Our introduction to Mongolian medicine (Cindy)

Although we had been prepared for what was to come, I will have to admit that the experience at National Center for Maternal and Child Health was both eye opening and rewarding.

To start our morning we make our way through the traffic, honking horns, broken sidewalks and dusty construction.  Once we arrive, we meet the oncology team to discuss new patients and events that occurred overnight prior to making rounds.  Dr. Sandler, I think they missed you; I tried my best to fill your shoes.  Although some physicians were on vacation, we were fortunate enough to have Degi, a fairly new oncologist, and Oyunaa, a pediatric resident, as part of our medical team who were able to translate.  Rita was also there ready and able to help as well, for which we are truly grateful.

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Examining a patient with Rita.

On our first day we rounded on every patient on the oncology floor.  A very full floor we must say.  There must have been 15 patients in house. There were plenty of teaching opportunities and discussion. Diagnoses included predominately ALL, but also AML, Histicysosis, Aplastic Anemia and a few Lymphomas.  The available chemotherapy drugs sound much better than years past, thanks in part to our previous teams’ recommendations.  However, there is more work to be done as it was quite heartbreaking seeing so many Leukemic relapses.  

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Discussing a patient’s case with the team.

With three to four patients in a room at times, it made no difference that there was no air conditioning – these children are so adorable and loving and quickly warmed up to Alex and John.  It was truly a heartwarming experience.  

Thanks to Dr. Sandler’s initiatives, I do believe that Hepatitis C PCR testing is under development.  On a bright note we were able to tour a new oncology building to be completed this fall.  The 2015 team should be quite impressed: Oncology alone will occupy 3 floors.  The cardiac cath lab will be located on the first floor.

 

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John, Alex and Degi mocking me as I worked hard to sign 100 certificates.

Our laboratory tour was quite impressive and afforded me the opportunity to view slides of a newly diagnosed patient.  I was excited to learn that flow cytometry is now available, at least on peripheral blood.  Acute Leukemia is now accurately diagnosed as pre-B ALL, T-cell ALL and AML.  A future goal might include the ability to perform Methotrexate levels so that high dose Methotrexate can be delivered.  

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With my anda (blood sister), Mongolia’s clinical pathologist.

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In my happy place. What a beautiful stain!

Lots of oncology, but hematology was not to be denied.  On day two I met an adorable little girl with 1% factor VIII, on weekly Advate prophylaxis!  However, we did learn that recombinant factor is in short supply and what a dream it would be for our Hemophilia Treatment Center (HTC) would be to “Twin” with Mongolia.  Missy, are you ready?

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Visiting with a Hemophilia patient.

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Discussing the clotting cascade.

The medical team remained eager to learn, always asking appropriate questions and very receptive to our input. It has been an amazing week, such wonderful people to work with.  I hope we can continue our Mongolian working relationship.  

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With the medical team.

-Cindy Gauger       

 

Reunion of the medical teams (John)

After two years, I am back to the National Mother’s and Children’s Hospital!  The rooms and corridors may have changed, but the friendliness and hospitality of Mongols remain. I was completely overwhelmed and touched by my Mongol friends’ warm welcome, even the people that I had met only once or twice during my last visit!!

After a brief Meet’n’Greet with the Hematology/Oncology group with endless coffee, tea, crackers, and the famous dried milk curds (Cindy’s/Alex’s first), we started going through some treatment protocols.  It certainly was very exciting to see that many of our recommendations from our first trip were put into clinical practice, including drugs we recommend to put on formulary, bone marrow needles, and diagnostic machineries.  We were so excited, we wasted no time and started seeing patients.

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Cindy and Alex get their first taste of airal (dried milk curd).

There are MANY major differences between Americans and Mongolians: geographic locations, cultures, faiths, languages, traffic patterns, diets, etc., etc. However, in the Hematology/Oncology wards, we are drawn together by the same calling to heal, to comfort, and to love.

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Entrusting the very lives of their most beloved children into the doctors’ hands, the parents’ eyes have the same mixed feelings of fear, uncertainty, and threads of hope… The same eyes that I saw two years ago.  The same eyes that I see back home in the US.

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Cindy rounding with a family discussing their young son’s diagnosis.

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Rita and Cindy discuss a babies symptoms.

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Oyunaa, Degii and Alex listen intently as Cindy reviews a case.

 

We see little brave warriors fighting for their lives receiving chemotherapy drugs that even adults fear.  We see a teenager girl broken into tears knowing that she needs to endure more vincristine infusions that cause her lots of pain with every dose.  We see families fight on with courage despite relapses, side effects, and failures.  We see worried fathers sitting at the end of the bed, wandering outside of the rooms sharing his deep love and concern in silence. We see mothers comforting suffering children with their loving arms and big hugs.  We see the same heroic stories beyond skin colours, cultures, and medical backgrounds back home and here in Mongolia.

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Cindy rounding really hard while John takes photos of the babies, the staff, the floor….

However, in the dark and partially ventilated Oncology ward, we also see angels in white coats who bring hope to every dark corner.  They may not be able to cure every patient, but I see the same hands of Mongolian and American doctors delivering not only the best skills in healing, but also care, comfort, and hope to the families they serve.  In their eyes, I see the same passion and determination to cure as possible. It is our honour to fight along side our Mongolian counterparts again to battle childhood cancers together.  May our busy week start!

 

Return to Mother and Child Hospital (Steve)

Two years ago I wrote: “It is the same in all nations and cultures everywhere: the look of fear in the face of a parent whose child has leukemia.”  Much has changed in UB over the last two years, but when I returned to the Mother and Child Hospital with the medical team I saw that one thing most definitely hasn’t changed: that fear-filled face of the parents on the oncology ward.
I spent Monday morning following along as Cindy, John, and Alex did rounds with the Mongolian doctors and residents through the pediatric oncology ward. We were greeted warmly by Dr. Chimgee and Degi, who speaks good English and has become our primary contact at the hospital. We were also joined by Oyunaa, a young resident in hematology-oncology who also speaks good English. Both John and I were delighted to see that people remembered us and were happy to have us return and offer our services.
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Cindy leading rounds with a young cancer patient.

I will leave the full medical explanations to those who are actually qualified, but I made a few observations that are perhaps worth sharing. First, it was great to see Cindy in action again. She was one of Jonathan’s doctors and always had such a wonderful attitude and personal style, no matter how dire his prognosis. Even in translation, her upbeat demeanor and compassion shined in the dim surroundings. It was also my first chance to see Rita working at her craft, and I was deeply impressed by her medical knowledge and professionalism.
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An anxious mom watches the rounds.

As we progressed through the rounds, I began to hear language I didn’t hear two years ago: “This is an 8-year-old girl with T-Cell ALL (Acute Lymphoblastic Leukemia).”  I glanced over at Rita, who looked equally surprised and leaned over to say to me, “That’s new–it’s the first time I’ve heard them use a full cellular diagnosis. They must be using the flow cytometer now.”  Regular readers of our blog will remember that, two years ago, on our first trip to. Mongolia, Eric Sandler suggested that the hospital try to acquire a flow cytometer, an expensive and technologically advanced machine which enables doctors to determine whether a patient with blood cancer has leukemia, lymphoma or some other type of cancer–and gives them the ability to isolate the type of leukemia or lymphoma (T-Cell or Pre-B Cell leukemia, for instance) and modify treatment accordingly. When the team returned last year, the hospital had managed to acquire a flow cytometer but didn’t have anyone on staff with the expertise to use it. Last year Eric suggested that they get some reagents to make the machine operable, and over the past 10 months they have somehow managed to do so and learned how to operate the device on a rudimentary basis–enough to make more nuanced diagnoses. Thanks to a little boy and his doctor, the Mongolia Bound teams are clearly making a difference.
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A young cancer patient eating breakfast.

The rounds were both heartbreaking and uplifting. As I said at the outset, I recognized and empathized with the grim expressions on the faces of the parents. (The children are almost always in better spirits than their parents, here in Mongolia or in the U.S.)  When we encountered an 11-year-old boy who had relapsed ALL, it struck a little too close to home and I had to leave the room with tears steaming down my cheeks.  But on the way to another section of the ward we encountered an anxious set of parents whose 18-month-old daughter had been sent to the hospital in UB because a countryside doctor thought the spots along her midriff might be the telltale bruising of leukemia. As Cindy and Rita peered more closely at the child lying peacefully in her father’s arms, they came to the same conclusion: those weren’t bruises but temporary blemishes, probably a dermatological rash. The little girl had no need to be on the cancer ward and could go home with her parents. The mother–who, it turned out, had spent four years in London–thanked us profusely in English. If only more of the diagnoses could have such happy endings.
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She is worried now, but she is going to get good news.

On Monday afternoon I headed over to soccer camp, and I will give a full report on how that’s going in my next post.

Our first visit to the Mongolian countryside (Cindy and Alex)

“Are you guys ready for this?” Steve and John asked us before we began our journey to the countryside of Mongolia.  Doogii our tour guide and Chuuka our driver greeted all of us with a big hug before we got into the infamous Russian van.

Our first stop was to visit the mighty Chinggis Khaan statue, which stands over 130 feet high.  Once inside we were able to dress in ceremonial Mongolian attire, which is generally worn during festivals and weddings.   As you can imagine we all had to be careful of General John and his sword.  We then climbed the stairs to the top of the horse’s head and enjoyed the beautiful panoramic view.

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Standing in front of Chinggis Khaan statue

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Standing on top of the horse’s head of Chinggis Khaan statue

With great anticipation we made our way to Blue Lake, our first Ger camp.  The true journey began when we took a quick left off of the paved road to begin our off-road experience.  One quickly appreciates the Russian van, which does not come equipped with seat belts, as Chuuka expertly navigates the maze of dirt roads in the countryside.   We were in constant awe of Chuuka’s amazing inborn GPS that enables him to choose which fork in the road to take, as there is not a road sign to be found.    Steve and John continually egged Chuuka on to run through the lakes and streams and to make the Russian van hit 45 degree angles.  Once we reached a 45 degree embankment on one of the many turns, the chanting started: “Chuuka, Chuuka, Chuuka . . . next we want 60 degrees!” The highlight of the day came when Chuuka came upon his first dilemma.  To go left through the soggy marsh (in which many vehicles had previously gotten stuck and needed towing), or through the flooded road which looked like a small lake.  He got out of the van and assessed the situation, which included tossing a rock into the lake to determine its depth.  When he returned to the van his mind was made up–he put the pedal to the metal and through the lake we went.  We all sat in amazement as we came out victorious on the other side, this time with all of us chanting…”Chuuka…Chuuka!!”

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Chuuka deliberating–through water or swampy mud?

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Through the water!

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Our view from the window as we drove through

At last we reached our final destination, Blue Lake.  Where do we begin?  Perhaps with the millions of flies which greeted us upon our arrival?  We tried to focus and learn the history of Blue Lake from our historian, Professor Steve, while fanning away some of the biggest flies we had ever seen.  Nothing sounded better at this moment than a hot shower. However, imagine our despair when we found that there was no hot water.  So we retreated to our cabin, where the catch and release of say 50 – 100 flies began.  We were, however, grateful for the one flushing toilet on the men’s side of the bathroom.  Our experience was topped out overnight at Blue Lake (which we affectionately termed “Fly Camp”) with howling wild wolves of the countryside just outside our window.

On day two we headed out to our destination of Khuduu Aral.  Along the way we stopped at a Ger to visit a family.  The parents were out in town for the naadam festival, but we were able to spend time with the five children who lived there and present them with gifts.  They eagerly accepted the shells, flashlights, and lanyards that we had brought for them.   The experience truly gave us an appreciation for the nomadic lifestyle of the Mongolian people.

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With the children at their ger.

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Our second detour of the trip was to an open field with a pen which housed approximately 200 sheep which were in the process of being sheared.  Cindy tried to console the sheep while each of us tried our hand at shearing.  We were quite proud when we left no incisions or wounds.

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Cindy consoling the sheep as we all took a turn shearing

We reached Khuduu Aral Ger camp and checked into our rooms equipped with TVs and scoped out the ever so important matter…..the bathroom and showers.  Hot water – check.  Flushing toilets – check check.

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The guys relaxing and enjoying the “upgraded” accomodations

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Can you tell we are happy about the bathroom situation?

After having lunch and getting settled we went to visit Chinngis Khaan monument (honoring the completion of The Secret History of the Mongols) and a spring that is known for helping with stomach issues.  Somewhere along the way our decision to not drink the water changed and we all took a swig from a bottle Doogii had filled.  Little did we know that the next day this water would look cloudy and brown in the bottle – ugh!  Cipro – CHECK CHECK CHECK!

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“Fresh” spring water – yummy!

Once back at Ger camp we walked down to the lakefront, which was popular for locals and tourists alike, and went ankle deep into the frigid water.  We headed back to take our highly anticipated “hot showers” (with the exception of Steve who ended up with just cold water) and got dressed for dinner.  Three bites into our salads, which consisted of vegetables and meat, John asked, “What kind of meat is this?”  The server replied, “Cow tongue” – great!  Our forks went down.

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Ahhhh – now this is the life! Relaxing in a ger

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Horseback riding along the banks of the Kherlen River.

On day three of our journey we headed to Steppe Nomads tourist camp in Gun-Galuut, where we were able to stay in Gers (traditional Mongolian dwellings).  Once we checked in – you guessed it, we checked out the bathrooms and showers, all of which exceeded our expectations.  We headed to lunch – which was BEEF!  With full bellies we made our way to the horses for some horseback riding.  Steve and John had done this on their previous trip and eventually took the reins from the guides.  We, however, allowed ourselves and our horses to be led.

After horseback riding we headed to raft down the Kherlen River.  We all gathered at the landing waiting to get into the raft while Doogii chatted with the staff.  We had no idea what all was said, but one by one we piled into the raft.   We all then looked at our feet which were submerged in at least 6 inches of ice-cold river water.  We asked if this was supposed to happen.  Doogii inquired and responded, “They said it’s OK.” Once afloat we realized there was no guide in the boat.  Again Doogii assured us “it’s OK.”  Just like that we found ourselves going down the river with horses on one side and cows in the pasture on the other.  At times we found ourselves drifting into rocks and turning circles.  After observing Doogii’s attempt at paddling we learned that this was Doogii’s first experience at rafting and furthermore that she cannot swim.  Oh boy! When we got to what we thought was the spot where we were supposed to land the raft, the staff member and Chuuka were waiting.  We spun a 360 degree circle for them when suddenly they yelled to not go around the corner of the river.  Not wanting to find out what was around the corner, we paddled as fast as we could to get to the shore.  Once back to the camp we made our way to the showers where there was hot water for everyone.  To top off the evening, we enjoyed fresh grilled lamb (thank you Chuuka), a glass of wine (which Steve, our wine connoisseur, rated as “crap wine”) while taking in the beautiful countryside view.

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Our beloved tour guide & grill master/gold-medalist driver

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John and Steve playing the ancient Mongolian game of anklebones.

DSC_3578We planned to hike to the top of the mountain the next morning after breakfast to take pictures of the river, but rain spoiled our plan.  However, on our way out we asked Chuuka to stop so that we could take pictures.  Fully expecting to climb to the peak of the hill, we were all shocked when Chuuka drove up the side of the hill, hitting what we deemed a 55 degree angle, so that we could take pictures of the beautiful view.  It truly was spectacular.

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View of the Kherlen River from the hilltop.

So were we ready?  Hmmm probably not – but we had an amazing journey and so much fun along the way.  A huge thanks to Doogii and Chuuka – we agree with Steve and John, they are Mongolia’s BEST tourist guide and driver!  The countryside trip would never have been so much fun without Steve and John!  “Professor” Steve’s knowledge of Mongolian history and language is quite remarkable (not to mention his expertise in wine) and John provided constant entertainment with his comical outbursts and his renditions of Mongolian throat singing.  It was truly amazing to experience Jonathan’s dream and we know that he was with us in spirit throughout our journey.

Cindy & Alex’s Top Ten Most Memorable Countryside Moments:

10.  Climbing to the top of Chinngis Khan Statue and dressing in traditional Mongolian wardrobe

9.  Finding out that your appetizer is cow tongue (thanks, John)

8.  Horseback riding in the beautiful countryside

7.  Experiencing nomadic lifestyle (visiting with children in their Ger and spending the night in

our camp Ger)

6.  Hot Showers & Flushing Toilets (or lack thereof)

5.  Grilling fresh lamb, drinking “crap wine,” and playing ankle bone while enjoying a

spectacular view of the Mongolian Countryside

4.  Driving to the top of the hill (hitting a 55 degree angle) for a spectacular view

3.  Experiencing “Fly Camp”

2.  Rafting without a local guide and your tour guide who has never been rafting and cannot

swim.

1. Driving with Chuuka, Mongolia’s gold medalist driver, through the back roads of Mongolia

and through small rivers

Mongolia 2015 Team – will you be ready?

-Cindy & Alex

 

John’s Return to Ulaanbaataar

I am John, once again the pharmacist of our medical mission team! Never had I ever imagined that I would have the opportunity to go back to Mongolia and now I am less than two weeks away from returning to the Country of Blue Skies!

It is the first time I return to a mission field and I have been very excited to have heard from the Second Team that many of our original recommendations were considered and taken by the Mothers and Children’s Hospital. Our Supportive Care Guidelines, recommended formulary drugs for common cancers, use of flow cytometry to guide leukemia treatments, etc, etc. were all being physically used in taking care of actual children in Mongolia!

I am also very excited to visit my Mongolian friends too, inside and outside of the hospital. I certainly miss their friendly faces, hospitality, care-free and always-happy attitudes in the vast Mongolian Steppes. My family has also been “getting into the mood” too! With Candace’s help: bedtime stories about Genghis Khan, chit-chats about nomadic lives, Mongolian wrestling in the living room, children with cancer in other countries, praying for Daddy’s trip, etc. etc. Along with our Youth Group in church, TsiLam and JunJun were inspired by the fact that all these… were started with one child’s dream.

I am getting ready to have another adventure with Jonathan. Although I miss all my comrades from the first trip, I am looking forward to have a great inspiring experience with Alex, Dr Gauger, and Steve. Last time I was inspired by the same passion of healing in a totally different country and culture. I was blessed with deep love shared between a father and a son. I was touched by the passion of two missionary families who devoted their lives taking care of orphans in a foreign land. This time I am ready for anything the Lord has for me under the Blue Skies.

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