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


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  2. What an amazing experience... Just passing my ATLS course I guess wouldn't buy me much working there? I love reading your post and living vicariously through your adventures.. We all still miss you much at Research and will forever cherish the days you were a part of our team, and will always be a little jealous of the teams you are now a part of!! Hope all is well! Can't wait to see what your next adventure is all about!!

    Erin Dickey