Touring the Mongolian Countryside, Part 2

August 4-7, 2019

We flew to Murun and drove to Double Lake by Toilogt camp, a fairly new camp at Lake Khuvsgul. The drive was, uh, interesting… much of it was on what I would call pretend roads, often on the floor of a dried up river.  To say it was bumpy is quite an understatement. Dramamine is a must for anyone who gets carsick. On the way to the camp we stopped and visited reindeer brought in from the mountains for just that – visitors paying to see the reindeer.  They also had a market for homemade crafts, jewelry, etc. 

We spent three nights at Double Lake, and I must say it is a beautiful place with superb views of the lake and mountains. They have gers to stay in, but we were in what would be best described as hotel rooms, each with a nice balcony that overlooks Lake Khuvsgul.  Breakfast, lunch, and dinners were provided in the lodge, and all the meals were very good. Meat, meat, and more meat – Mongolians like their meat! 

Monday morning, Eric, Dana and I took a boat ride with our tour guide across the lake and met another reindeer family. The woman, her brother, and her four year old daughter make the trek from the mountains every summer, bringing 7 of their ~20 reindeer with them. 

Horseback riding made up most of Tuesday.  We started in the AM and rode for about an hour, then went out again in the afternoon for ~3 hours, including a trip up the mountain on horseback for spectacular views.  Tuesday night ended with a huge bonfire. 

Wednesday started with breakfast, our last meal at Double Lake, then made the drive to Murun to fly back to Ulaanbaatar.  More riding along the pretend roads, but a different route made it bumpy for a shorter duration.

We had some time to shop in Ulaanbaatar Wednesday and will be starting our trip home Thursday through Beijing (with a side trip to the Great Wall).  It has been a long time away from home (away from the 904), but I have seen a country and culture that is truly amazing. The people are extremely friendly, the landscape is beautiful, and there is much to learn from the Mongolian people.

I look forward to returning next year.  

Larry

Touring the Mongolian Countryside, Part 1

August 3, 2019

After the exciting, educational week at the children’s hospital, Eric, Dana and I ventured out to the countryside, starting with the Mongol Nomadic Ger Camp. They had an interesting nomadic show, basically a cultural demonstration of how they live.  First up was riding a yak!  Besides the many yaks, they had horses, camels, sheep, and goats to see.  And a dog. 

We saw how they prepare sheep wool (including Eric taking a turn beating the wool with sticks), make milk vodka, and entertain themselves with a couple of games (e.g., ankle bones). I sampled milk tea, and of course, milk vodka – it was very acidic and definitely not my favorite, but at least I had a chance to try it. One of the men put on a show with his horse-
riding skills. Towards the end they had a concert using their horse-head fiddles (morin khuur) and throat singing. 

Just as interesting was the mini-Naadam festival that happened to occur that weekend at the camp. Dancing, horse racing, archery, and of course wrestling. It was a great way to sample was goes on during the very large, three-day festival in Ulaanbaatar in July. 

Lastly, I spent my first night in a ger at the Mongol Nomadic Ger Camp.  This was not roughing it (luckily) – there was electricity, running water and a private bathroom with a shower.  I’m not the roughing it type of person, so it was perfect.

Larry


NCMCH ’19 Comes to an End

Days 4 & 5, 2019

The week has come and gone in what seems like in a flash.  One might say our work is done, but that’s far from true. 

One of my dad’s favorite quotes was from Reinhold Niebuhr:  

“God, grant me the serenity to accept the things I cannot change, 
Courage to change the things I can,
And wisdom to know the difference.”

That very much applies here. We have to accept that there may be things that cannot change given the limited resources the physicians face. They do the best they can with what they have.  

But there are things we can work towards improving… Trying to make sure the appropriate meds are made available to the kids that need them, making sure important laboratory tests are obtainable, and much more. 

I saw many interesting patients and families, and hope I have made an impact for the short time I was here, not only on the patients and their families, but the staff and residents as well. I am indebted to Dr Sandler for inviting me, and thank all the wonderful staff at the hospital for the opportunity to be here and make me feel so welcomed and appreciated. I am especially grateful to Turshee, my wonderful student who spent the week at my side translating my every word. 

I hope to return next year and continue what I started in endocrinology at NCMCH.

Larry

Days 1 and 2, 2019

30 July 2019 – Days 1 & 2

We made it to Mongolia without any major travel issues.  The flights were indeed long, especially the 14 hour trek to Tokyo, but tolerable. And not even long enough to watch the entire Harry Potter series of movies (no, I didn’t try). 

My first two days at the children’s hospital have come and gone. Yesterday I met two of the three pediatric endocrinologists that work at NCMCH; the other is on maternity leave.  I toured the endocrine unit which shares space with nephrology.  I’m amazed at how large the children’s hospital is, spanning multiple buildings, connected by multiple underground tunnels.  

I was able to spend time with 4 patients, 3 of which were hospitalized (two with type 1 diabetes, one with Graves hyperthyroidism) and one outpatient, an 18 year old boy with severe short stature (only 56” tall) from hypopituitarism, not diagnosed until 3 years ago. Amazingly, he has been placed on growth hormone and has demonstrated some catch up growth. Plus, his growth plates remain wide open (they look like an 11 year old). He will be attending a university soon and, appropriately so, is anxious to go through puberty! 

The 15 year old girl with poorly controlled type 1 diabetes stopped checking blood sugars because she just got tired of doing them – really no different than many of the patients we see at home! But in Jacksonville and the rest of the U.S. and other developed countries at least we can rely on technology – continuous glucose monitors for example.  Not here, not yet. 

Today I met a 4 year old girl with precocious puberty and an almost 15 year old boy with diabetes insipidus and central hypothyroidism. I suspect he also has other pituitary deficiencies as well but time (and some additional testing) will tell.

The patients bring a bag full of written records, radiographs, MRI images, etc., wherever they go. The records follow the patients. At home we use an electronic medical record that can sometimes be shared from one organization to another. Most of the time, however, we struggle getting records from other physicians. Although the records they use here are paper based and simple, there’s something to be said for having them wherever they go, whichever specialist they see. 

I was able to do something I haven’t in a while: talk to patients and families (with the help of a translator of course) without concern for billing, time constraints, RVUs, and other logistic clinic issues that are not very relevant here. It was wonderful!

I look forward to seeing what tomorrow will bring. 

Larry

Team Mongolia 2019

7/23/2019

It is hard to believe that in under one week our journey to Mongolia will begin. Time has flown since Dr. Sandler asked me to join him and planning started several months ago. The excitement is building day by day, but so is the anxiety: A 29-hour journey with a long, 14-hour flight (plus another at 5.5 hours), the 12-hour time difference, concern regarding finding food I can eat and not eating foods I may not want to without offending anyone, the language barrier, and a general fear of the unknown all contribute to the nervousness of this type of trip.

One huge lingering question is how I will contribute as a pediatric endocrinologist. How will my knowledge of thyroid disorders including thyroid cancer in children contribute to their health? How will my research and clinical experience in childhood diabetes in a world supported by diabetes technology help the children of Mongolia? What about all of the other pediatric endocrine disorders I’ve studied all my career? Will I be able to use that experience and knowledge to enhance the health of Mongolian children in 2019 and beyond?

This will be my second journey of similar pretense – the 1st was to Nairobi, Kenya, about 7 years ago. While there for two weeks I had the pleasure of teaching pediatric endocrine fellows in a country (continent, actually) in which there is a shortage of pediatric endocrinologists.

This trip will be quite different, but the goal is the same… not only teach other medical staff (physicians, medical students, etc.) what I can about pediatric endocrine medicine, but learn a great deal as well. I greatly look forward to seeing children with a variety of endocrine disorders and teaching at the National Centre for Maternal and Child Health, but I also very much am excited to learn about the practice of medicine in Mongolia and their culture.

~ Larry

Larry A. Fox, M.D.
Pediatric Endocrinology, Diabetes and Metabolism
Nemours Children’s Health System-Jacksonville
Associate Professor of Pediatrics, Mayo Medical School
Medical Director, Northeast Florida Pediatric Diabetes Center

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