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Adam Spong - Medical School Elective in Mongolia

I vividly remember sitting in a busy ENT (ear, nose and throat) clinic on a sweltering summer morning and seeing the look of surprise spread across my Consultant's face as I proudly announced Mongolia to be my medical elective destination. As he put it "..outer Mongolia was the place where my parents threatened to send me as a boy if I didn't behave". While I knew Mongolia wasn't a prison camp for naughty children, his reaction did bring home to me how little many people in the UK, know about Mongolia. So I suppose it was with a sense of adventure and discovery I chose to spend my medical elective (a 2 month period for final year medical students where one can go anywhere in the world to study medicine) in UlaanBaatar, Mongolia. That and rumors of unclimbed rock (a not so secret passion of mine).

At my medical placement

My decision to come here rewarded me with a wealth of medical learning, interesting experiences and an opportunity to make some great friends. I will never forget arriving at seven am having been awake for twenty-four hours, and being watched with delight as I took my first sip of airag (fermented mares milk and I'm still not sure how you milk a horse). It has an interesting palate to say the least but eventually you come to love it. Similarly, nothing really prepared me for working in the Mongolian medical system; it's something you just have to do.

In total I spent seven weeks working in several departments at the Mongolian State 2nd General Hospital. I began my time in the Anesthetic/Intensive Care Department which provided me with a fascinating contrast to the UK medical system since I had just spent the last three weeks at home working in the same specialty.

I found the basic principles of anesthesia and intensive care were similar in both countries, for example placing the sickest patients in the hospital in one area so they could receive necessary round the clock care and physiological support while they recovered but there were some stark differences too. Many were due to financial restrictions in Mongolia, which meant that certain pieces of disposable equipment like ET tubes (endo-tracheal or a breathing tube - maintains a patient's airway if they can't do it themselves) had to be re-used with implications for transmitting infections between patients. Whilst at first this was a strange practice, it doesn't take long to realize that if you don't re-use this equipment a patient will die in minutes if they have no airway and can't breathe.

With the lack of equipment however, it was interesting to see inventive solutions to clinical problems, such as using simple latex examination gloves as drainage bags.

A typical day would start at 8.00 where we would change into scrubs before convening for the 8.15 ward round. Afterwards I would then examine all the patients on the unit and review all their lab and investigation. The morning might then be spent in theatre or seeing patients with the admissions doctors on ambulance runs and I would then return to the department to review any changes in the patients before finishing my day at 4pm.

With my medical supervisors

The majority of my time in the hospital, however, some 5 weeks, was spent attached to the Internal medicine team under Dr Jaga and her colleagues. They are an exceptionally friendly team of doctors and were always very keen for me to learn and see patients, as well as to exchange experiences. It was especially useful and fun to spend time with the junior doctors, at a similar stage in their careers to me. Spending my days here I soon saw that Mongolia has a wealth of clinical signs (examination findings that indicate disease) waiting to be discovered by final year medical students in preparation for their Finals. In the UK you would have to wrestle a crowd of medical students and junior doctors to even get a quick listen to the early diastolic murmur of aortic regurgitation, it's just so rare. Thus it's with great pride that I can say I diagnosed my first in Mongolia, and though not the most glamorous specialty I would recommend internal medicine as a great starting place for any elective student.

From Internal medicine I was also able to move between other departments in the hospital, including Radiology, Endocrinology, Neurology to name a few and I was grateful to Dr Jaga for giving me such flexibility.

The range of diseases in Mongolia was also vastly different to that of the UK. The Mongolian population prevalence of the Hepatitis B & C viruses (virus which infect and damage the liver) is approximately 30% which when added to a heavy alcohol consumption creates a large burden of liver disease upon the population. Thus I have seen many presentations of end-stage liver disease in my two months here and have an improved my understanding of its emergency management. Mongolia is a must for any budding Hepatologist.

The greatest obstacle to medical study in Mongolia however, is the language barrier. Though some of the doctors speak English, very few of the patients do and this creates a challenge since the majority of diagnoses are made just by talking to the patient. I would recommend trying to learn some Mongolian phrases to help in taking histories, but it's amazing how much you can understand using sign language and diagrams. Furthermore, being forced to rely upon my clinical examination skills has taught me to trust them as well as understand their limitations.

Mongolia wasn't all work though; I have met some fascinating people along the way and made some good friends. Finding the indoor climbing wall in UB was a particular highlight and meeting Oolch a local competition climber was amazing, let alone getting to climb with him. Spending a weekend in Terelj, walking and bouldering was a real highlight. I will also remember fondly the time I received a prank phone call from Otgoo..."not Otgoo"..funny I thought, sure it was her...only moments later her infectious laugh erupted from my phone, and I had fallen for it.

I have loved every minute of my time in Mongolia, at times it has been frightening and frustrating but I wouldn't change a thing. It's a unique place that as a friend once said "gets under your skin" and I couldn't agree more. When I leave I will be sad to go but I'm sure I will find an excuse to return. I would certainly recommend Mongolia as an elective destination with a difference, the challenges won't be easy but for me the rewards were plenty.

Adam Spong

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