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‘We’re in the business of saving lives, get it?’ One of the ICU doctors who treated Alexey Navalny in Omsk explains how Russian physicians handled the case and why he thinks activists’ criticism is unfair

Source: Meduza

Boris Teplikh, the head of the Anesthesiology and ICU Department at Moscow’s Pirogov National Medical and Surgical Center, was one of the doctors summoned to consult on Alexey Navalny’s treatment in Omsk, after the opposition politician needed hospitalization and slipped into a coma on August 20. Teplikh then returned to the capital and wrote a Facebook post where he defended his Russian colleagues’ decision to delay Navalny’s transfer to Berlin and their reluctance to rush a diagnosis. Doctors in Omsk ultimately concluded that Navalny’s condition was due to a “carbohydrate imbalance.” Navalny’s family and fellow activists, meanwhile, insisted from the start that he was likely poisoned — a suspicion later confirmed by doctors at the Charité Clinic in Germany. Meduza special correspondent Svetlana Reiter spoke to Boris Teplikh about his work in Omsk and the chances that Navalny was poisoned.

The Charité Clinic has released a statement saying Navalny was poisoned with an agent from the cholinesterase inhibitor group. Did Russian doctors look for poisonous substances?

Yes, we looked. 

You looked for cholinesterase inhibitors?

That was the first thing we looked for.

And you found nothing?

We found nothing.

How did German doctors find something where Russian doctors looked and came away with nothing? How is something like that even possible?

It’s unlikely, but you’ve got to bear in mind that we had forensic toxicologists on the search and they have these super-chemists who work with chemical warfare agents. They’re slightly different. 

At the German clinic, they’re reportedly treating him with atropine [used to treat certain types of nerve-agent and pesticide poisonings].

We also gave him atropine.

And it didn’t help?

Well, his condition stabilized.

The German physicians say Navalny was placed in a medically induced coma. 

That was done while he was still in Omsk. Navalny was put in a medically induced coma within 10 minutes of being admitted to the hospital.

But I thought you’d written that the cause of his coma was unknown?

He was admitted in a coma. It’s not clear how it began.

And then you “dosed him”?

Yes. You always “turn off” someone in a coma of unclear origins to save what remains of their consciousness.

Note to readers: As late as the evening of August 20, hours after Navalny’s hospitalization, health officials in Omsk reported that he was “in a natural coma” and breathing through a ventilator.

How did you end up in Omsk?

The administrators called and asked if I had any strong objections to them offering to fly me out. I didn’t object. 

But you understood of course that you weren’t flying out for just any old patient. You knew politics were involved in the case.

No, I didn’t. I flew there as a doctor to see a patient.

Okay, so you find out that you need to fly to see this patient. What happened next? They got you a ticket and you went to the airport?

No. There was a video conference organized with the doctors, and we discussed the patient’s condition. In that call, we realized that a flight would be necessary because a lot was still unclear. We developed a treatment plan while we were in the air. At the same time, we were waiting for an answer from the toxicologists. A few hours later, we were in Omsk. 

Note to readers: Health officials in Omsk say the hospital that treated Navalny invited multiple anesthesiologists, neurophysiologists, and critical-care physicians from Moscow to join expanded consultations on Navalny’s treatment, at the request of the Omsk ICU and Navalny’s family.

Why didn’t the toxicologists fly with you?

The toxicologists were on the scene. The most important thing for them was the lab work. Once that was done, they’d deal with any leads and how to go about treatment. Their task was to identify possible problems and either confirm or reject them. The toxicologists from Moscow were in contact with me all night and they explained what they’d ruled out.

Toxicologists from what institution?

From the Moscow Medical Center for Forensic Medicine. Their lab was handling it.

And what had they ruled out?

They’d excluded a wide range of substances. First and foremost, they said they checked for organophosphorus substances [cholinesterase inhibitors that range from insecticides to Novichok] and ruled them out.

If we believe the Charité Clinic, however, these toxicologists missed something.

Let’s wait and see what they find at Charité.

Note to readers: German doctors cite clinical findings that indicate “poisoning with a substance from the group of cholinesterase inhibitors.” According to the Charité Clinic, “the specific substance involved remains unknown, and a further series of comprehensive testing has been initiated.” Anatoly Kalinichenko, the deputy chief physician at the hospital in Omsk that originally treated Navalny, has said in response: “Either we or the lab made a mistake or this is all disinformation.” 

Based on that first video conference you joined, what was understood about Navalny’s condition?

It was clear that the patient had severe metabolic problems and that he was in a coma of unknown cause. Since the toxicologists were dealing with ruling out the influence of external factors, we were exploring other variants that we could work on based on our knowledge and experience. 

What were the metabolic problems?

I don’t know how to answer that question within the limits of patient confidentiality. There were severe metabolic imbalances.

A drop in blood sugar?

Various severe metabolic imbalances.

You ruled out toxicology because the toxicologists were handling it?

We didn’t rule it out. I repeat: People competent in this area were responsible for toxicology. This is not our specialty and we were asked to deal with other problems outside of toxicology.

And yet the chief physician at the Omsk hospital said quite confidently that this was not a poisoning.

That’s not exactly what he said. I was standing right beside him and I heard everything. He said we didn’t have the data because the toxicologists hadn’t found anything, which is why we were working through different theories. 

Note to readers: “The diagnosis of ‘poisoning’ was definitively ruled out on the basis of chemical-toxicological expertise,” regional health officials told the news outlet RBC in a quote attributed to Omsk chief physician Alexander Murakhovsky. Deputy chief physician Anatoly Kalinichenko was slightly more cautious in his remarks, explaining a day after Navalny’s hospitalization that blood and urine tests carried out by that point had detected no traces of poison. “So, at the current time, the diagnosis of ‘poisoning’ remains at the back of our minds, but we don’t believe the patient was poisoned.” Kira Yarmysh, Navalny’s press secretary who was traveling with him when he suddenly became ill, immediately concluded that he’d likely been poisoned.

Except for a carbohydrate imbalance…

I’ll say it again: There wasn’t just a carbohydrate imbalance. There were rather severe metabolic imbalances and many serious abnormalities.

Is it possible that the poison detected by doctors in Berlin may have provoked these imbalances?

It’s possible. That is why we’ve asked the toxicologists about it.

The Charité Clinic’s statement indicates that Alexey Navalny was apparently poisoned with a cholinesterase inhibitor. How did they manage to determine this?

They haven’t named the test they performed or the toxin itself.

You say Navalny was given atropine — an antidote to poisonous substances. 

We gave him atropine because there were indications for it.

What kind of indications?

Indications in various fluctuations. We administered it because of these indications — not as an antidote.

What kinds of indications typically call for atropine?

Various ones. We could read through the [medication’s] instructions, but it would take a long time.

Why did they turn to you for consultations in the first place? Was there something that caused uncertainty among the doctors in Omsk?

Of course. They had questions about formulating a diagnosis, so they requested specialists. They requested specialists, we came in, and then we sought the advice of more specialists. That’s how it’s always done if the diagnosis is complex enough. Consultations always expand and expand, with more and more doctors joining in — both by video conference and in person. But this wasn’t about thinning out our responsibility: the experts brought in were seriously needed. It wasn’t like we said: hey, let’s invite all the doctors in Omsk and get a hundred people in on this consultation. 

They summoned specialists for expertise on concrete issues, calling in neurologists, endocrinologists, toxicologists, and cardiologists. If they’d needed a specialist with a narrower focus, for example, a neurologist who studies the activity of a certain part of the brain, they would have called for one of those, too. Let me repeat: When someone is sick, we work through the situation. While questioning the toxicologists, we were simultaneously testing other theories.

But the toxicologists weren’t part of the consultations?

Says who? They took part. Navalny was in the hospital’s toxicology wing and the department’s head participated in the consultations. 

Was Navalny on a ventilator from the very beginning?

Yes, a “Chirana” ventilator. 

That model’s not exactly fresh off the assembly line.

Yeah, well, it’s a good mid-range machine — a fairly new model. Usually, the toxicology department doesn’t have serious lung-injury cases, so they don’t need top-flight machines. If equipment like that is needed, it’s special-delivered. In general, the Chirana is a common machine in Russian hospitals, manufactured in Slovakia, and reliably mid-range.

Was its capacity sufficient?

At that moment, yes.

How did you communicate with Navalny’s family?

I only communicated with [his wife] Yulia and his brother [Oleg Navalny]. They behaved as properly as possible under the circumstances and were fairly even-tempered. They asked the right questions, calmly and without getting emotional. 

One thing that’s attracted a lot of attention is a photograph of three men in civilian clothes sitting in the chief physician’s office. Did you see these people?

Yes, I saw them.

Do you have any idea who they were?

Ordinary people from the intelligence services. Don’t you think they should be the first to arrive if there’s a suspicion of poisoning? The appearance of people out of uniform where there’s suspicion of poisoning causes a kind of bizarre surprise. They started questioning doctors right away, taking statements. It turns out that it’s bad if they do their jobs and bad if they don’t. They had to be there. 

Do you know if they were from the Investigative Committee or the Federal Security Service?

I don’t know. They didn’t question me.

Did you suspect any fluctuations in Navalny’s cholinesterase levels?

There were signs of a cholinergic crisis and we were ruling out potential causes. Do you know what a cholinergic crisis is?

I don’t.

It’s a disruption of the metabolism. We’re holy men, you see. There were toxicologists there, and despite the use of any poisonous substance, if that’s what happened, we saved his life, which is what allowed him to go to Charité. We’re in the business of saving lives, get it?

But how did you save him?

In various ways.

Was he given a glucose drip? Is there a timeline for administering glucose?

Yes. Minutes. 

If we assume that he was in a hypoglycemic coma…

Then there could have been a deep metabolic disruption after normalizing the glucose levels.

Do you believe it was reasonable to transfer him to Berlin?

It was understood that he needed to be transported to a higher-level clinic — there was no doubt about that. But it could have been one of the Russian clinics.

Why did doctors insist on conducting multiple consultations?

Because his condition was changing. It was volatile, if you will, and changing several times a day or sometimes by the minute, like a patient in critical condition.

Do you know how claims that Navalny couldn’t be transported got started?

No one said that. The discussion was about the patient’s condition being unstable. As soon as he stabilized, they permitted his transfer. 

You said Navalny’s relatives were given the records of all tentative diagnoses. The documents indicate that toxicology was excluded?

I don’t know. I didn’t see the paperwork, but that should have been included, in theory. I wasn’t the one who gave the relatives the full report, but everything should all have been described there in detail.

What was your job as a critical-care physician?

To identify the patient’s main pathological syndromes and try to alleviate them. In principle, this is a critical-care physician’s job. Say the patient isn’t breathing — you need to ensure respiration. If there’s no circulation, you need to ensure circulation. You raise low blood sugar and lower high blood sugar. No fluids? You add some. As you’re busy with this, the search for a diagnosis continues. Our job is to keep the patient alive through varying degrees of alleviation while that’s happening.

Depending on whether a case is severe or mild, you either find out quickly what’s causing the pathological syndromes and you eliminate the cause or, if it’s impossible to do that quickly, you start to treat the patient’s symptoms while the search goes on. For example, with a patient in serious condition, you need to conduct a CT scan. We have to ensure safe handling so the patient can undergo this procedure without harm.

Why did you decide to write a Facebook post defending the doctors at the Omsk hospital?

I have a Facebook account and I write there often, so this question is a bit awkward, I think. I write about everything, on different subjects. It’s a personal page. Basically, the doctors in Omsk and the rest of us confronted a clinically difficult diagnosis that challenged us — it was professionally very difficult. Everyone was focused on just a single goal: a way out of this bad situation. When we were all done, the patient was transferred and I boarded a plane. Then I saw countless posts about murderer doctors that were completely untrue.

Yes, there were many mistakes. The mistakes early on can be explained, like limiting the wife’s access to the patient. There’s probably an innocent explanation here: when something tragic has happened, our first inclination is to keep people away. It’s clear that Navalny is something of a bogeyman for the regions outside Moscow. Nobody’s scared of him here in the capital, where there are all kinds of movements and representatives and schools of thought, but there’s fear and there’s marginalization out in the regions. 

The people not directly involved in medical care made these mistakes as a reflex. It’s a common problem: we turn you away first and think about it only second. But it was all sorted out very quickly, while they spent forever playing up the footage of Yulia Navalnaya being denied access to her husband, even though there was already a calm, constructive dialogue and discussion of the problems by then. And that’s when I decided to write my post.

But if they find organophosphate poisoning in Navalny that Russian doctors missed, your post will be forgotten instantly.

Let’s remember the Skripal poisoning. How many days did it take until they realized the problem was organophosphate poisoning? Three or four. In other words, the British doctors, like us, were clearly focused on saving the patients’ lives until the problem could be identified, which is exactly what we did in Omsk.

When you stand up for the doctors in Omsk, you’re also in effect taking responsibility for the toxicologists who couldn’t find any poisonous substances.

All I can say is that the patient would no longer be alive if we, as emergency-room doctors, hadn’t done our jobs.

You say you prepared the patient for transfer. On social media and in the news, there are reports that the Russian doctors refused to release Navalny from the hospital. What really happened?

We told the German doctors that the patient’s condition was extremely unstable at first but was now stabilizing. As soon as his condition settled, we were ready to discuss his transfer. Those who say there’s no such thing as a patient who can’t be transferred are just sloganeering. Doctors need to understand why they’re transporting a patient — to save him or just to haul him away? If you want to save the patient, you’ve got to realize that any displacement can be harmful. We tried to reduce the risks of this handling. Please find me a doctor who will claim that moving a patient is inherently safe. That’s a big lie.

The German doctors said at the start that they’d transfer him in a sealed pod because poisoning was suspected. The very process of moving someone into a sealed pod takes time — it took us half an hour to transfer him from the ambulance to the pod. It was clear to the German doctors and to us that the patient needed to be stable in order to survive all the jostling.