Monday, February 15, 2016

Emergency Medicine from the Kingdom of the Thunder Dragon


 Emergency Medicine from the Kingdom of the        
Thunder Dragon

Jigme Dorji Wangchuk National Referral Hospital, Thimphu Bhutan


At 1pm an ambulance, staffed by driver and EMT with very basic skills, arrives.  Inside there is a contorted mass of three Indian laborers, passengers from a vehicle that had rolled several times down a 150 meter embankment about 4 hours south of Thimphu on the road to Phoentsholing.  I am certain that none of them were wearing seat belts and there was surely no air bags in their vehicle.  They are pretty beat up, several with obvious head injuries, blunt chest and abdominal trauma and injured extremities.  They had travelled the 4 hours along a very bumpy, windy road in various states of repair typical of a Bhutanese highway in the back of a Toyota Landcruiser with one stretcher and besides an oxygen tank, no real first aid or emergency medical supplies.  There had been no attempt to expose the patients to determine extent of injuries, or to obtain even simple vital signs.  They were followed a short time later by a second ambulance with 2 additional patients, another 3 had been transported to a more local facility with apparently minor injuries.  There had been no ambulance report prior to arrival and ED staff were unaware that they were coming.  Injured extremities were not splinted, wounds were simply dressed with the dirty clothing the patients were wearing and no pain medication had been given as there is no ability of the medics to start IVs and administer anything stronger than an oral paracetamol (tylenol). The patients were wheeled into the department with a brief stop at triage for routine vital signs and assessment of level of consciousness.  They were brought back to the treatment area with no report from the medics of the nature of the accident, injuries or actions taken pertaining to the event.  This is complicated further by the fact that none of the patients speak either English or Dzongkha (Bhutanese).

Despite the fact that a situation like this in many western hospitals would activate a mass casualty event and a flood of resources to the Emergency Department, the nurses and junior doctors at Jigme Dorge Wangchuck National Referral Hospital in Thimphu Bhutan methodically went about their business as they have many times in the past.  There is no “Trauma Team” activation, no response from surgery, anesthesiology or other departments. There was no sense of panic among them, just an attempt to identify life threatening injuries in a timely fashion.   Gone is the concept of the “Golden Hour” of trauma resuscitation for if any of these people had a life threatening injury, they very likely would have expired on route.  Some went to the CT scanner  though none had the “panscan” (an essentially full body irradiation in CT in search of injuries not evident on physical exam) so common in modern Emergency Departments, particularly in countries with an overzealous personal injury liability environment.  Some had X-rays, all had a bedside ultrasound FAST scan looking for signs of internal injuries.  Lacerations, including a nearly completely avulsed ear and several deep head wounds were repaired in the ED, fractures were splinted.  Several of the patients were observed in the ED for a bit and fortunately no one had life threatening injuries. 

The scenario described plays out daily in Bhutan’s national referral hospital in Thimphu.  It is the only facility in the country with access to any type of surgical subspecialty or any level of ICU care.  They very frequently receive profoundly sick medical and trauma patients that have traveled great distances in a bad state with very little in terms of stabilizing their conditions in a pre hospital setting.  Conditions like diabetic ketoacidosis, sepsis, and respiratory failure, on presentation to a hospital require rapid care including IV fluids, medication drips, a slew of blood tests, cultures, radiographic imaging, antibiotics and transfer to an ICU.  In a country like Bhutan with one national referral hospital where medical specialists are concentrated, these patients will most often present to a rural hospital or Basic Health Unit (BHU) where only very basic care is available and it is administered by very junior medical personnel.  With the limited resources at hand, they are unable to properly care for, package for transfer and anticipate the things that can go wrong over the next 24 to 48 hours that it will take to get the patient to definitive treatment.  A dose of antibiotics and perhaps some IV fluids is what they get before hitting the road in an ambulance with an EMT with very, very basic training looking after them.  This is not to say they they are not hard working or intelligent people, they just lack sufficient resources and training at this point to meet a standard of care deemed acceptable in a developed country.  They are keen learners and yearn to do better for their patients. 

                                                 Bhaisajyaguru, the Medicine Buddha
 Lapis Lazuli blue in color, dressed in the robes of a monk, his left hand resting in his lap 
with a bowl of amrita, the nectar of immortality and in his right hand he is holding a branch of the healing myrobalan plant.
    The idea of Buddha as a healer is based on the notion that the Enlightened Ones are healers and the Four Noble Truths of Buddhism can be loosely interpreted as based on a medical model of diagnosis, etiology, prognosis and therapy.  For his time, the Buddha demonstrated a very good grasp of anatomy and physiology and has been referred to as the Omniscient Physician who removes every pain.  “May I be the medicine and the physician for the sick.  May I be their nurse until their illness never recurs.”

Health care is a universal right for the citizens of Bhutan though it is not a uniform service.  The quality of care provided will differ vastly depending on where you are.  There are some 100 or so Basic Health units staffed by a health care provider though in many instances I think this means with very basic training.  They refer patients on to either one of 4 regional referral hospitals which are also quite basic in their capabilities or Jigme Dorje Wangchuck National Referral Hospital in the capital city of Thimphu in western Bhutan.  Here they can have surgeries, get some level of ICU attention and overall acceptable care.  More complex cases such as heart or spine surgeries are referred to hospitals in India or Thailand on an as needed basis and is paid for by the government.  There is also a pathway in the country to pursue the traditional medicine practice that has been passed down through the centuries and the government also will provide this care free of charge. I am certain that under certain instances this is a viable and effective option but I once encountered a man who had a broken femur and had spent a few days in the countryside rubbing herbs on it in an attempt to heal it.  Only when that didn’t work did he accept  ambulance for the 9 hour ride over the national highway pictured below with only some paracetamol to dull the pain.  He is one tough mother as the Bhutanese overall are.  Despite the fact that prehospital personnel are not adequately trained, I saw some real heroes.  An ambulance one day arrived with a sick newborn that had been intubated prior to transfer and had been ventilated with a bag valve mask (had someone breathing for him) for some 6 hours in the back of one of these ambulance for six nausea inducing hours.  The infant arrived in stable condition was put on a ventilator and transported to the ICU soon after arrival.  I did also see people die of treatable illnesses such as respiratory failure and sepsis due to the length of time it took them to get to definitive care. 

The road is in the process of being widened to hopefully accommodate two lanes of traffic but this will take some time and expedient transfer will continue to be a challenge.  They do now, as of November 2015, have the first helicopter in the country, though it is also to be used to ferry around dignitaries and tourists, so it is unclear to me how much of an impact this will make.  A dedicated medical retrieval helicopter would be quite useful as trips that could take up to 3 days by road could be covered in a helicopter in less than an hour. 

Once in the hospital of Thimphu patients are cared for by fairly junior doctors but they are looked after by a very capable group of experienced emergency nurses and two residency trained emergency physicians who know how to recognize and care for sick patients.  They often have to make due with limited essential supplies and, on occasion, a lack of important medicines.  We once cared for a patient in complete heart block who would need to be transferred to India for a pacemaker insertion.  Essential emergency department care involves transcutaneous pacing through pads that stick to the chest but we did not have the pads this day.  In modern departments they are a common and disposable item.  Here they had used one set over and over again until it no longer stuck to patients chest and was no longer available.  I think in the end we tried some medications including a dopamine drip to attempt to increase his heart rate to hold him over while awaiting transfer to India.  He seemed to do OK while in the ED. 
When this is your national sport...

...this occasionally happens

There is a bit of tuberculosis ,which is highly communicable, in Bhutan.  Modern hospitals have isolation rooms with reverse airflow so as not to contaminate the rest of the ED.  Some will even have a isolation room in which patients with compromised immune systems would be placed.  The concept of isolation when a TB patient arrives is to put a mask on everyone else in the department.  Not the proper N-95 particulate respirator masks that would actually prevent transmission of TB mind you but the flimsy paper masks worn by surgeons so that if they sneeze or cough they won’t spew secretions all over a patient.  Again it seems to be fine as I did not hear of any health care workers contracting TB but if I start coughing a bit of blood tinged sputum you may want to stay away from me.

    You can tell Guru Rinpoche by the whisp of a mustache and the thunderbolt he always holds in his right hand.  Legend has it that he flew in from Tibet on the back of a tigress and slew the Thunder Dragon then meditated for three years in a cave where the Tigers Nest Monastery now sits.

Bhutan is a wondrously spiritual place.  The last bastion of the Tantric form of Buddhism practiced in the Himalaya with all of its interesting legends and stunningly detailed artwork of their deities displayed subduing various demons or in the carnal embrace of a cohort, Bhutan is a fantastic place to go for a visit.  Temples, monasteries, chortens, stupas, goempas, and dzongs with their unique architecture and incredibly detailed artwork dot the countryside.

Often referred to as the last Shangri-La, in reference to the fictional near paradise Himalayan location in James Hilton’s novel Lost Horizon, it may be one of the last places that the inevitable creep of western style capitalism driven by self interest and greed will take hold.  The very beloved 4th king decided that GDP is a poor measure to use for the quality of life of a country so he developed the concept of Gross National Happiness (GNH).  GNH is based on 4 basic pillars; good governance, sustainable development, environmental conservation and preservation of culture.  The leaders of Bhutan are committed to ensuring that the inevitable socio-economic development sure to come as the country essentially emerges from a sort of feudal existence does not degrade their traditional beliefs and way of life. It is a nation that by all measures would be considered among the least developed with a high rate of what would be defined as poverty, yet over 95% of people live in their own home, there is no malnutrition or starving people, and there is free education and basic health care coverage for all of its citizens.  In essence, all of their basic needs are met and they are generally a very happy group of people.

One of the many manifestations of Dorje Phurba
a diety of positive forces who subjugates the negative
influences of the three worlds.

It is still a place where most people walk about in the traditional dress, kiras for women and ghos for men.  You will encounter many buddhist monks in their flowing saffron robes walking about and you will have this sense of serenity of being in a place where the pursuit of material possessions is not what drives people.  That is until you hear the ring tone set to some western pop song go off and watch as the monk pulls out his iPhone and cheerfully starts talking to it. 

The Four Harmonious Friends is a much beloved tale in Bhutan with its portrayal of social and environmental harmony.  As the story goes, the bird finds the seed and plants it.  Then the rabbit waters it and the monkey fertilizes it. Once the seed sprouts and it begins to grow, the elephant protects it.  After awhile the it grows into a beautiful tree with healthy fruit.  By working together and sharing their individual talents, the four friends are able to reach and enjoy the fruit.

The 2 weeks before my volunteer assignment was spent on a whitewater kayaking trip through Bhutan with some old friends from Colorado as well as some new friends from all over.  It was an amazing trip where we made our way across the country from east to west running the rivers in each valley  draining the high Himalaya.  On one such day we had finished a run on the upper Mangde Chu near Trongsa and were making our way by van to the next destination when the road was blocked by a group of villagers attempting to put up a massive pole with prayer flags on it.  They certainly could have managed on their own but they graciously accepted our offers of help.  At one point I was holding the end of a support pole with a Bhutanese man in the colorful traditional dress.  We were straining together to try and push the pole up when his mobile rang.  He answered it, took a look at me and in very clear English reported “its the office, I have to take this” and with that he was gone, leaving me alone at the end of the support pole.  I was mostly amazed that he had mobile coverage in this remote river valley but it also made me realize that this very special place is becoming more like the rest of the world at a quickening pace. 

Not all is happiness in this kingdom.  They too must contest with many social ills that plague the developed world.  Alcohol use is rampant and the Emergency Department was often full of patients with the consequences.  Alcoholic liver disease, gastrointestinal bleeding, and domestic violence secondary to intoxication are very common.  There are also now disputes among men that are settled with violence, certainly not the way of the Buddha.  I have heard that petty crime, once non existent is becoming more common as is rape and other forms of violent crime. 

I fear that it is human nature to covet the things our neighbors have and am concerned that as Bhutan becomes more capitalist and market driven, people will begin mistaking a new phone or a new car as the right path to happiness.  This is a bit of a slippery slope and I for one am in no position to instruct them otherwise for I quite like my iPhone and car. As a westerner I find it quaint and beautiful that a country like Bhutan still exists and it is certainly in the worlds best interest to maintain societies like these.  However, is it in their best interests if we try and encourage them to maintain their traditional ways?  We go there, comment that “oh the people look so happy and should not get TVs and the internet as that will make them less happy” but who are we to say. 

That is enough of a rant but my one suggestion to any one still reading is to go to Bhutan soon as it is still a marvelous and different place but it has been, and is, rapidly changing. 

Many thanks to the good people of Bhutan and the emergency department at JDWNRH for being wonderful hosts and teaching me far more than I could teach you.  Thanks also to Health Volunteers Overseas for providing me this incredible opportunity.

Entering Ema Datse Canyon on the Mangde Chu.  I am the yellow helmet disappearing into a hole 

"Better to not know which moment may be your last.  Every morsel of your being alive to the infinite mystery of it all.  Its a pirate's life for me, savvy"
                                                                Captain Jack Sparrow

Monday, February 1, 2016

Penises and Punakha

Weekend #2 found us driving over the beautiful Dochula pass to go and  explore  the town of Punakha. Punakha is the home of the Divine Madman Temple. The temple is said to be where infertile couples go for divine intervention, which involves being blessed on the head with a giant wooden penis. This would explain the Phallus symbols adoring many buildings. We had many a laughs over the course of the weekend, we even went as far as making a game regarding who counted the most penises.  Talk about taking road trip games to a whole new level! Ok, so we are a bit immature but we know you all are laughing too!!
Dochula Pass

Festive ejaculating paintings
Divine Madman Temple

hiking through a village on our way to the Temple in the distance

Brads idea...not mine

DO you feel like someone is watching you??

A penis with wings...just the souvenir I was looking for!!

Erect and Happy

These restaurant signs were all over Bhutan. Cum means that they sell shots of liquor with the meal, not what your dirty mind might be thinking!

Happy or Horrified???
The kids thought these looked like rockets.
Back to the phalluses (or is that phalli?). Buildings have elaborate and often huge penises tied with a ribbon and nothing is left to the imagination. The Lama Drukpa Kunley also known as the Divine Madman was quite the rebel in the Buddhist religión. He made general use of his penis to fight demons, convert woman  to Buddhism and mock the religious establishment. His sexual exploits are legendary, on one occasion when he received a blessing thread to hang around his neck, he wound it around his penis instead, saying he hoped it would bring him luck with the ladies!! Needles to say Owen and Brad never tired of the penis jokes, the girls got a little tired of the penis talks until Brad started offering money for whoever spotted the most penises. Game on, we hit the jackpot when we entered  the local shops. Penis souvenirs were everywhere! Large, small, long, short, hairy, not hairy, and all the colors of the rainbow. Lindsey walked out of a store with a few wooden penis keychains to share with her good friends. It was a funny moment when we were at the Auckland airport going through customs and the customs agent asked to see all of our wooden ítems. We were all trying  to keep a straight face as she was inspecting our penis key chains. I told her that there was a good story that went along with our souvenirs , and she replied "some things are better left to the imagaition."

Unfortunatly  the unusual and unique painting of erect penises on the sides of homes is being threatened by foreign prudishness and the srtictures  of globalisation. This virile art form has been a tradition for over 500 years, and would be a shame to see it disappear as more and more Westerners enter this beautiful Kingdom.

Khamsum Yuelley Namgyal Chorten

The next day we headed to the second biggest Dzong (the Bhutanese equivalent of a medieval castle) in the village of Punakha. What an awesome sight it was!! Breathtaking to say the least. We scaled steep wooden steps that act as a kind of draw bridge at night to secure the place, to enter a massive courtyard with an enormous Bodhi tree. This is where the royal wedding took place last year. It was a quiet morning with us being the only non monks and just a  handful of monks roaming around the Dzong. The place held a great peacefulness as we wondered around the courtyard and visited the main temple which held bid beautigul buddha statues.

The Dzong sits at the confluence of the Mo (Mother) Chhu river and the Pho (Father) Chhu river. 

We returned back to Thimphu along the same route, however this time the pass was covered in fog and we could not see  the nearest hillside, let alone the Himalayas  in the distance. Our faces still sore from all the laughter  that involved the counting of hairy penises. And with a few funny souveniers in our bags we were sad  to be leaving the penil wonderland but also thankful for a womanizing monk with a unique means of battling supernatural evil. The treacherous roads are starting to feel like familiar territory. A weekend away like no other.

Monday, January 18, 2016


  Taktshang Goemba (which translates as Tigers Nest Monastery)

Every day here has elements of adventure, but the past  weekend has presented true adventure as we have travelled to Paro to hike the Tigers Nest Monastery.  Simply getting anywhere in this country is a challenge. The roads are mostly partially sealed, bordered by steep drop offs, hair pin corners, no center line markings and pot holes that look more like craters. Seat belts are not part of the equation as it is safer to not wear, just in case a quick exit from car the car is needed before it plunges over the edge. Yikes.. I have learned to just look out across the horizon as we are driving, never down. Thankfully we never exceeded 50 km, as I don't think my nerves could of taken  high speeds as well. The first weekend we travelled to the iconic Tigers Nest Monastry, which is the most famous and sacred site  of all Bhutans monasteries. Legend has it that Guru Rinpoche flew  to the site of the monastery on the back of a tigress to subdue a local demon and then mediated in a cave for 3 years, 3 months and 3 days. It is also said that the orginial building was anchored to the cliff face by the hairs of a female celestail being. At an elevation of 3140 metres it is an architecutal feat, and hiking up to it was a considerable feat as well. Sadly, we had no tigress to fly us up the top so we had to rely on our hiking boots .It is well worth the effort. Altough well visited, it does not feel touristy. The place invokes a sense of wonder, as to how this ancient building was built back in the 16h century. Tigers Nest is a very majestic and spiritual place to visit, and I suspect that the celestial forces will have it sitting there for a millennia to come.
Locals  selling their goods at the start of the hike.

Horses are available to ride to the top 

Another beautiful prayer wheel we passed on our way up

tea break on the way up

This is the Tashi Tashi Café high up on the trail, it is a converted old farmhouse .We stopped here on the way up for tea and then again on the way down for lunch, with its sweeping views of the Paro Valley down below, and overlooking Tigers Nest it was ideal lunch spot. 
Glimpses of Taktshang like this spurred us on to our final destination

Machig-phu Lhakhang which is where Bhutanese pilgrims come to pray for children

The short hike down before it was up the other side to complete the 700 steps to get to the entrance of the monastery. 

This is the beautiful waterfall that spins the prayer wheel right below  which then sounds a bell every time the prayer wheel spins. SO as we are hiking we hear the sounds of the wind, water, creaking of the prayer wheel, and the bell. Truly magical in not only visual but auditory as well. 
Prayer wheel

entrance  to monastery. No cameras allowed  past this point

Love this sign on the trail
Two characters ejoying the day

We stopped at the cafe for some lunch

A yummy vegetarian buffet of  bhutanese food, red rice, ema  datse ( large green VERY HOT chillies) lentil soup, and buckwheat noodles.  

A great lunch spot, one we will always remember not only for the location but  also the conversation. Owen about made the Europeans choke on their food next to us as he so inocently confused the word "virgin" for "vegan", as he loudly  exclaimed to us that that "he was very happy that he was NOT a virgin"!! 

Our guide, Lekey, who took care of us on the weekends by sharing his beautiful buddhist religión with us and showing us his country

Khuru is a popular darts game played on a field about 20m long. The darts are homemade from a block of wood, and a nail, and maybe some chicken feathers for flight. These guys were playing a game on our way down from the hike so we had to stop and watch.

Notice the VERY small target in the middle of the picture

The colorful scarves around their waist represent the number of times they have hit the target.  In this photo they are doing a song and dance  to celebrate the success of a throw. 

                                                                    Drukgyel Dzong (fort)
Dzongs are like fortresses, but they also house a monástic section and the local district adminstration. Zhabdrung Ngawang Namgyal, known as Shabdrung or the unifier of Bhutan brought the whole country under one rule for the first time back in the 17h century. He is worshipped as a diety all over the country. Most of the Dzongs were built by him.
This Dzong was built in 1649  in a location chosen for its control of the route to Tíbet. This is the location where the trail from Tíbet enters the Paro Valley. Once the Tibetan invasiones ceased, this became a major trade route. The Bhutanese traded rice with the Tibetans for salt and bricks of tea. Maybe took a week to cross the border after treking up and over the mountain pass to get to Tíbet with heavy bags of rice strapped to their backs. 

Mt. Jhomolhari

                                                           PARO DZONG 
This massive forttress is a great example of Bhutanese architecture

We couldn't resist....

The fine details of these massive Dzongs is awe-inspiring.  Bhutans secluded nature means it has one of the most unique cultural traditions in the world. However, this distinctiveness is under threat from globalalisation.  The Choki Traditional Art School in Thimphu is dedicated in preserving the traditional and cultural arts of Bhutan. Weaving, painting, and wood carving is taught to the students for 6 years. After that the students typically go back to their villages and work on temples with painting masters.  

Iron chain bridges are everywhere. They are festooned with brightly colored prayer flags. They are quite flexible, acts almost like a trampoline. There are often big gaping holes, throughout from the wear and tear of use. Looking down you can clearly see the river below, flowiníg with gusto, clear and cold. Staying dry depends on the 600 year old chains!!

This is the national animal of Bhutan, the Takin. They are kept in a reserve a few kilometres outside of  Thimphu . These strange looking creatures look to be a cross between a bison, goat, yak, and rhinoceros.