Notes From Hairenik
September 3, 2008
Last October I began to feel strange pains in my lower back which originated on my left hip. The discomfort became sharper in a couple of days then spread to the right side and eventually up the middle along the spine. Walking was cumbersome and at one point even dressing was nearly impossible. I could not even bend forward to put on my socks in a seated position. I found that icing or applying heat to the back round the clock was the only solution to alleviate the pain and after about a week or so it subsided, but not altogether. Relief was not brought about by taking pain medications as they did absolutely nothing. I figured the pains had something to do with stress or nerves but couldn’t prove that and I also couldn’t find any documentation about what may have been causing the distress on the Internet. At that time it was actually the second occasion when I was afflicted with that condition, having suffered from it a month or so prior. Meanwhile, as I was struggling to stand from a seated position every so often throughout the day I was also enduring excruciating testicular pain. I explained the situation to a coworker and he offered to take me to a doctor who he knew for an examination.

The doctor worked in a children’s hospital in Yerevan’s Arabkir district, only a mile down the street from where I worked conveniently enough, but he occasionally saw some adult patients who were referred to him. He was actually a specialist in sonography and examined me with a machine producing ultrasound images. Upon rubbing the detection wand over my abdomen he immediately asked me whether I knew I had a gallstone, and I responded that I did not. He examined my kidneys and found them to be free of stones. Nevertheless the gallstone was 12mm in diameter, large enough to be concerned about but since I did not experience any pain whatsoever related to it I chose not to worry so much. He never found anything wrong with my back per se, and sure enough the pain went away after a few days, never to return again, oddly enough. Turns out that there was some fluid in the sack of my left testicle that was the culprit of the pain there, which for some reason is not uncommon among men, and the solution to that problem was to wear tighter-fitting underwear. Needless to say that predicament is no longer something which is of any concern.

One evening in November, however, I woke up in the early hours with a back pain that felt as though it was attributed to a muscle cramp or lying in a bad position, but shifting my body did nothing to help. The pain intensified and simultaneously I felt that my stomach was bloating with a build-up in gas pressure. Gradually a sharp pain struck me it the middle-right side of my abdomen, and I found myself rolling around in bed from side to side trying to find some comfortable way to lie down. I imagined that the pain must have been similar to that felt by a stabbing victim. I endured this horror for one hour, after which the pains subsided and I eventually fell asleep having been exhausted.

Two months later I experienced a second such attack. At the onset I began drinking some peppermint tea as I read or heard that it helps to alleviate various gastrointestinal discomforts, most notably gas. After only a few minutes the pain intensified to a level of extreme agony. I returned to bed and rolled around there, murmuring things to myself about my love for life and I began to embrace pain believing that it was a simple indicator to stress that I was alive. Then I started to curse womankind for not being beside me during those moments of torture to comfort me by employing their metaphysical methods of healing, the properties of which have yet to be documented by modern science.

The next day I decided to incorporate the “gallbladder flush” widely documented on the Internet. While I was in Boston during the holidays I consulted my doctor about what to do with the gallbladder—whether to remove it or to implement folk remedies to release the stone. He thought it wouldn’t be a bad idea to wait to see if I would indeed have another attack, since often people who have suffered from gallstone pain do not endure it again in their lives, and they simply live with the stones but without discomfort. He figured that the flush was worth trying although he wasn’t nearly convinced it would have any benefit. Nevertheless it was worth a shot I figured. The plan I found would only take about 12-18 hours altogether to complete. First I was required to drink two glasses of Epsom salts dissolved in cold water over the course of two hours beginning at 6:00 pm, having refrained from eating anything for four hours prior. Then two hours after the second glass was drunk, I would have to down a mixture of a half-cup of extra virgin cold pressed olive oil (ordinary olive oil wouldn’t do for some odd reason) and a half-cup of freshly squeezed lemon juice. That stuff, which was essentially salad dressing, was actually refreshing compared to the metallic, bitter taste of the salts. Apparently Epson salts dilate the bile duct, and the oil and lemon would in theory jiggle the gallbladder into such a frenzy that the stones and any other devilish debris would be shot out through the duct and into the small intestines, but only while I was asleep lying on my right side in a fetal position. Since the salts causes the intestinal tract to contract while scrubbing the lining clean, everything dwelling in my bowels would have been eliminated over the course of a few hours after having drunk my third glass of Epsom salts in the morning, meaning that I would be compelled to rush to the toilet about two-to three times an hour for half the day. I was intrigued by this remedy which appeared on several Web sites, swayed into believing the testimonials that “it really works” were indeed true. It was suggested that a strainer be placed in the toilet bowl just before each bowel movement so that the stones could be collected. Indeed there were some small lumps and bumps there, but nothing near 12mm in size. Using a spray nozzle I discovered that the things there were not stones at all, just compacted bits of debris in the intestines. One article which I found online written by a doctor who was essentially discrediting the gallbladder flush explained that those lumps were actually globules of olive oil, the reason why they were green in color. I repeated this flush a month later having felt constipated and hoping that the stone would be expelled in the process. Another attack soon thereafter proved that I had been wasting my time and that gallbladder removal was inevitable.

Back in March I went to see a specialist in the Nayiri Medical Center on Proshyan Street in Yerevan. That place is for the most part the closest thing one can find to a Western-style hospital in terms of cleanliness, modern technical facilities, and professionalism in my experience. However the doctor who I met was very pushy about insisting the gallbladder be removed the very next day. He seemed too young and inexperienced, and added to that he was fast-talking, so I was turned off from the start.

Throughout the spring and summer the pains became more frequent, and always unpredictable. During the month of July I experienced an attack on a near weekly basis. While in Boston in June my doctor explained to me that being able to schedule gallbladder removal surgery during the course of my 10-day stay would be very difficult. The abdominal pains became excruciating in early August and it became nearly impossible to sleep or even to go to work the morning after an attack. A visit to a polyclinic after a complete day of constant relentless intestinal pain for a follow-up sonogram confirmed that the stone had increased in size to 14mm. My employer knew my situation and I asked his advice about whether to try to rush back to the States or to have an operation performed here, a idea that I was weary of. However, his brother-in-law who I also know works for the Ministry of Health, and after making one phone call he determined the specialist I should see.

The procedure that is most often used for gallbladder removal is a laparoscopic cholecystectomy. Four small incisions are made in the abdomen. Inside each incision a thin, delicate instrument is inserted—one of three surgical tools or a special camera. The gallbladder is found, it is snipped away and extracted through one of the holes, all without open surgery, and the entire operation lasts about an hour. Patients recover in no time with minimal discomfort and can resume eating a normal diet not long after the operation, within a few weeks at the most. In Armenia the procedure has been in practice since 1992, first performed at the Malatia Medical Center. Their Department of Endoscopic Surgery is considered to be the best in the country, and thus it was where I wanted to go. I was given the contact name and phone number and visited the hospital about two weeks ago to speak with the doctor. Dr. Vardan Borozan is a man aged about 40 years, very easygoing and laid back. I liked him almost immediately and for some reason my trust in him solidified fairly quickly through his mannerisms and sincere frankness. He said setting up an appointment for the next day or the day after was not an issue, so I agreed to have it performed on Thursday, August 21. It was absurd to wait any longer.

I arrived at 9:00 am as he requested and was taken down by Alvard, the head nurse of the department staff, to have various tests performed. While we were waiting for the elevator to go down she began to flirt by telling me that I was a “pretty boy” and inquiring whether others have ever told me so. In the clinic a woman took blood from me using a technique I did not even know was practiced—she stuck a needle in the crux of my arm where blood is usually extracted but allowed the blood to drip freely into tubes, exposed to the air. When a tube was filled she placed it into a stand and had a second tube ready to be filled. The tubes were not subsequently sealed and I don’t know what happened to them since I was led to an adjacent room where an electrocardiogram was performed on me using a machine which made strange squeaking sounds as soon as it was started up. It may have been one of the first models produced during the heyday of the Soviet Union a few decades ago by the sound of things. The woman performing the test placed these odd awkward plastic cups on my chest which pinched the skin to stay in place. I joked to myself that the belts and pulleys needed to be oiled or something, and sure enough Alvard complained to the woman performing the test that the machine needed to be lubricated. Another woman took my blood pressure and asked a few questions. Then a young guy, probably an intern, wrote the findings on a form while Alvard teased him then gave it to her. We went back up to the ward and I waited in my room for the anesthesiologist to stop by. He asked me if I had an complaints or concerns but I hadn’t at the time which seemed to disappoint him. In retrospect, I should have asked him to put me out before I was brought down to the operating room. Then a haggard woman appeared wearing thick glasses asking me to follow her into the adjacent room to be shaved. Her jaw dropped the moment she saw the carpet of hair on my chest. The most practical way at their disposal for shaving chest hair apparently is to use a dull double-edged razor. About every 20 seconds she would be turning the screw at the end of the razor’s handle to adjust the blade’s fitting, and each time she did so I thought it would come apart in her hands or else on my chest. All the while she kept repeating, “My, you have so much hair!” The procedure took at least 10 minutes it seemed. Perhaps with a sharp razor she would have saved a minute or two.

I returned to my room and awaited further orders, chatting with my girlfriend Anush who had thankfully accompanied me (and was simply fantastic in caring for me during this entire ordeal). The razor woman reappeared and exclaimed “Christian, it’s time for surgery. Let’s go.” I looked at her speechless for a few seconds, failing to understand how we were to go to the operating room. Then I realized that I was expected to walk down, while wearing my street clothes and shoes. Within a matter of a few seconds a slight seed of panic was sown in my gut. While going down with her the seed took root rather quickly and when I walked into the operating room the vines of panic were by then reaching out from the back of my throat. The operating room was dark, but appeared to be decorated at one time in shades of green and blue. The cement floor was black. In the next room, sort of a storage area, I was required to take off my clothes and hang them on a single hook. I took off my socks then was reprimanded by her for doing that so I put them back on. She told me to wear some dusty sandals that were on the floor which did not fit. In the room along the lime-green tiled walls were stainless-steel tables on which it appeared burners were affixed, and on each one was a large steel pot riddled with vent holes. There was all sorts of stuff in there which terrified me. Then wearing only my briefs and ankle-high socks I was led to the operating table, which resembled an ironing board but was sturdy at least. I was expected to lay my head on a doughnut-shaped cushion which had been repaired several times it seems with transparent tape and upon first sight it appeared unsanitary. Over my head was a gigantic operating light with various lamps, several of which were not on, but it was bright enough. In the far extreme side of the room were two wide tables with all sorts of surgical instruments lined up along them on blue cloth. Nurses were coming and going chatting for no reason. The doctor wasn’t in sight, but nevertheless the anesthesiologist was ready for me. I caught a glance of something inserted under my back for lumbar support which was comfortable but also appeared dirty, at least to my paranoid eyes. Then the razor woman came up to me while I was laying there and started shaving away again, in a tizzy that she had forgotten one spot at the base of my sternum where an incision was to be made. Then with her fingers she brushed away and also blew the hair off my chest. By the time she was finished I was off the table. Everyone there became victim to my affliction of panic.

“Hey, what’s going on in here? It’s so dark, where are the lights? How are you going to operate without any lights on? This place looks dirty, why don’t you clean the place? And what’s in that room? Who are you people, where’s the doctor? There’s dust on the floor and on the walls. It’s not clean in here, it doesn’t look clean. I’m out of here!” I headed to the room where my clothes were kept. Now that I think about it the whole scenario could have been taken for a scene from a Woody Allen film.

The anesthesiologist walked up to me, holding up his hands to the right of his chest, signaling me to stop. “Listen, nobody is forcing you to be here. We don’t need your theatrics.”

“This whole place is a theater,” I replied. “No one does anything until the doctor gets down here, that’s it.”

He was called at once and appeared less than two minutes later. In the meantime one of the nurses mentioned to me that I wasn’t the first person to freak out there. By then I was sitting on the operating table trying to figure out a way to calm down and go through with it all. Dr. Vardan arrived and started chatting with me--he was really terrific, his very presence chilled the fear that was consuming me and he persuaded me to lie down, assuring me that all was fine, that the tools were new and clean and so forth. He left to change for surgery, and the anesthesiologist injected something into my left arm. I stared up at the lights and in less than 10 seconds I blacked out.

The next thing I remember I was starting to come out of the anesthesia. As far as I know they had transported me to my room and were moving me to my bed. Things were very blurry, my vision was in black and white, my hearing impaired. I remember complaining that it was painful, whatever it was that indeed hurt, speaking in Eastern and Western Armenian interchangeably. I think I said something in English to Anush, then I blacked out again.

When I finally came out of it I noticed that four small incisions were stitched neatly on my abdomen. I was not in great pain, partly because Alvard kept injecting me with something to help me sleep. By late afternoon I was drinking some water and walking about my room. I stayed not one night as is customary after these procedures but two, as the doctor told me the next morning that the gallbladder was filled with puss, with very little bile remaining in there, and thus I was also on antibiotics. My gallstone, the size of a small olive, is actually an aggregate of very tiny beads which is why the stone has a pocked surface. Basically the operation was performed in the nick of time as I understood. Although I was skeptical at first about having the surgery completed in Armenia, I am glad I didn’t return to the States as I originally intended. Quite honestly, I don’t know if there would have been such a difference in the post-surgical care from that I received in Malatia, which on the whole was very good if not excellent. Alvard told me she has been working at the hospital for 47 years—since it first opened—which would put her at close to or even over 70, although she seemed to be at least a decade younger. My room was basically spotless and illuminated well with natural light, complete with a compact air conditioner, a coin-operated television, a couch, table, and even a small refrigerator as hospitals in Armenia do not generally serve food to patients. At first I was allowed to eat soft fruits, juice, and some light dairy products like sour cream. Then I was required to drink liters of water. I also managed to eat some mashed potatoes and a boiled chicken leg which Anush had brought in for me. By Saturday afternoon I was kicking back at home enjoying my pain-free life. On Sunday friends were coming by to visit and I was eating the fresh grapes and peaches they brought along, feeling terrific. The next day I chilled out at home to heal a bit more but I was anxious to go back to work, so at late morning on Tuesday I went to the office. The air conditioner was on full blast and since where I sit is directly in the path of the vents my lower back started to ache almost instantly, which hadn’t happened before. At lunch time I decided to eat light and have some plain yoghurt. The guys I work with had bought some bread, cheese, grapes and peaches so naturally I had to try some of that. Then I had some water to wash it all down. Soon I realized that I felt very full, as if there was no room at all anywhere in my abdomen for any additional liquids or solids. And I did not eat a huge amount. Something was wrong, I felt it. My back started to ache and I could feel gas pressure building again in my intestines. I left work and went home to sit and contemplate what was going wrong. Perhaps it was the cabbage salad that I ate the day before? I also made a peanut butter sandwich for lunch—could that have done something to cause the discomfort? I searched the net and confirmed that indeed peanuts can wreck havoc on some people although I never had any issues in my life with them. Cabbage is known for causing flatulence so that was a no-brainer. But I couldn’t understand why the gas could not be expelled, not with walking, by stretching or even by taking charcoal tablets which are supposed to neutralize it. That feeling of having overeaten lasted the entire night, but by the morning it subsided to be replaced with intense gas pains. Something was obviously not right with me, but I attributed the issues I was experiencing to bad food choices so soon after the surgery. Last Thursday I visited Dr. Vardan to have the stitches removed and explained to him what was going on. At first he said that some of the pains I described were normal but when I told him that my stool was light colored he looked worried. He told me to take some kind of Russian medicine which helps clean the liver, thinking that there may have been some tiny stones that clogged up some of the narrower ducts. I was to swallow four tablets a day. When I got home I took the first dose, then waited six hours before taking the second as the pharmacist suggested. During the afternoon I was applying ice or heat to my back as the pain flared up. About 30 minutes after taking the second dose I vomited some clear liquid, with white masses floating on the surface, and did so three more times during the night, all the while in restless agony. I called the doctor to tell him what was happening, and he suggested to take some pain killers before I visited him the following morning at his insistence.

We met him in the hospital lobby and he whisked me away to the sonography room. This time along with the technician he carefully checked every blob and speck that appeared on screen. She asked me to extend my stomach by taking a deep breath and holding it, which I did for quite a long time before stopping to take yet another one and did so a few more times. It was only when my abdomen was extended that they found a 7mm stone stuck in the bile duct. He explained that there were two solutions at my disposal—one was to stay in the hospital for a few days and take medication in the hopes that the stone would dissolve and pass through the duct. The other was to have an endoscopic procedure performed to access the duct, enlarge it and allow for the stone to pass through into the intestines, which he strongly advised and I was ecstatic to try. Unfortunately his equipment was temporarily out of commission, so he sent me to a specialist who he knew personally and spoke to him first by phone to arrange for an immediate operation.

Dr. Boghosyan worked in the Diagnostic Medical Center located in Achapenyak, about a 15 minute ride by taxi from the hospital. We entered his office to find him sitting at a desk near the door reading a newspaper. In the middle of the office was the operating table and all the equipment necessary to perform the outpatient procedure, including video equipment. Dr. Vardan confirmed that I would be put to sleep, and the doctor’s nurses who were prepping me also said the same when I inquired about 10 times. They prodded both arms for nearly 15 minutes trying to inject what I believed to be the anesthetic but couldn’t find a suitable place as my veins were “too tough” as they repeated. One of them had the nerve to ask why I was so tense after eight failed attempts to insert the needle. They had to call a nurse from another department to give it a try, and she was immediately successful which was a bit worrisome, seeing as I was expected to trust this doctor and his assistants who were proving to be utter morons. They told me to lie on my left side and inserted something resembling a plastic box into my mouth to keep it open. Suddenly while I was still alert and awake they started to insert the apparatus into my throat without warning. I signaled for them to stop and they were perplexed as to why I was refusing. “Did I not I tell you that I didn’t want to be awake for this? I don’t want to see anything or feel anything, I thought that was clear!” Apparently making me feel slightly numb was more than enough for them. They said that the anesthesiologist would have to come down but wouldn’t be available for 20 minutes. In the meantime I was told to sit on a bench in the corridor, feeling as though I had drunk about four shots of vodka within a few minutes. While I was waiting I noticed two people go in there and then out for an endoscopic examination it seemed. Apparently from what I was subsequently told people here have no problems with having long cord-like devices inserted down their esophagus and into their guts while being completely awake, so long as they had nothing to eat the entire morning. It was just me who was being problematic, silly me. A half-hour later the anesthesiologist arrived on the scene, asked me if I was the guy who needed his help as he noticed I was about to pass out in the corridor, and then I was recalled into Dr. Boghosyan’s office to lie down. The anesthesiologist’s nurse injected me with something and I was told to lie on my side again. Someone inserted the thing in my mouth and I closed my eyes. Then the nurse in what seemed to have been no more than five minutes having past told me to wake up as it was over (vsyo is what she said I believe). The doctor showed me the video recording of the procedure—the stone was bright yellow in color and was stuck firmly in the duct. There seemed to have been some puss at the site of obstruction according to what he explained. The operation was successfully completed and I walked out of there in a matter of minutes. The entire time in the taxi on the way back to Malatia I was feeling incredibly relaxed and for the first time in weeks I was completely pain free. Although the narcotics naturally aided my euphoria, the relief was essentially instantaneous. Dr. Vardan insisted that I remain under his care over night so that I could be administered antibiotics which I agreed to more than willingly so as to not risk a return trip a few days later due to some other unforeseen complication. That day Nurse Hasmik was there to take care of me, another fantastic woman who was extremely friendly and helpful, nevertheless not as flirty as Alvard. For several hours I could only take sips of water, but by the evening I could eat small cups of fruit yoghurt and drink as much as I could. I was discharged by Dr. Vardan the following morning and have had no recurring bouts of torment since then.

Over the last few years I have heard some horror stories about medical treatment in Armenia and I never had any reasons to doubt them. It was because of those testimonials that I became paranoid about having surgery performed here to begin with. Walking through some corridors in Armenian hospitals can be a mind-blowing experience bordering on absolute horror. But despite that the second gallstone was not detected before the surgery was performed, I have no regrets about my decision to seek the medical advice of Dr. Vardan because quite simply I do not believe that I would have certainly received better care in Boston under the circumstances. Western medical practices are unrivaled, there is no refuting that, and ideally I would have preferred to have the surgery performed in the States. But if virtually the same kind of care can be received in Armenia, albeit not in a completely modernized hospital and while coping with Armenian logic, why travel half-way around the world for a routine procedure? That was my foregone conclusion after speaking with Dr. Vardan for only a few minutes. Clearly great health care can be obtained in Yerevan, but often a complete upfront cash payment in full is necessary to benefit from it. I can only hope that people living here who need to see talented, dedicated doctors are indeed able to manage somehow no matter how thinly their finances may be stretched.

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Anonymous Anonymous said...
Extremely detailed and informative writing with excellent observations. Could you please indicate also the amount of upfront and full payment? Hope you are doing well after the operation.


Blogger Christian Garbis said...
The cost of the gallbladder removal surgery was 300,000 AMD, or $1000, which included costs related to the overall hospital stay, medications, all medical tests including blood tests, and so forth.

Unfortunately the costs for the stone removal from the bile duct were an additional expense of 100,000 AMD since it was performed elsewhere. The procedure itself cost 80,000 AMD and there was a separate payment to the anesthesiologist of 20,000 AMD, which seems very high but at least I did not feel anything when the endoscopic devices were inserted in my mouth and down into my abdomen. But the money spent for everything was well worth it since I am feeling fine, with no digestive issues at all and most importantly no pain. After 10 days have passed I can keep a normal diet.

Anonymous Chrissy said...
Ouch. I am going to stop complaining from now on when I feel a little bloated after a big meal. :)

Anonymous Narbey Derbekyan said...
Hi Christian,

Thanks for sharing your first-hand account with medicine in Armenia. Glad you're feeling better. I've wondered about medicine in Armenia.

It would have been more expensive here in the States for sure.