National Day, Chest Tubes, Indian Pressure Cookers, Challah, and Horses

So, a pretty eclectic bunch of topics today. On Saturday, I went to National Day with Ayumi, a Japanese nurse who is working in the ICU under the auspices of JICA, the Japanese international development agency. They run a program quite similar to the Peace Corps. She is here for two years. She is a very good ICU nurse from a highly developed medical system. When we have compared notes, there are no differences of significance between US and Japanese ICU care.

Ayumi in national dress, as they call it here.

We got to sit up in a VIP area again, and got a good look at the festivities. Some of the dances and pageantry were a bit different from last year, with mask dances as well as other presentations.

Royal Bhutanese Army Marching Band

Traditional procession before king arrives

Group of monks

The King

Buddhist benediction before the King's speech

Mask Dancers

Bhutanese Bagpipe Band

We did not meet the King this time; he spent most of his time in the general admission stands. Several members of the royal family said hello (his sisters and younger brother) and chatted a bit. Ayumi showed me a new restaurant after the proceedings where we had brukpa, which is a thick noodle thukpa (noodles, vegetables, preserved meat) that is very spicy but extremely good.

Sunday was chores and shopping. Renewed my stock of vegetables, and got an additional heater and an Indian pressure cooker. The pressure cooker is, well, interesting. To put the lid in (that is not a typo) one puts the two handles at 90 degrees to each other, you then slide the top in, and then align the handles. A rubber gasket makes the seal, and you then squeeze the two handles together until the metal loop on the lid catches the lip on the pot. Pop on the regulator and you are good to go. Definitely not Mom’s Presto. On the other hand, I was able to make some dahl (lentil soup) in 10 minutes instead of 45. I know it's kinda weird that I spent so much time describing a pressure cooker, but the design was intriguing. In particular, it is an absolute HORROR to clean. Food gets in under the lip on the pot and it's difficult to see whether you really do have the thing clean or not. Maybe it's cheaper to make???

Unassembled; black ring on the lid is the gasket.

Lid goes inside the pot.

Fully assembled. Note ring on the end of the handles.

So, I went to this store called the Eight Eleven (none too subtle, eh?) It is actually quite a good store, get lots of good stuff there, easy to maneuver, good choice. They had some baked goods, one of which, I swear, looked exactly like a challah.

I had to laugh. It’s called a sweet  bread. Real challah is sweeter, and uses egg. This did not. Still pretty good, though.

This morning, I was minding my own business walking to work down Doebum Lam, which is one of the three or four main streets in Thimphu that run parallel to the river; it is sufficiently important  that some portions have a median divider. The hospital is directly on this street. There were these two guys herding horses down the middle of the street during rush hour, to the consternation of drivers, especially taxis. Apparently totally legal, police just watching, no one interfering.

Horses on one of the main drags. The two guys are the drivers, or whatever they're called.

The final installment today is medical, and also shows another way of doing things. The picture below is of an incredibly cheap, simple pleural drainage system. Apparently they almost never use suction here.

(chest tubes picture)

Very weird. The white plug at the upper left allows you to vent air, if need be. You can't see it easily, but there is a tube running down the middle of the bag that ends in the liquid. That's the water seal. Before attaching to the patient, you put water in to create the initial water seal.  What I don't understand is how the water seal threshold pressure doesn't change if there is drainage and the fluid level rises. An area for exploration and self-education. Ayumi had never seen anything like it either.

Well, that’s it for today. Life is nothing if not interesting.

Paro, and a heart wrenching experience

This is a little longer between posts than I had hoped for. Both Eileen and I have been under the weather from either mild flu or a particularly nasty strain of cold virus. We are both recovering, and I have the energy to write a blog entry.

We went to Paro for the weekend. It is not terribly far from Thimphu, only about an hour's drive, but has a very high concentration of monasteries, the national museum, and of course, Tiger's Nest.

 We started our trip at the National Museum. The old museum had been damaged in the earthquake that occurred in September (2011) and was not habitable.

You can see part of the wall falling away on the left.

On the way up (we took one of the usual Bhutanese shortcuts--shorter as the crow flies, but calves of steel are needed for the climb) we saw a man making Bhutanese bricks. The soil is quite clay-ey and earth is rammed within a wooden frame until the earth block is suitable size.

The museum itself was in a bit of disrepair due to the earthquake. The collection was partly in the new building, partly in the old building-- we saw masks, and thangkas, and pictures of royalty. Short visit, but fun.

We then visited the Paro Dzong, which is  an interesting construction-- one half houses the provincial administration, and the other half has monks. The dzong is situated overlooking a river. Quite impressive on the outside, but really, there wasn't terribly much to see on the inside.

Some of the wall paintings we could see

Temple cat.  Taken with a zoom; he was way the heck up there, but also out of the way of the dogs...

We visited a couple of lakhangs, which are monasteries. These were quite interesting but we were not allowed to take pictures inside.

Kyichu Lakhang, one of the oldest in Bhutan

Dungtse Lakhang, famous for its chorten shape. Wall paintings were amazing.

We walked to but were not allowed in Drukyel Dzong, a dzong with  a commanding view of the valley. Previously badly injured by fire, it was made uninhabitable by the recent earthquake. The walk around it really let your imagination run with what this place must have looked like in its prime.

We stayed in a very nice hotel that night and went to Tiger's nest the next day. As I said last year, the climb is spectacular, the inside is spectacular, the view is spectacular.  Eileen expressed considerable concern about her ability to do the climb, but she did it handsomely.

On the way down, we stopped and ate at the Taktsang Cafeteria, which served really delicious vegetarian fare.

All in all, a fine trip.

Medically, several interesting developments.
One of our patients was placed in skeletal traction. The pin was put in place by an orthopedic technician and was not supervised by the orthopedist. He did a nice job. The ends of the pin are quite sharp, so they were protected with a couple of old injectable medicine bottles.

Two patients today were quite notable. One woman was admitted to ICU after a thoracotomy. She had hydatid cysts in her chest.  Her CT scan is pretty amazing.  It looks like she did not suffer anaphylaxis, and I am going to need to do a lot of reading on what to do from here in terms of additional care.

The final story has to do with an Indian laborer.  There are lots and lots of Indian laborers here. They do all the nasty stuff-- the hard labor, the dangerous jobs, the dirty jobs. They live in shanties at the worksites and try and send at least a little money home. They are the poorest of the poor. One of these poor fellows had a brick fall on his head while not wearing a safety helmet. He developed an acute subdural hematoma and needed to go to the operating room.  His fellow laborers and friends were very worried that he would not get care, because he would not receive care in India because he couldn't pay. We explained what was going on, and that he needed surgery. I was sitting at a desk. His two friends came around the desk, prostrated themselves, and held on to my legs while begging me to take care of him.  I was simultaneously horrified and touched-- horrified that anyone would kneel to me, and touched by their care for their friend.  He had his surgery, and appears to be doing a bit better. He has a long way to go. We'll see what happens.

I am not sure how much more touring I will do. My left leg is quite a bit weaker than I had hoped, and the hills are murderous. I do great on the flats, can walk endlessly, but there simply are no flats in Bhutan.  This will be to the benefit of the nurses and docs, as it will force me to plant myself in a chair and write a couple of lectures.  Hopefully, this weekend is National Day and I will attend that on Saturdayl

The Chorten, and a bunch of medical stuff

One day after work we went to the National Chorten. Avoiding the obvious question, a chorten is a Buddhist religious monument/shrine that contains saintly relics or is dedicated to the memory of a holy person. The National Memorial Chorten is dedicated to the memory of the third king of Bhutan, a devout Buddhist who did much to further the teachings of the Buddha in the 20^th century. We walked clockwise around the Chorten (this is the only direction that one can walk). I had had a difficult day, and the walk, the dedication of those surrounding me, and the environment were quite calming.

The Chorten itself; note scale!

Elderly ladies praying with prayer wheels

We have been lazy, and have not done much after work. We do a bit of shopping, either eat out or make dinner, and then watch Indian television (or the BBC or CNN). Eileen writes to her friends, and I do my sleep studies and/or pound away at the blog.

 Work has been a bit challenging, and has been going differently from last year.  There have been fewer ICU patients than last year. It feels as though the resources available to diagnose and treat patients have contracted, and I have encountered knowledge deficits that I thought we had addressed. I have been asked to see a large number of patients on the medical wards. This has been a consultant’s dream, in that I get to just write my impression and plan, and don’t need to worry about massive documentation.  In fact, massive documentation is impossible in that (a) I can’t take a history in Dzongha, (b) many patients have no idea of their health history (some don’t even know their date of birth—born in the boonies a long time ago) and (c)testing is by and large unavailable. I have seen three cases of lung abscesses. TB excluded in all of them. One case is almost certainly the right middle lobe syndrome from hell; she might be the only RML syndrome that I ever recommend for operation. The youngest patient is 16. I was told that "we Westerners are not as susceptible to these diseases." Bronchoscopy is pretty much out of the question. We’ve (not the royal we, me and the equivalent of the hospitalist) seen a case of a hemithorax obliterated in a young man with a primary brain tumor, the CT of the chest is pending. Today, I was asked whether or not a woman in her 30’s should be referred to India for mitral valve replacement because of mitral stenosis from rheumatic heart disease. Thank you, UpToDate!!!! (for the record, valve cross sectional area was 1.25 cm2 and anything but sitting made her breathless. Send me a postcard from Calcutta…)

For those of you who are less than thrilled with SCM and the EEHR, let me offer an alternative perspective. I have been working in paper for the past 10 days, and the amount of time wasted on admittedly dumb things imposed by meaningful use, insurance companies, compliance, those zany folks from Allscripts, and unintended consequences created by yours truly and his minions are more than offset by an orderly, available database of information that you can use to really take care of your patient. I know that electronic medical records has had a rocky road at MaineGeneral, but from the perspective from the male medical ward at Jigme Dorje Wangchuck National Referral Hospital, we are so, so fortunate.

This coming weekend we will spend in Paro, about 50 km away. There are lots of old monasteries, the Paro Dzong (fortress), and Tiger’s Nest.  More on that when we return.

First full day at work, and our first weekend

Well, my first full day at work was a bit of an eye opener.  I got to dig in a bit more about my patients, and talked to the docs.

The docs were extremely nice, genuinely happy to see me again. We chatted about the year’s interval. Although the nursing staff had made some changes, the docs really hadn’t made any. The blood gas analyzer was taken out of service because they ran out of reagents and cartridges. The company from which they obtained these materials had been blacklisted because of corruption, and so there was apparently no longer a vendor available on the Indian subcontinent. I was told that they had reviewed their statistics for the last three years, and had decided that from their perspective and analysis, they did not need blood gases.  I ventured that perhaps one did not for one or even two days of simple postoperative ventilator care, but not for anyone who was really sick or for a prolonged vent stay.  This will require some work.

To the positive, there appear to be fewer drug shortages.

Some of the patients will be quite challenging. The young fellow who embolized from rheumatic heart disease, infarcted his brain, and then hemorrhaged  has now bled into his ventricle and has new areas of ischemia. Our presumed leukemic will hopefully go shortly to Vellore Christian Medical College, which is the site of choice for patients from Bhutan who need true tertiary care. Our patient with depressed consciousness unfortunately developed subtotal atelectasis of the left lung. I gave instructions for aggressive pulmonary toilet, and hopefully I can avoid bronchoscoping her.  We’ll see what Monday holds.

We were lazy and got up late on Saturday, and went to the market. Vegetables, cheese, fruit and a couple of souvenirs from the vendors.  All the guidebooks say that the prices are fixed, but we consistently were able to get prices knocked down by 10-20%. I made us a tame version of ema datse, the infamous cheese and chilies dish, using a fair number of chilies but softening the blow with a flat bean similar to a snow pea. Pretty good, if I do say so myself.

We went to see the Buddha today. Long climb, exacerbated by a number of wrong turns. However, we were rewarded with the site of a couple of women weaving at the side of the road.

The day was chilly and overcast, so the view wasn’t quite as good as last year. Eileen actually let me take her picture:

There continues to be work on the base of the Buddha, and here’s a picture of some Indian workmen ( a lot of construction is done by Indians) crushing rocks  

  The Buddha himself is quite striking. .

We dragged our middle aged bodies back to our apartment, had some lichi nectar and some  sweet fried dough snack, and took a much needed rest. Eileen made some nice vegetarian fried rice, and we split a bottle of Red Panda (a very nice unfiltered Weiss beer).

I am not going to report on Eileen’s clinical activities. She will tell her own story in her own way.

Back to work tomorrow!

Life is Change

Greetings from Bhutan! We made it!

Life is change, or change is life, or maybe a little bit of both. Been in IT too long, and did a gap analysis, the gap being between last December and now:

Bangkok and flights: We had an uneventful journey from Portland to Bangkok. I had expected to see more evidence of water damage (we were pretty close to a canal), but the only thing I saw were some sandbags that had not been cleared away and more debris on the street than last year.  Alas, we met no dignitaries on the plane this time.

In and around the apartment: The apartment is, well, the apartment. There have been a few changes here and there—some changes in drapes and electrical appliances, but the dogs are there, the wet road is there, and the hemp still grows at the side of the road. No more combination lock.

Around town: .  It has been fairly warm the last couple of days. (Global warming?   Nah, no such thing. Just a bunch of scientists looking for funding and attention.) To my mind’s eye, there are fewer young people wearing traditional dress.  Everyone around town is displaying a picture of the royal couple; the marriage was only 6 weeks ago or so. In the pictures, the queen is an absolutely striking woman. The infamous “shortcut” down to the main town has been closed (pooh!). There is extensive construction everywhere.

Hospital: About 50-50 new nurses vs. those there last year. Didn’t see any of the docs yet. Two of the nurses went off to Singapore for 2 months for an intensive critical care nursing course. In addition to chart dividers, there are now some simple vent bundles, instructions for sterile suctioning of ET tubes, better equipment stocks; I am really pleased.  They are such nice people—genuinely glad  to see me again, and I was equally happy to see them. Patients at this point are quite interesting and will warrant more discussion—a 14 year old with a massive stroke almost assuredly from a rheumatically damaged mitral valve—sterile or septic? Not sure, only did one blood culture. A very unfortunate man with AML and pulmonary infection—the AML was identified as a consequence of the pulmonary infection—he’s getting stabilized before being sent to India for induction chemo. Finally, a woman with a global depression of mental status that is improving; probably a viral meningitis or encephalitis, but it’s hard to say without CSF analysis.

Me: Left leg is NOT happy on these hills. Apparently 30 minutes a day on a treadmill at a 12% grade, 4 mph is not the same as walking the streets of Thimphu. Hopefully this will get better. As Eileen said, this is exactly the exercise you need to do in order to strengthen the muscles you need to do this exercise.

Eileen: Still getting used to the place; walked around a bit on her own today; she’ll get started at the hospital tomorrow, we hope.

More as life unfolds here.

A Very Brief Update

I'm going back!!

I will return to Bhutan for December, 2011. I am incredibly excited. Flights purchased, Bangkok hotel reserved, insane obsessing started; all is right in the world.  Unfortunately, Eileen will not accompany me, as the visa rules for "accompanying spouses" were changed. A month on a tourist visa would be prohibitively expensive, and the complimentary visa is not longer offered. What a shame.

I will post more as plans gel and I get closer to departure. Whoopee!!

Those promised final thoughts

This is the hardest post to write, because I feel like somehow I need to bring it all together and make sense of my experience. I'm probably being way too hard on myself, but the urge is there.

Overall, it was a wonderful experience, made wonderful by my Bhutanese friends and colleagues, and by the other HVO volunteers. I could not have asked for better apartment mates, dinner companions, and fellow philosophers.  My Bhutanese colleagues were smart, hard working, and eager to learn as well as being incredibly gracious hosts. Were there flies in the honey?  Of course. As some of you have heard me say already, the blog has been sanitized to protect the guilty. There was some care that was far from perfect and there were a couple of people floating around who were a bit harder to endure and I didn't like the trash everywhere, but those topics are for private conversations. I'm not complaining, but it is important to me that readers understand that I was aware of the less good and was not walking around starry-eyed.  Overall, it was a terrific experience and I very much want to go back and work in Bhutan again.

So, I guess the questions I need to answer is what did I learn and did I help promote positive change?

What did I learn?

North Americans are incredibly lucky. Our material wealth is obvious, although I'm not sure that it creates as much happiness as we would like to believe.  However, trappings of prosperity like central heating, potable tap water, and good roads make life more pleasant and should not be taken for granted. It takes the contrast of living in Thimphu to see that clearly. What we don't realize we have is freedom and democracy. Now, I know that sounds corny. Anyone who knows me is well aware that I'm not a flag waver. However, we take for granted that we can speak freely, make suggestions, challenge authority, try something new, and demand change when things are not working as they should. This is the real gift of freedom. Growing up in a culture where acting freely is taken for granted creates innovation and progress, and we are the beneficiaries of that culture.  Democracy is new to the Bhutanese. They are learning how to use it, how to speak up, how to try new things, and not settle for the status quo when the status quo is not good. Hopefully they will learn to take the good of our system and maintain the graciousness and outlook of classical Bhutan. I think they will.


The second thing that became evident to me was how we take infrastructure for granted. I was given the opportunity to give a lecture on what could change in the ICU. I did so, being polite and respectful but direct. My pitch was about infrastructure. I had framed it in terms of predictability and consistency, but it really comes down to the same thing. A working infrastructure means that when you flip the switch, you don't wonder if the lights will come on, you assume that they will.  In medicine, infrastructure is not only about a physical infrastructure, but an infrastructure of ideas, assumptions, and systems. You can use a blood gas analyzer because there is a system in place to make sure that reagents are always on hand. You can use a ventilator because there is a system in place to make sure that there are spare parts available. You can care for a very sick patient because you know that certain medications will all be available. When global health experts talk about sustainability, it's another way of saying that the host country has created an infrastructure of ideas, things, and systems so that the process functions independently of any one person. Sustainability and creation of an infrastructure is a consequence of widespread acceptance of the new idea or process; key players have decided that the work of creating and sustaining the infrastructure is outweighed by the benefits bestowed by the new system.  I think that needs assessment is a huge piece of change, but that we need to understand what leads to sustainability and creation of infrastructure and apply those ideas vigorously. The flip side of that is that much of what makes American medicine so effective is not cutting edge technology, but that infrastructure of things, ideas, and assumptions that makes a supply chain work and that puts the right patient in the right operating room with the right surgeon who is going to do the right operation with the right instruments.

I think those two ideas were my two big philosophical takeaways. There were a bunch of other things too.  I greatly missed my wife, confirming that after thirty years I am still crazy about her. At the same time, I was able to function socially without her present, which was reassuring. I'm lousy at social situations, and needing to go it alone for a month was hard but healthy. I have always known that I am adaptable; that was confirmed with the ease with which I slipped into life in Thimphu and how I tried to cobble together treatment plans when my usual meds and tools were not available.  By contrast, I saw another view of our medical care system:  big, bloated, hyper-regulated, over-funded and not always functioning in the patients' best interests. The only problem I have is that I have no idea of what to do with that observation. I got to live for a month in a country whose chief concern was Gross National Happiness rather than Gross National Product. I learned that Gross National Happiness was not about everyone walking around giggling, but that the collective welfare, the collective prosperity, and collective health of the citizenry was every bit as important (if not more so) than any one individual or group. I got to live in a place with an entirely different aesthetic, and I loved it. I spent time with wonderful, gracious people who were more than willing to share what they had with me. That was worth the trip in itself.

What did I leave?  Well, to be honest I'm not sure. I'd love to know if the nurses quietly removed the chart dividers the day after I left. I hope not. That seemed to be an easy win. I know I got my message across about ventilator management, and I think I got my message across about fluid management. Antibiotic choice and use-- not as sure about that. We did get physical therapy into the ICU, which I think will be sustained. That will be a good thing. I was involved in the first discussions about better ICU training, and I hope that the docs and Ministry of Health can get some training slots for the docs.  My anesthesiologist and internal medicine colleagues wrote a letter to the ministry complaining about drug shortages. I was not directly responsible for this, but I like to think that maybe my willingness to speak up about the problem and not simply accept the status quo played some role in facilitating that complaint.  I talked repeatedly about reliability and consistency and how it was equally important to have a steady supply of spare parts and reagents as to buy the machine in the first place. I hope that got some traction. Finally, I said repeatedly that good ICU care was about being meticulous rather than having high tech. That's a disappointing thing to hear because toys are fun, but it is critical to success.

So, that about wraps it up. My 30 days in the spotlight are over. No more celebrity status as the American ICU doctor. Back with the computers, and meaningful use, and balky electronic medical records and my one day a week of sleep clinic.  I hope this has been an interesting thread to follow.  We'll pick up again when I go back...