

[promedglobal]

Alla:

Thanks for the helpful responses. What I am trying to do is not fall into the trap of "These doctors are all primitive butchers who have not seen the light of EBM".

Obviously, many of the treatments they use work. Just as obviously, many work, but are unacceptably dangerous for someone who deals with western patients (ex. IV aminophylline certainly WORKS, and is usually the only medicine available to treat bronchospam in the local clinics, but in the event of a negative patient outcome, I am expected to explain why the local doctor who works for me didn't give an albuterol treatment first, so I spend a lot of time training my employees in western protocols.), and then there are treatments that, no matter how hard I try to understand the logic, just flat do not make sense.

Example- Calcium chloride/calcium gluconate injections: This seems to be some kind of cure-all treatment, and often makes no sense to me, but I vividly recall working in the basement of a bombed out hospital in Bosnia during the war when a woman came in in anaphylaxis. Where I would have given Adrenalin SQ, Benadryl and a steroid, she got calcium. Layed there on a gurney and twitched for about 15 minutes, then got up and left. I still scratch my head over that one.

I do my best to understand that things like IV catheters are an expensive luxury in a poor country, so starting IVs with good old-fashioned steel needles is the rule of the day. X-ray film is expensive, so I TRY to be understanding when the radiologist only wants to take AP and lateral films, and doesnt want to do an oblique of my patient with a calcaneal fracture. It's a hell of a lot harder to understand what his objection is, when it's MY damn film they are using, and I am paying him some decent vzyatka for his time!

There seem to be a number of medicines that are unique to the former soviet union. I would love to hear what you think are real "gems" that have yet to be accepted in the west, and what are, for a lack of a better term, "snake oil". I don't have enough experience here to really make an informed judgement. Patients will come to me after having been treated with stuff I can hardly even find reference to on the internet. I always ask, "Well, did it help you?". Sometimes they say yes, sometimes they say no. A double-blind, randomized, placebo controlled study, it is not!

Jim

[VI]

Jim,

Just watch out! Your local colleagues may look confident and knowledgeable but remember - they DO NOT have as good education as you do. Or, even worse, they may have good education in some concepts you would never agree with.

Good luck.

PS: they give antihistamines to everyone to deal with the allergic component of virtually everything.

[JuliaMI]

There is great place where you can get "pearls" from Russian doctors (in Russian only, sorry):

www.feldsher.ru

This is the place for "Skoraya" (Russian analogue 911) people. Strangely, many of them know English and even read Cochran but all of them have to use the same meds and work in THAT system.

Regarding things mentioned already:

aminophylline IV: great for immediate relief of single asthma attack. As every other xantine, can cause tachyarrithmias (as PVC runs), anxiety (for what we usually gave some dimedrol IM at the same time), AD fluctuations and, as I suspect, myocardial distrophy on the long run. If you have someone getting in ER on the daily basis, I would prefer to put patient on steroids (is it really so bad that even bethamethasone unavailable?!)

[promedglobal]

VI

By allergic component, do you mean the medicines sold often have allergens in the inert ingredients or that simply many of the medicines are inherently allergenic?

Julia

I looked at the Feldher.ru site (I read Russian far better than I write it). Incidently, I worked with some Russian trained feldshers on Sakhalin Island. Although they lacked familiarity with much of the equipment and techniques, I thought they had had a quite good training program, as they quickly grasped the practical applicability of our equipment and procedures and seemed more flexable than the physicians.

aminophylline: Yes, it does work, but we must follow standard of care (one of the main things I have had to communicate to my local employees is that there IS such as thing as a "standard of care") as it is practiced in the US, and so aminophylline is a 3rd line drug for acute asthma/bronchspasm.

Thankfully, we are able to import many meds from the US and UK due to special agreement between the US government and the host nation (this is a military project).
The greatest benefit is the ability to have controlled drugs: the soviet regulations for the possesing and storage of narcotics are staggeringly strict, and I would not like to be left with nothing but diclofenac for acute pain relief and dimedrol for a sedative, which would be the only injectables we could obtain locally.

Jim

[VI]

NO. They belive that most of the diseases have an allergic components, so they add anihystamines to most of the treatment regimes.

[Dr. Mom]

NO. They belive that most of the diseases have an allergic components, so they add anihystamines to most of the treatment regimes.

It would be funny, if it would not be true...
On one hand - Nasonex was advertising through the winter that nasal steroids are good for colds
On another hand - think about - all diseases either from "nerves" or from "allergy".

On the serious note, as with everything else, the truth is somewhere in between. And too often what is overdone in Russia is too frequently overlooked in the US.

Passing Boards is not a measure of medical proficiency - it just shows the ability to mechanically memorise some (not alsways important) data.

[promedglobal]

On the subject of something I think would be GREAT to introduce to America:
Biolac (biolak?)

My youngest son was born in Ust-Kamenogorsk. He was one of those kids who is allergic to everything, and my wife could not breast feed. We tried all kinds of different formulas, I ordered the $25/can hypoallergenic stuff from the USA, and he would turn a lovely shade of red after even that.

I was rather unhappy with the local medical system at that time, as the neuropathologist said he had "hypoxia", because (at less than 1 month old) when she stood him on his feet his toes curled under, and when she layed him in the head down, knee-chest position he turned a mottled blue-white color . They predicted all sorts of dire problems for him such as learning disorders and retardation, and wanted us to treat him with cavinton, massage, etc, which I refused (I let him have the massages. I quite like those myself.) as I did not feel that giving drugs to improve brain microcirculation to an infant was prudent. I called our pediatrician in the US and he said for kids who are allergic to even the hypoallergenic formula, they usually give them goats milk. Gee. I'll just run down to Safeway and pick up a case of goats milk. NOT. I had visions of me milking a goat that was tied up on the balcony of our 9th floor apartment.

[He is almost 4 now, by the way, and other than being a "hooligan" and still suffering from mild allergies, is extremely bright. I am suspicious of this diagnosis of "hypoxia" because his Apgar was normal, and most of the kids I heard about born there supposedly suffered from "hypoxia". When I told the pediatrician about the toe thing and turning mottled in the knee-chest position his response was "Infants don't even completely develop the nerve connections to their feet until about 6 months. And if you put ME in the knee-chest position with my head down, I turn sort of mottled blue too. This doesn't mean a thing." I feel sorry for the countless mothers who are sure their children are going to grow up retarded in Ust-Kamenogorsk..... ]

We eventually tried "Biolak", which I gather is something like hypoallergenic "detsky kefir", since thats what it tastes like. The hospital makes it, and our son had the least reaction to this of everything we tried. It was a pain in the rear: my wife would go to the hospital every morning and pick up 2 bottles, but it was worth it, since he loved the stuff and didn't look nearly so much like a little fat strawberry as when he tried other formulas.

The other experience I had that I was very satisfied with was the quality of the speech therapists (logoped) we had who tutored our older son. He was having a great deal of difficulty learning to speak, due in large part to a small cleft lip. I spoke to the president of the American association of speech therapists, who happened to live in the town our oldest son was born in, and I described the logopeds therapy sessions and the excercises she used (some as simple as blowing on a pinwheel). He said that sounded exactly like what was needed, and that often very simple toys and exercises were just as effective as high-tech equipment. Considering that he recently got a 5 on his Russian gammer test, it seems the therapy sessions have paid off.

Jim

[Dr. Mom]

On the subject of something I think would be GREAT to introduce to America:
Biolac (biolak?)

Dear Jim:
Most probably I am telling this story for the 25th time (what to do when you are getting old?) but many-many years ago (1991 to be exact), during my peds. residency interview, I was describing the GI guy my experience with probiotics and and all my research and so on and so forth. Since then he did consider me somewhat... strange, but I anyhow was accepted as they were 2 residents short. that was the time, when everybody in NJ were treated with rocephin via the IV pumps for presumed Lyme disease. In the hospital 6 miles from us pediatric residency accreditation was even suspended, as all pediatric floor was filled with "Lyme" patients and everybody else were sent to us as an overflow. Kids were pooping their brains out, but if there was no C. Diff in the stoll, the diagnosis was "toddler's diarrhea" or something else. me and another "Russian" resident managed to find some probiotic in the hospital formulary, ordered it, but the attending calmly explained to us in the morning, that ... this medication was not approved, needed, safe, and so on and so forth...
Then about 10 years ago "Pediatri News" published on the first page (!) an article that probiotics can prevent (wow!!!) antibiotic-related diarrhea... Since then probiotics are slowly making their way into the official medicine, but way too slow.
Companies, manufacturing formula for the US (Ross, MeadJohnson and Nestle) are too buisy developing "Low iron", "lactose free" and other formulas, while ignoring the fact that in Europe probiotics are used for ages... Oh, I can complain about it again and again....

The other experience I had that I was very satisfied with was the quality of the speech therapists (logoped) we had who tutored our older son.

Good specialist is a good specialist - in Ust Kamenogorsk or in New York.

[gidoc13]

I'll put my two cents into probiotic (Biolac) topic. Being familiar with probiotic since infancy thanks to my Mom (lyophilized Bifidum bacterin, Lactobacterin or just plain cultured kefir etc. for diarrhea-antibiotics or travelers, or just for proper digestion) used it in practice as a GYN (in former life)-PID, with antibiotic treatment, candida etc. Naturally, as a gastroenterologist I tried to use it here-and got same response as Dr. Mom-at best- sceptical, not to say worse. Nontheless, I use it despite all the scepsis. Recently few attendings were asking me how to use it, so hopefully with time official medicine will accept it here as well.

[promedglobal]

A local girl came in this morning, one of those patients that when she walks in through the door you can tell she is SICK.

She had been put on the sick list and hospitalized for a week for ovarian cyst of 3cmx2.7cm. The treatment was daily infusions of Sodium Thiosulphate, Plazmol, kanamycin, vitamin b6/b12 and oral metronidazole.

Her Ant. Fossae are covered in bruises from the repeated infusions. Still in a lot of pain.

Her dipstick UA (the most advanced laboratory analysis we have here) shows leukocytes and trace blood. She got ketorolac for pain, ceftriaxone, and an appointment for an US the next day.

Last week another local girl came in with gross hematuria and bilateral flank pain. Looks a bit toxic, w/ a mild fever. She was referred to the hospital, where they wanted to treat her with gentamycin, 5-nok(vitamin injections), metronidazole IV, and injections of aloe extract. She refuses to take any sort of tablet whatsoever, as she says she immediately vomits them up. She came back to our clinic and said she didn't want to be treated in the hospital. I didn't blame her. So she got an IV of cipro 200mg, ketorolac for pain, and 500cc NS twice daily. Veins are awful...I start a saline lock for the infusion. IV catheters are virtually unobtainable here...we have to hand carry them in. After a couple of
days she is feeling better and we arrange for her hospitalization to continue the cipro, since we are not set up for inpatients, and she lives 20 miles away. We suspect pyelonephritis, and my local doctor, bless his heart, is not more happy with giving gentamycin to these patients than I am.

Sigh.

[VI]

5-NOK is not a viamin. It is nitroxolin, an antimicrobal. I was not able to find any western information about it. Maybe someone with access to MArtindale could give you detailes.

[promedglobal]

Aha, ok, thanks for that- I will look into it.

Something that might interest Dr. Mom:
http://www.bmj.com/cgi/content/full/333/7576/0-c
BMJ 2006;333 (11 November), doi:10.1136/bmj.333.7576.0-c

This week in the BMJ
Probiotics are relatively safe and beneficial

The benefits of probiotic bacteria such as Lactobacillus and Bifidobacterium seem to outweigh any potential danger of sepsis say Hammerman and colleagues in their review of randomised trials, Cochrane controlled trials, and case reports (10.1136/bmj.39010.630799.BE). While anecdotes of Lactobacillus sepsis exist, retrospective reviews suggest no greater risk of systemic infection from these bacteria than from endogenous commensals. Prospective studies have reported that probiotic therapy is clinically useful and safe in immunocompromised adults and premature infants, although safety is relative not absolute.

[promedglobal]

From Pubmed, this rather interesting article which supports our experiences in Tajikistan:

Ter Arkh. 2000;72(6):30-5. Links
[Antibacterial drug resistance of gram-negative agents causing urinary infections in female outpatients in Russia: results of multicenter study]
[Article in Russian]

* Strachunskii LS,
* Sekhin SV,
* Abramova ER,
* Reshed'ko GK,
* Petrochenkova NA,
* Eidel'shtein IA,
* Suvorov MM,
* Krechikova OI,
* Il'ina VN,
* Petrova TA,
* Gugutsidze EN,
* Furletova NM.

AIM: To investigate the spectrum of gram-negative agents causing acute and recurrent cystitis in outpatients and sensitivity of uropathogenic E. coli to antibacterial drugs; to compare drug resistance of uropathogenic E. coli isolated in Russia and other countries. MATERIAL AND METHODS: The spectrum of gram-negative bacteria was identified in 299 cases of acute and recurrent cystitis in Moscow, Smolensk and Novosibirsk. 271 E. coli uropathogenic strains were examined according to CA-SFM and NCCLS criteria for sensitivity to ampicilline, gentamycin, trimetoprim, co-trimoxasol, nitrofurantoine, nalidixic acid, pipemidine acid, norfloxacine, ciprofloxacine, nitroxoline. RESULTS: E. coli, K. pneumoniae, K. oxytoca, P. mirabilis, P. vulgaris caused acute and recurrent cystitis in 90.6, 6.4, 1, 1.7, 0.3% of the examinees, respectively. For Moscow relative agents were: E. coli (80.8%), K. pneumoniae (13.1%), K. oxytoca (2.3%), P. mirabilis (3.1%), P. vulgaris (0.7%). In Smolensk E. coli, K. pneumoniae, P. mirabilis were isolated in 96.3, 2.5 and 1.2%, respectively. E. coli occurred in 100% of Novosibirsk cases. Mean Russian values of the resistance to ampicilline, gentamycin, trimetoprim, co-trimoxasol, nitrofurantoin, nalidixic acid, pipemidine acid, norfloxacine, ciprofloxacine, nitroxoline were the following: 33.3, 5.9, 20.3, 18.4, 2.9, 5.5, 4.4, 2.6, 2.6 and 94.1%, respectively. Resistance to 2 and more drugs was registered in 18.4% of E. coli strains. CONCLUSION: Cystitis in women was in most cases caused by E. coli. The highest resistance among uropathogenic strains E. coli was observed to nitroxoline, ampicilline, trimetoprim and co-trimoxasole; maximal antibacterial activity against uropathogenic E. coli was shown by fluoroquinolones (norfloxacin and ciprofloxacin).

PMID: 10900645 [PubMed - indexed for MEDLINE]

We have found that our patients have the best result when treated with ciprofloxacin. The local physicians almost never prescribe cipro for UTI, despite its wide availability and relatively low cost. Gentamycin and 5-nok are the usual treatments.

In talking to my colleagues here, they agree that there is a big problem with resistance to SMZ (biseptol) and ampicilin, as people self-treat virtually any malaldy, especially colds and coughs, with these two drugs.


As an aside, I note that treatment of ovarian cysts seems to be MUCH more aggressive here. A simple follicular cyst which would be treated with NSAIDs in the USA and allowed to resolve on its own, quite often results in hospitalization and even surgery.

Jim

[promedglobal]

25 y/o female, RLQ abdominal pain. She is borderline for appendicitis, my Tajik colleague thinks it may be colic because she ate a bunch of seeds earlier in the day. It looks too much like appy to me, so I tell him we will start an IV, give her Metronidazole 500mg and Rocephin 1gm IV. She gets 500cc of NS and the antibiotics, and after a couple of hours spikes a fever. Rebound tenderness, + obdurator sign, + Rovsings sign, nausea and a fever....time to send her to the hospital to make friends with a surgeon.

I hang a 1L bag of NS and tell my doctor to take her in the ambulance. He says, "With the IV?". Yes, with the IV. And the Propaq monitor. This is not because I am worried about the girl: the hospital is a half hour away and she could easily go in a taxi. But I want my doctor to get practice transporting patients who are critical.

He arrives at the hospital, and they promptly yank out the IV. She gets a CBC and her leukocytes are 12,000. Off to surgery where she gives birth to a nicely inflammed appendix, and the lights go out just as they are closing. Electricity only a few hours a day here.

I ask my Tajik doctor why they pulled out the IV, as I started it so that 1)She could get IV antibiotics, and 2)Replace perioperative fluid loss and 3)Stay NPO, and 4)As a medication route for the anesthesia.

His answer was enlightening. "They don't start an IV for such a simple operation as appendectomy". Ok....so how do they give the anesthesia? "Ether". Premedicate with IM injections. IVs are for blood and if she crashes during the operation.

Waste not, want not.

[jester]

WOW!

I am so old that when I was doing my internship in anesthesiology I have seen ether anesthesia ( though it was not single ether), but I have never heard of anesthesia/ operative manipulation WITHOUT and IV ....

Just to be mean ;) - they do not use IV because they do not waste IV's for such minor things, but why did they pulled out the one which was already there and was "wasted" anyway?....

[JuliaMI]

WOW!

I am so old that when I was doing my internship in anesthesiology I have seen ether anesthesia ( though it was not single ether), but I have never heard of anesthesia/ operative manipulation WITHOUT and IV ....

Just to be mean ;) - they do not use IV because they do not waste IV's for such minor things, but why did they pulled out the one which was already there and was "wasted" anyway?....

'Cos of "my nikogda etogo ne delaem". "Kupili bilet i poschli peshkom - nazlo konduktoru".

I never saw ether anesthesia but quite a bit of surgeries (including appendectomy, BKA and a whole lot of operative obstetrics) without IVs and with single monitor being BP measured q5-10 minutes by hand. To ego ne mogli postavit', to sestry chay pili, to igolok ne bylo, to rastvora, to ya vse eto prinesla, a pacient uze na stole....

[promedglobal]

Whenever I send a patient I think will need surgery, I send them with an IV bottle, infusion set, and an IV catheter. I did so with this girl, and I also sent along 2 ampules of ketamine, some ketorol, dimedrol, and metoclopramide. All these things are generally available, but this was over the Nauruz holiday, and I wanted to be sure she got at least these few meds as the pharmacy is closed, and the hospital has little in stock (you buy everything at the pharmacy across the street).

I think one of the biggest problems is simple: the local doctors here dont know what an IV catheter is. They can't comprehend that a patient could be transported, and wander around the hospital, with an IV infusing. My doctor had never seen or used an IV catheter until he came to work here, and he still does not entirely trust them being used as saline locks (thinks they will clot off and that when you flush it will go to the brain and the patient will stroke).

He said that if the people in the hospital saw him bring in a patient with an IV running, they would laugh and think he is crazy.

Maybe they used the extra IV set and catheter that I sent with her in surgery. But I suspect what they did was mainline the ketamine (her sister told us she acted goofy after the operation, a sure sign they used ketamine).

Too bad: it was a GREAT IV. I put it in the OB vein, and secured it with a Veniguard. She could have gone 12 rounds against Rocky Balboa and that thing wouldn't have come out.

There is no oxygen, and no monitoring in this hospital, except as mentioned, a BP cuff and stethascope.

I actually find it quite fascinating. While I applaud the ability to "make do" with limited resources, such as operating without an IV, in times of war or when there is simply nothing available, I honestly cannot support that same philosophy being carried over when you have the resources, but choose not to use them. As Julia says, here the issue is simply: My tak ne delaem.

[jester]

I know this philosophy. It's international - I've heard the words " this is the way we do it here" from most of my attendings ( here, in the US) no matter what issue - no difference in philosophy, just different economical background.

They do not have O2? And they operate under anesthesia? WOW.
We could have ( in Ukraine) the supply of O2 interrupted ( it happened quite often at night if you didn't secure the fresh tank yourself and our ventilators were able to work only on air), but not to have it entirely?....

They are bravehearts. Their patients are the players in Russian roulette (though they do not know it).

[JuliaMI]

They are bravehearts. Their patients are the players in Russian roulette (though they do not know it).

Some of them know. That' why I host already fifth family of my friends coming here for mom having TAH/BSO (and then radiation and chemo).

Totally agree - psychology is the same. "Listen, the patient has unstable heart rhythm already and that's only IV sedation with propofol - I don't see any indication to ondasentron. - But, doctor, WE ALWAYS DO IT FOR EVERYBODY here!!"

[jester]

Totally agree - psychology is the same. "Listen, the patient has unstable heart rhythm already and that's only IV sedation with propofol - I don't see any indication to ondasentron. - But, doctor, WE ALWAYS DO IT FOR EVERYBODY here!!"

Amazing :lol: Propofol has untiemetic properties, which maybe even better than ondansetron :smile: For PONV

[promedglobal]

Yep, no oxygen. The manifold system hasn't been used in years, due to lack of maintenance, and given that there is no running water or electricity most of the day, obtaining bottled oxygen is probably not high on anyones list of priorities. I have been told by the deputy minister of health that the only medical oxygen generator is in the capital, and is over 30 years old. Of course, there is non-medical grade oxygen available. It works good. Don't ask how I know this....

Tajikistan was always the poorest and most backward of the Soviet republics, and things haven't changed much since then.

Most of the equipment in the hospitals is 1970's vintage. I think there must have been a big push in that period to modernize the hospitals, but after that, nothing happened, and of course things got much worse after 1991.

I compare Tajikistan to what Kazakhstan (the other former Soviet republic I am most familiar with) was like in the late 1990's. Tajikistan is easily 10 years behind the other central asian states.

Because of the civil war, I think a lot of the surgeons here are comfortable operating under the most austere conditions. So, for them, operating without an IV or oxygen is probably no big deal: at least they (usually) have some light and actual catgut or silk, instead of regular cotton sewing thread!

They are certainly not slouches when it comes to making do: one young soldier here was shot in the leg by accident. Hit the femoral artery. I was not here when it happened, and he was taken to the hospital without any first aid. Miracle he didnt bleed to death on the way.

They operated and placed a temporary graft of some plastic tubing they had laying around, and transfused whole blood from another soldier. Saved the kids life, without a doubt.

Jester is right of course. This is why I tend to piss people off when I make them tell me WHY they do things a certain way, and make them show me the proof that their way is best.

I know this philosophy. It's international - I've heard the words " this is the way we do it here" from most of my attendings ( here, in the US) no matter what issue - no difference in philosophy, just different economical background.

They do not have O2? And they operate under anesthesia? WOW.
We could have ( in Ukraine) the supply of O2 interrupted ( it happened quite often at night if you didn't secure the fresh tank yourself and our ventilators were able to work only on air), but not to have it entirely?....

They are bravehearts. Their patients are the players in Russian roulette (though they do not know it).

[promedglobal]

Our work here is winding down, and I am trying to help out the local hospital (Central Regional Hospital/SRB).

I recently "donated" a Propaq to them. Actually, what I did was give it to them on "permanent loan". It was interesting that the staff seemed to intuitively grasp the concept, and the difference between a donation and "permanent loan". Left unspoken but certainly understood, was "You can't sell this to buy yourself a new car" and "If the deputy minister of health tries to take it so his brother-in-law can use it, or sell it, then you can tell him it doesn't belong to you, it belongs to some American who loaned it to you."

So I go up to the hospital for a hemmoroidectomy to give them some inservice training on using the Propaq.
I went in to surgery and explained that the important thing to remember was to always take a baseline set of vitals with a manual cuff and good old fashioned Mark I ear and eye. So I say, "Whats his BP?" just as they are about to push Ketamine. They ho- and hum for about a minute, until someone grabs a BP cuff and checks the guy: BP 140/90.


So they push the ketamine. They dont start an IV, but rather stick a metal syringe needle into the guy's arm, and secure it with a piece of tape. This then becomes the IV. I hook up the monitor and his BP is 200 over 110 in the left arm. Of course, this is from the ketamine. They all look a bit concerned, and finally take a blood pressure on the right arm- 180/100. So, the monitor is working. After a few minutes the BP drops back down to 140/90.

I explain the pulse oximeter readings, which are about 88. I say this is typical of patients that are given sedatives, and that anything under 90 is considered hypoxia. They do a jaw-thrust, because they have no oral airways. Not even a simple gaudel OPA. I explain we would give this guy supplemental oxygen to bring his sats up, but they dont HAVE any oxygen, so thats a non-starter. In any case, his sats come up on his own after a few minutes, as expected.

About halfway through the procedure the guy wakes up and starts looking around, so they start hollering at each other in Tajik until one of the anesthetists wanders over and pushes some more ketamine. I'm thinking that was a good idea.

The surgeons seem fairly competant and the operation went without a hitch.
For premedication they gave Atropine IM and diazepam.

They were all quite impressed with the Propaq, especially the young anesthesiologist. I think he pretty intuitively grasped the concepts involved.

I am supposed to assist soon with a more complex operation, probably a open cholycystectomy. They said they would use Ketamine and Sux, and that they have a ventilator. They showed me an ancient soviet ventilator (no oxygen of course) that actually seemed to function fairly well. It did basically as much as my AutoVent transport ventilator, which is the size of a paperback book.

The anesthesiologists begged me for ET tubes, which I supplied. I quizzed him on difficult airway procedures, and he said if they can't intubate with a laryngoscope, he would try digitally, and if that failed, go to a surgical airway. I don't think they have heard of trans tracheal retrograde wire-guided intubation.

They have almost no knowledge of "modern" medicines such as midazolam or propofol or etomidate or the newer non-depolarizing paralytics such as vecuronium or rocuronium, etc, although I expect these were covered in medical school, it was probably something along the lines of "These exist, but you will never see them, so don't worry about it." Surprisingly, even ketorolac, which is widely used in the other states of the CIS (and everywhere else on the planet!), is not available in Tajikistan. They often receive drugs from humanitarian aid donations that they have no idea how to use, and these sit on the shelf. Because the internet is so limited here, none of the doctors know how to search the internet for drug information. So for example, they received ceftriaxone and diflucan as part of an HIV treatment program (along with antivirals) but had no idea what the ceftriaxone was beyond "some kind of cefalosporin".

[jester]

"The anesthesiologists begged me for ET tubes, which I supplied. I quizzed him on difficult airway procedures, and he said if they can't intubate with a laryngoscope, he would try digitally, and if that failed, go to a surgical airway. I don't think they have heard of trans tracheal retrograde wire-guided intubation."

Well, long before you go for transtracheal retrograde wire-guided intubation there are some much more easier steps and absolutely less invasive. Light wand, for instance, or Fastrach LMA - not that I suspect they have them... If they have had O2 ( or Ambu) - there wouldn't be a problem - they would probably just mask the patient, anesthesiologists all over post-sovok are efficient with mask-ventilation - luckily enough there are not too many 300-pounders around.
=====================
Are you going to some other places as well?

[JuliaMI]

Jester, LMAs are somewhat known in former USSR (though still usually smothered in an ocean of Lidocaine jello - who knows why) but FastTrachs... have mercy! You can tell them about Bullards and Glidescope as well.

The question is why they don't use jet vent - it doesn't require almost anything. Can be used even with the bid and not very sharp IV needle.

Yesterday I told one spinal surgeon how I was taken out of the bed on POD#7 or so (compression fracture T4T5, fixation, neuro stuff slowly improving by itself) and told, plainly, to go ahead and move my big fat #$*% around. No narcotics, of course. The guy answered privately that he would be happy to be able to do something like this, for it should make rehab 100% more effective. But, he continued, here you'll be sued in a second if you attempt to do it w/o that sweet dose of Dilaudid, and with the dose on board you just cannot get the dude moving.

[jester]

Jester, LMAs are somewhat known in former USSR (though still usually smothered in an ocean of Lidocaine jello - who knows why) but FastTrachs... have mercy! You can tell them about Bullards and Glidescope as well.

The question is why they don't use jet vent - it doesn't require almost anything. Can be used even with the bid and not very sharp IV needle.

Yesterday I told one spinal surgeon how I was taken out of the bed on POD#7 or so (compression fracture T4T5, fixation, neuro stuff slowly improving by itself) and told, plainly, to go ahead and move my big fat #$*% around. No narcotics, of course. The guy answered privately that he would be happy to be able to do something like this, for it should make rehab 100% more effective. But, he continued, here you'll be sued in a second if you attempt to do it w/o that sweet dose of Dilaudid, and with the dose on board you just cannot get the dude moving.


Because they do not have OXYGEN!!!! If they did - they plain just could have mask-vent the patient ( we did million times - difficult airways back home are not at all difficult ;) I have never seen any inborn malformation, the ENT deformoties proceeded straightforward to awake tracheostomy by ENT ( no fiberoptic scopes).
And I never suspected that there are LMAs in that CRB in Tajickistan, just pointed that there are steps BEFORE retrograde intubation - that one is probably the one to be applied in a situation without anything, even oxygen.

[jester]

Yesterday I told one spinal surgeon how I was taken out of the bed on POD#7 or so (compression fracture T4T5, fixation, neuro stuff slowly improving by itself) and told, plainly, to go ahead and move my big fat #$*% around. No narcotics, of course. The guy answered privately that he would be happy to be able to do something like this, for it should make rehab 100% more effective. But, he continued, here you'll be sued in a second if you attempt to do it w/o that sweet dose of Dilaudid, and with the dose on board you just cannot get the dude moving.

Oh, God, folks here are bathing in narcotics after the most minor cut - a lot of them are expecting to be able to dance after operation - "why am I hurting so badly" - when beeing woken up from soundless sleep with HR 72 and BP 120/65.

The only ones who do not request narcotics - quite the opposite - are recent immigrants from Europe.

[kinetic]

In my opinion there are several roots to this problem. The main one, probably, is the fact that the most of the general public genuinely believe they have just about as much medical knowledge as any doctor. This could be because an uncle of their neighbour suffered from a similar condition a few decades back, or because their granny worked as a carer in a hospital.

Keeping this fact in mind, most patients expect drastic actions with an immediate result no matter how insignificant the ailment is. Multiply these epectations by ten if the patient is paying money for their treatment.

Combine this with the fact that evidence-based medicine is almost unheard of among the medical profession and lack of fundings - and you get post-soviet medicine at its best.

Some of the treatments are quite effective and I wish a few of them were more widely accepted at the West. For instance, i.v. no-spa (drotaverin) works excellent for my wife's renal colics and I still inject it (brought from home) as required, rather than driving her to the hospital for a morphine shot.

Others work on psychosomatic level and are just as effective. While working on "skoraya" i witnessed a brilliant method of treating panic attacks called "fractional infusion by colours", which consists of two saline drips (one in each cubital vein), coloured with thiamine and B12 respectively, infused one at a time, each for 10 minutes.

One need to be aware of plain dangerous practices and find the right balance between the effectivness, the cost, and the patients demands for the rest of them, IMHO.

[JuliaMI]

In my opinion there are several roots to this problem. The main one, probably, is the fact that the most of the general public genuinely believe they have just about as much medical knowledge as any doctor. This could be because an uncle of their neighbour suffered from a similar condition a few decades back, or because their granny worked as a carer in a hospital.

Keeping this fact in mind, most patients expect drastic actions with an immediate result no matter how insignificant the ailment is. Multiply these epectations by ten if the patient is paying money for their treatment.

Combine this with the fact that evidence-based medicine is almost unheard of among the medical profession and lack of fundings - and you get post-soviet medicine at its best.

Some of the treatments are quite effective and I wish a few of them were more widely accepted at the West. For instance, i.v. no-spa (drotaverin) works excellent for my wife's renal colics and I still inject it (brought from home) as required, rather than driving her to the hospital for a morphine shot.

Others work on psychosomatic level and are just as effective. While working on "skoraya" i witnessed a brilliant method of treating panic attacks called "fractional infusion by colours", which consists of two saline drips (one in each cubital vein), coloured with thiamine and B12 respectively, infused one at a time, each for 10 minutes.

One need to be aware of plain dangerous practices and find the right balance between the effectivness, the cost, and the patients demands for the rest of them, IMHO.

I work now in a place serving 99% inner-sity poors (Detroit, being exact). You know, there're three main differences between them and many my former Russain patients:
- black vs white
- speaking the language they consider English vs. one those considered Russian
- drinking mostly cheap whiskey vs. cheap vodka.

That's it. Everything else is just as you mentioned above, except here folks don't pay anything. They actually expect me to figure out a way how they're going to climb the tree but don't scratch anything in the meanwhile. They can request their stable comatose relative staying in Neuro ICU ($10.000/24h) in order "yo' ganna fixin' she', dok, RIGHT?!!" and no consideration about money ticking.
Oh, yes, in Russia, at least I never saw fully illiterate folks exept a few in Pskow villages. Here in Detroit they are abundant to the level making me tearful. That's typical to see an adult unable to write "husband" or "spouse". Even with spelling. How do they manage to drive - God Merciful only knows.

PS - agree with some FDA non-approved techniques/drugs. Our Russian way to salvage infected PICCs by doing serial locks with 75% ethanol is now widely accepted around Detroit medical center and beyong it locally. But we cannot do any meaningful research on this, and IRB committee already put his lead-made Vetoe. We're doing this anyway, indeed.