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"Adrenaline and the ordinary in varying proportions"

Yale Medicine Magazine, 2001 - Spring


A student’s exposure to medicine in this former Soviet republic reveals a different rhythm in the OR and a vastly different take on relations between doctor and patient.

On the surgical service at First Hospital in Yerevan, the Republic of Armenia’s only teaching hospital, rounds begin each morning at 9:15. This might seem late to a doctor from New Haven, where residents and students “pre-round” at 4:30 a.m. in preparation for the daily ritual two hours later. But here in Yerevan the surgeons virtually live at the hospital and there is little need to catch up each morning.

Rounds are conducted in Russian, the lingua franca of professional and intellectual life in this former Soviet state, and consist mostly of a seated discussion in a smoky room. There is no operative schedule as such, no operating-room start time. The operating room is reserved on a first-come, first-served basis by alerting the nurse in charge that there will be a patient arriving shortly, after which begins the process of negotiating for staff to assist in the surgery. Emergencies are numerous and take priority, but the hospital has no emergency room. Patients are evaluated in the driveway, the hall or the doctors’ offices depending on the severity of their illness.

On this hot, dry morning, Gevork Yaghjyan, M.D., Ph.D., and I are back in his office by 10:15, the time when patients and doctors begin to file in for the day’s consultations. The door opens without a knock: “Gevork Vigenovitch, ais deh a?”

“Is Gevork Vigenovitch here?”

An assistant professor, Gevork is the youngest faculty member at Yerevan State Medical University, and at the age of 31 he has already earned his patronym, a sign of respect. Gevork is one of eight microsurgeons in Armenia, a country of 3.3 million inhabitants bordered by Azerbaijan, Georgia, Iran and Turkey.

Every day is different: no clinic days, no operative days, just a combination of adrenaline and the ordinary in varying proportions. There is no call every third or fourth night. There is call whenever you are lucky to be on the schedule. And if you are one of the only specialists in the country, call is every day. Doctors here ask for extra duty. It is their only true source of income, not counting the official pay of about $20 a month. How many of us would enter a profession with numbers like that?

In addition to what they earn from the hospital, the surgeons receive fees from their grateful patients. What they are paid depends on the means of the patient’s family. It is not unheard of to receive a ton of potatoes, or even a cow, from a patient unable to pay in cash. It falls to Gevork as surgeon to make sure that the anesthesiologist, nurses and others who assisted receive fair compensation—a matter that can become quite complicated when the currency is livestock. Remuneration comes in other forms, too. In outlying country hospitals, the pay might be a home-cooked meal followed by toasts of vodka brought to the hospital by the family to celebrate a successful operation. It was difficult for me to imagine American surgeons sitting down to a meal with the patient’s family. They laughed when the doctors told them that I was not used to such close relations between patient and doctor.

The personal touch in Armenian medicine is apparent in other ways as well. Apartment buildings usually have a doctor living there. So that even when doctors are home, for all intents and purposes they are on call. Any emergency is their responsibility—not a legal or an administrative responsibility but an ethical and human one that everyone takes for granted.

Once a medical student named Artur was traveling in the mountains of Nagorno-Karabakh, six hours away from Yerevan. Nagorno-Karabakh is an historically Armenian land and a focus of Armenian art and culture. Under the Soviets, Stalin redrew maps of the region and included Nagorno-Karabakh in the Soviet Republic of Azerbaijan. Fighting broke out there in 1988, shortly after the region asked to be annexed to the Soviet Republic of Armenia, and the conflict intensified in 1991 when Nagorno-Karabakh asked to become an independent state, as had Armenia and Azerbaijan. A cease-fire has been in effect since 1994, with Nagorno-Karabakh now functioning as an independent republic.

Artur was among a group of medical students traveling to the region when soldiers stopped their bus at a checkpoint. The worried students stepped out onto the road to be searched. Artur recognized the scarred hand of one of the soldiers from a photo he had seen in a lecture in Yerevan. “Was Gevork your surgeon?” Artur asked, thinking quickly. The soldier said, “No, Gevork was not my surgeon.” He paused and looked at Artur, sizing him up, then wrapped his huge arms around the student in a bear hug. “Gevork,” he declared, “is my brother.” With that, Artur and his fellow travelers were sent on their way.

Our scrupulous avoidance of treating one’s own family or friend is unthinkable in a country where all business is conducted on the basis of personal contacts and many patients and doctors become friends for life. Gevork is well known in Nagorno-Karabakh. During the peak of the fighting in the early 1990s, he made dozens of trips by helicopter to perform reconstructive surgery. The first time Gevork invited me to the hospital in Yerevan, it was to help him change the bandages of a soldier from Nagorno-Karabakh who had been flown to the capital after a land-mine explosion.

Each day in First Hospital brings new surgical challenges. One day, a girl from a region near ex-Soviet Georgia was brought in. Local doctors had treated her after a bad car accident, but her leg became so infected that the skin had to be removed from the knee to the ankle. We treated her with antibiotics and then skin was grafted from both hips to cover the defect. There was the patient with a gunshot wound to the buttocks that had severed the sciatic nerve. Another gunshot victim arrived with the third and fourth metacarpal bones of the hand fractured beyond recognition. There was a young girl with a facial nerve severed by a small injury who looked fine until she smiled and her face took on a twisted shape. For the longest time I forgot about what we commonly think a plastic surgeon does. In the middle of the relative chaos of First Hospital, there are the rare few who seek cosmetic surgery, breast augmentation, rhinoplasty or facelifts. These seem frivolous in a place where every induction of anesthesia and every operation bear an unbelievable risk compared to those done in the vastly more controlled settings of the operating rooms back home.

Gevork knows that world as well. Early last year, he came to Yale to study the physiology of surgical flaps with J. Grant Thomson, M.D., an associate professor in the section of plastic and reconstructive surgery. Gevork, back in Armenia since last May, will return to Yale later this year as a Plastic Surgery Education Foundation fellow.

Yale’s involvement in Armenia has been steady since the earthquake in 1988. Staff from the Erebuni Hospital have been training at Yale. One of Armenia’s recent ministers of health, Gagik Stamboltsyan, trained at Yale before assuming his new position. Under the direction of then-Chief of Plastic Surgery Stephan Ariyan, M.D., the Yale Center for Plastic and Reconstructive Surgery was built at the Erebuni Hospital in Yerevan to accommodate the increased need for reconstructive surgery during the clashes in Nagorno-Karabakh. Several operating rooms were completed and Armenia was also chosen as one of four sites for the Yale/NASA telemedicine project that links doctors around the world in a network meant for teaching and consultation. More recently, Artoum Sedrakian, M.D., a young cardiac surgeon from Yerevan, came to New Haven as a Fulbright scholar to conduct clinical outcomes research with cardiologist Harlan M. Krumholz, M.D.

. . . . .

My father was born in Jerusalem to Armenian parents. My grandmother and grandfather came from the Armenian cities of Marash and Zeytoon, in what is today eastern Turkey, and fled as children in the wake of the massacres of Armenians in 1915. My grandmother was orphaned as a result of the massacres and was sent to an orphanage for Armenian children in Lebanon. She grew up in the orphanage and became one of their best students. There, she became a teacher. At a teachers’ conference in Lebanon she met her future sister-in-law, who hastily arranged for her to marry my grandfather. My grandfather lived at that time in Allepo, Syria. They married in 1933.

Their first child, my aunt Hermine, was born in 1934. That same year, my grandfather went to Jerusalem in search of a better life for his growing family. Jerusalem boasted a large Armenian community until the late 1950s, and part of our family was already living and working there. My grandmother and aunt followed him in 1935. My grandfather made shoes and, in time, came to run his own factory, employing over 20 men. He lost everything during the Arab-Israeli War, when Jerusalem was partitioned and his family was sequestered in the Armenian Quarter of the Old City of Jerusalem. He could no longer travel throughout the Middle East as he had done, taking orders for his products. Many families began looking for sponsors in the United States. A grade-school friend of my grandfather, long settled in Boston’s Armenian community, had seen his name and photograph in a church publication, and offered to sponsor his relocation to America. In October of 1957, my family set sail from Beirut on the SS Corinthia, bound for the United States. They arrived on Christmas Eve.

My father was 16 when the family arrived in Massachusetts. After high school, he went to Boston University, then served in the Army. At Fort Bragg in North Carolina, he met my mother, and they married and moved to Phoenix after he left the service so that he could attend graduate school. They returned to Boston in 1973, where he pursued his career in the hotel industry and where I grew up.

My curiosity about Armenia grew while I was in college. I wanted to explore a land I had heard described in mythic terms throughout my childhood. After my junior year in France in 1991, I applied to the University of Michigan Summer Language Institute in Yerevan and left the labyrinth-like streets of Paris for the unpaved mountain roads of a truly foreign country. When I arrived, many French, American and Armenian-born doctors were still providing earthquake relief. Almost four years later, determined to become a doctor, I attended the Armenian Medical Congress in Boston as part of a plan to visit Armenia in July 1995. I had graduated from Smith in 1992 and worked in the pubic health field in New York City for several years, on projects designed to improve prenatal care and boost immunization rates.

The Congress served as a crash course in the current status of health care. Armenians from all over the world had come to listen to then-Minister of Health Ara Babloyan, M.D., and see how they might help fortify the country’s health care system. I phoned a friend, Alain Hovnanian, M.D., a physician in Paris, to tell him about my trip and to ask how I might be helpful to him while in Armenia. There was a notable pause and a sigh of relief. He had just received a letter from a woman named Assia, whom he had met in the village of Gogaran, where he had helped in the reconstruction of an 11th-century church. Assia was on chronic dialysis and, given the state of the hospitals and pharmacies, was unable to buy necessities such as fistulas, filters and tubing. Although kidney disease is a serious health problem in Armenia, as it is in the United States, organ transplantation has not yet been established as a widespread therapy. Alain asked if I would be able to transport supplies to Assia and communicate his concern. I did so, and four years after I had first met Alain in Paris, I found myself on a back road in the village of Gogaran looking for Assia’s house, which I had been told lay somewhere past the beekeeper’s house but before the potato fields.

It was during this trip in 1995 that I met Gevork. I asked him if I could observe in the operating room. There I witnessed my first operation, the setting of a woman’s broken femur. To my surprise, I loved surgery. I watched as a cardiac surgeon from Oregon augmented the ventricle of a 12-year-old girl. Hrair Hovagumian, M.D., had come to Armenia for a month to instruct other surgeons and ended up taking an indefinite leave of absence from his university post. He remained in Armenia, where he is now performing three open-heart surgeries a day and was grinning widely when I last saw him.

Since arriving at Yale as a first-year medical student in 1997, I have had five more opportunities to return to Armenia. Each trip has been a chance to reformulate plans, to re-evaluate decisions and to reflect. These trips have been a break from the ordinary and a chance to understand how truly fortunate we are. For me, travel has served as both a buffer and a catalyst between periods of contemplation and intervening periods of hard work. I began my thesis, Legal, Professional, Public and Policy Barriers to the Development of Organ Donation and Transplantation in the Republic of Armenia, in 1998 in cooperation with the Armenian Ministry of Health.

My initial contact with the Department of Plastic and Reconstructive Surgery at the University Teaching Hospital in Yerevan in 1995 led to repeated visits over the last six years and an education in reconstructive surgery that has continued despite the distance. Gevork and his colleagues have shared their work with me long-distance, e-mailing images of their most interesting cases. I have spent long hours with Gevork and the other surgeons, traveling by road to the military hospital in Nagorno-Karabakh. We have visited every hospital in the Republic of Armenia, checking on the progress of flaps created earlier in the day.

The patients I have seen in Armenia have provided the most vivid reminders of why we practice medicine. One was a young boy whose forehead was burned so badly by an electric shock that there was no flesh to cover his skull. Another was a little boy holding his severed finger in a dirty dishtowel. There was a boy whose nose was all but removed by the bite of a dog, a young woman whose breast was reconstructed after a mastectomy, and a woman whose lips and nose were eaten away by a basal cell carcinoma, neglected for years due to lack of money.

Despite limited resources, Gevork has been able to form a small laboratory in Yerevan where he is investigating the factors that allow his patients to heal. All the reagents in the lab are painstakingly prepared from scratch by the students and residents. He purchases rats himself from a man who breeds them for medical research. In New Haven I don’t think Gevork ever got used to ordering rats from a catalog or seeing animals treated better than most of his patients in Yerevan. The true mark of luxury to him was that a veterinarian would be called should a lab rat fall ill. Indeed, Gevork’s experience at Yale has been a far cry from his life at home. He is constantly amazed by the organization of things, by the operative schedule, by the way an instrument magically appears when a surgeon calls for it, by the orderly progress of clinic and follow-up visits, by the labs and by our easy ability to sequence DNA, make radioactive tags for molecules and measure ischemia. He is amazed but I also think he feels the same way that I do, that we give up something in return. There is a bond with patients in Armenia, a sense of urgency and vitality that often seems to be missing here.

. . . . .

A knock on the door brings a new patient eagerly peering past the crowd of residents and patients that routinely fill Gevork’s office and spill out into the hall. I hear the familiar “Gevork Vigenovitch, ais deh a?” and wonder what the day will bring.

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