Chart Dividers

Okay, for all you medical types out there, this is where it starts getting very interesting.  My first day on the job actually happened the day I arrived. An extremely nice volunteer who was on his way out took a couple of us around and showed us the innards of the Jigme Dorji Wangchuck National Referral Hospital (hereinafter referred to as the JDWNRH). The signage is just a tad different from the US...

Doma? Betel nut, which is a sympathomimetic, said to "help with the altitude"

There is the new and old hospital. The new place is actually heated, which is wonderful. Construction is basically concrete slab. Elevators are present but appear not to be used.

I was introduced to the administrative assistant who extended my visa (I'm given 2 weeks at entry into the country and then need to extend my visa for another fee), registered me with the Royal College of Bhutan Medicine, and obtained travel permits for me, because as a foreigner I can't cross a district border without a travel permit. It's pretty pro forma, but you need to do it.

I then met the administrator for the programs. We chatted about my qualifications. He found out I was a critical care doc by training and summarily decided that I was pretty much going to be detached from the internal medicine program (all the clinic stuff) and was going to spend my entire month in the ICU "because there are issues."  That was pretty much fine for me, as the outpatient stuff looked REALLY intimidating-- massive crowds, huge patient loads. I came here really wanting to help in the way that I could, so I said fine, and I wandered up to the ICU...

The JDWNRH ICU

 I was brought up to the ICU and introduced around to the brothers and sisters (remember now, we are using British terminology. These are the nurses). They were very deferential, unnervingly so, but quite competent. The chief of anesthesia then came in. The anesthesiologists run the ICU and he was very pleasant, welcomed me, and asked for my help. He started telling me about one of the patients whose right chest was whited out on Xray and was going to send the patient for CT. This poor man was an acute quadriplegic from an RTA (road traffic accident) who was being shipped to Kolkata (Calcutta) when he arrested at the airport. He was then brought back to Thimphu, where he regained consciousness, but not the ability to breath. I was able to see a cutoff in his right mainstem bronchus on X-ray, and suggested he needed bronchoscopy rather than a CT scan. I was told that the anesthesia docs didn't know how to do this procedure, and it had never been done at bedside before. I told him I'd be happy to do it for him, and proceeded to perform the first bedside bronchoscopy through an endotracheal tube in the history of Bhutan. It was a little funky, with a lot of jury rigging, but the staff was thrilled to help and I did in fact remove an enormous mucus plug. However, his oxygenation did not improve, so I said fine, go ahead and do the CT scan. The staff was about to put him on a gurney to take to CT. I suggested that it would be two less transfers and a lot easier if we just moved the patient on the bed. This was entirely new. However, we eventually got an oxygen tank on the bed, got a working ambu bag, and took the patient on the bed to CT. It should be noted that the elevators don't work, and we used the ramps between floors. That was hard work.

I went home that night, excited about these two things I had done. Susan, my roommate who has extensive international experience as a pediatric emergency room doc, and I talked about how I might make best use of my time here, and she suggested just looking at everything-- every process, every procedure, and try and identify what could be improved that was simple. 

The next day, I went back to work and started looking around the place and tried to start zeroing in on things that might be simple and warrant change. I put this aside and started looking through the chart of that sick patient. The chart was literally a bunch of papers thrown together in minimal chronological order with a minimal division of document type. Orders were either inferred from the doctors' notes after oral communication or scribbled as part of the note.

I went out at lunch and looked for chart dividers. I couldn't find anything made for that purpose, so I bought some flimsy file folders made of bright red plastic, and punched holes in them. We created a face sheet, lab, xray, nursing notes and flowsheets, and doctors notes sections. The nurses thought that was great and immediately started re-doing all the charts. I'll buy more dividers on Monday so we can finish up. I then took the history and physical sheets, crossed out history and physical, and wrote orders. I explained how I would write my observations in the H&P section and that there would be separate, clearly defined orders. I also suggested that the brothers and sisters might want to sign underneath the orders when they were completed.  They were a little hesitant about this, but are willing to consider it. We'll try it this coming week. Finally, I demanded that we use the "American System."  The brothers and sisters got very excited about this and asked what this was. I said that the American System is that 1) If you think I am doing something wrong, tell me. 2) If you don't understand what I said, ask.  New stuff.

One of the surgeons said he was not going to let me go back to the U.S.

Chart dividers.... I guess we aren't going to worry about an EMR quite just yet.

Next: The Buddha and the Chorten