First, an update. Two of my patients died over the weekend. One was an 88 year old man who had been wonderfully resuscitated by the staff, but who succumbed anyway. My other patient, the 20 year old quadriplegic, ultimately died from sepsis complicating his condition. As I have said in other posts, it would have been a terrible struggle had he survived the acute phase of his injury.
Now, to the heart of the matter. I have been remiss in not talking about my Bhutanese colleagues. There is a cadre of about 8-10 nurses who work in the ICU, using a 3 shift model. In many respects, they are like U.S. nurses, advocating for their patients, administering the medications, and gently and subtly making sure us doctors don't do anything silly. They are enormously resourceful, figuring out ways of reusing expensive equipment we would consider disposable, and making do under less than optimal circumstances. My one serious criticism is lack of patient education, which is very much cultural. We've talked about that several times, and that is an issue that will take time.
Nurses act as respiratory therapists, as there are none here. The other things that the nurses do is work with the attendants. Attendants are family members that basically act as CNA's. They help bathe the patients, empty urine containers, feed the patients (including NG feedings), and act as an additional set of eyes and ears.
Attendants also help procure medications. There are certain things not available in the hospital, so the family goes out and buys it-- protein supplements, for example are ordered for tube feeds along with the rice porridge, so the family goes off and buys the Proteinex. On the other hand, the attendants are given a daily meal by the hospital when they show their attendant pass.
Personally, the nurses are lovely people. I have already been invited to two functions for this coming week in anticipation of my departure and there are a couple of Christian Indian contract nurses who are holding a Christmas get together. We take tea together around noon, and either they or I bring a light snack and have, well, tea. They are extremely respectful, disconcertingly so, and I cannot change that despite my antics and pleas to the contrary. They are extremely open to new ideas, and have been eager to learn. They have been true colleagues.
My physician and surgeon colleagues are also dedicated, wonderful people. The majority of the docs get their M.B. in 6 years in India although for example one young GDMO got his MD in Cuba-- the Latin leavening of his Bhutanese personality has made him an utterly delightful dinner companion. They then return to Bhutan to work as GDMO's ( I believe that stands for general duty medical officers) staffing the district hospitals, health centers, and the referral hospital where they do Emergency Room (Casualty here) duty, and assist in understaffed services. They can end up doing this for years until the Government allows them to use one of the training slots to go abroad and develop specialty training. It can be very arbitrary-- suppose a peds residency slot comes up, but you always wanted to do surgery. If you pass up the peds slot you may stay a GDMO for a long, long time. Many of these folks readily admit that some of their training was suboptimal, and they have been very receptive to new ideas and have worked hard to self-educate. They are extremely dedicated, and make the best use they possibly can of the knowledge they have. Docs tend to be businesslike with patients and families, a bit like US medicne 30 or 40 years ago. I don't know if this is a permanent cultural difference or the system will evolve as ours did. More importantly than anything, despite the hardships, they have not left Bhutan and they work hard for their patients.
The system is tough on the patients and the practitioners. There are constant shortages (I could not give KCl IV today, the hospital was simply out of IV potassium chloride additive) which occur for different reasons depending on who you talk to (I'm not touching this!) and that can run the gamut from nuisance to life threatening. These folks are big on improvisation; they need to be.
Another cultural observation I've made is that care is terminated only by the patient improving or dying. We've now had several instances where the patient clearly was not going to survive and there was no discussion about stopping treatment. If the reader recalls a previous posting about the brain injured 6 year old, I declared her brain dead almost 24 hours before she was taken off the vent when she became asystolic. This no one's fault or bad care or patient paranoia; the system simply has not evolved to be able to hold those conversations.
Patients and practitioners are much less worried about personal modesty. The wards have 8 beds, and they are mixed sex. Women have no compunctions about lifting their shirts in full view of the rest of the room to allow examination. As a rule, patients and families tend to be quite stoic about prognosis and want to go home to their home village for their final days.. They are also incredibly stoic about pain; my ER colleagues repeatedly told of 5 year-old's simply holding still while being stitched up. Pretty amazing.
My colleagues also know stuff I don't, and they have been gracious teachers. Apparently organophosphate insecticide poisoning is extremely common here; I saw my first case of it here. Both the docs and the nurses filled me in on how to care for these patients, what drugs to use, how to make the diagnosis. It was great. The other cool thing I've seen is really good physical exam skills; these guys can find and tap a pleural effusion that I'd need ultrasound guidance to even see, much less sample.
So, as it should be, this has been a two way street. I've offered some specific skills and organizational observations; I've been taught grace under pressure and resourcefulness in the face of material deficits as well as some interesting pieces of specific information. I'd call it an even trade.
I hope to get in at least three more postings-- domestic life, food and one final big walk around town. We'll see how it goes.
On an utterly unrelated note, it is very, very dry here (hasn't rained since I got here). Small forest fires are common-- looking out the window of the ICU break room I saw this:
Until next time.
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