Best picture of the whole trip

This is the best picture of the whole trip:

Yup! Finally got it working. JDWNRH has an UpToDate license for a year! Now, all I have to do is show them how to use it, create the necessary usage reports, and most of all make good use of it. I am really, really happy.

Yes, I fix things!

Those of you who know me know that I fix things. Well, I brought along my trusty multi-tool for just such an occasion. The plugs on electric fixtures here are really badly made and they are always failing, often catastrophically. Most sockets have burn marks around them.

Well, one of the heaters gave up the ghost. The plastic had melted and fused, and the plug came out--

Here's another view of the molten mess:

Went out and bought a replacement plug and back in business!

Meanwhile, back at the hospital, found this interesting sign:

I've marked my hospital shoes so that they won't get disappeared. Mind you, if they did disappear that wouldn't be the worst thing in the world. These are cheap Chinese knockoffs of cheap Chinese knockoffs (crocs) of clogs:  I think they will stay in Bhutan. They hurt my feet.

I undertake a modest exercise program at home, consisting of some very lightweight weight training and walking every morning. The walking is covered, no problem there. I'm borrowing the PT department's weights for a couple of minutes every day:

We are making some progress at work. The UpToDate installation is almost complete. I also had my first contact with the interns, a group of Bhutanese docs who have just finished medical school abroad and are getting more training before being turned loose on the population. Interested,  nice, want to learn. More on that as we have more experience.

The patients remain challenging, with patients so seriously ill that many would only receive palliative care in the States. It's extremely difficult to readjust my thinking to figure out what to do for folks who are so sick that. We've had a young man who hung himself and failed, and is now effectively brain dead, but the family can't accept it. We have had a lot of liver failure and kidney failure from alcohol and hypertension respectively. I will continue to try and wrap my head around this.

Andy and I had dinner at the Bhutan Kitchen, a prix fixe meal that is a showcase of Bhutanese cooking. A little toned down and a little expensive for the tourists, but it was pleasant enough. The best part was that there was a cat running around the restaurant. It came over and pestered us, begged for some food (did we give in? of course!), and was extremely friendly.  I will need to get some good cat pictures. There is clearly a Bhutanese cat breed, very specific appearance and markings, quite handsome.

It snowed!

Snowed this morning, so there was a national holiday. The snow in Thimphu came down in big globby flakes and did not stick at street level. It was very pretty, though.

The clouds lay low over the mountains, also very pretty...

Hospital was empty, and all the docs went home early. No, I don't understand it either. I told them that I routinely drive in 10-15 cm snow and was looked at in disbelief. Also some of the people said that it was a holiday because it was the first snow, and other people said it was because it was the last snow, and I think they got worried that it was really going to snow and pulled the trigger way too early.

Lots of changes

Wow, 2 years is a long time! I was warmly greeted by the folks that had worked with me; which was very nice to have happen. The ICU is now 7 beds-- 4 general ICU and three neuro specific, which is a good thing. There is also now a pediatric ICU, which is also a very good thing. They can now segregate out and work with the really sick kids in a more aggressive way. I am still getting my bearings a bit on the medical stuff, and will report in greater detail later. There apparently was an intensivist who sorta just volunteered under his own auspices for the last 6 weeks and had just left. There is a massive amount of building going on, you literally can't walk a block without tripping over some construction site. The internal medicine docs are now on the third floor by US count and second floor by Bhutanese count. I am extremely disappointed to have a Western toilet. The other volunteers are an interesting, varied group. More on them later. It very nice to have Andy Hertler along. Out to eat again tonight.

Air France has good food!

So, I made it to Bangkok without incident but my bag did not. My flight to London was delayed, so I had to rebook, which made them change which plane I took, and surprise!! My bag didn't make it. Finally, delivered to the hotel so I can enter Bhutan sans odeur. Andy and I took a walk, and having seen most of it before, I didn't take a whole bunch of pictures. Only the important stuff, temple cats and an interesting bird. Google is being a bit fussy about security so the pictures will be delayed. So, sitting in business class Air France lounge. Gotta love the French, food is GOOD and the coffee is WONDERFUL. More when we get to Bhutan.

Back sooner than I expected

So, after thinking I wasn't going back to Bhutan for a while, my friend Andy Hertler turns out to be going to Thimphu for a month at JDWNRH doing oncology. How could I resist? More seriously, I had had mixed feelings about returning. As I considered what I had done there, I realized that in Bhutan as in the U.S. change comes slowly. Getting an entire hospital to use chart dividers is actually a pretty big deal. One of the docs I had spent time with, Dr. Yangchen, was posted to St. Michael's in Toronto for a year of critical care training. The docs were eager to use my little netbook with UpToDate on it. After considering it all, I did decide to go back, sans Eileen this time, for another month of working in pulmonary and critical care at JDWNRH. I will be going in March, 2014. I have obtained a grant from UpToDate to provide UTD access to JDWNRH for a year. All we need is a static IP address, which I think won't be too much trouble. What will we try and do? Install UpToDate Keep pushing on handwashing Enter orders on a separate sheet Understand palliative care Specific help with specific patients in ICU (always the core) Getting there will be a bit interesting. I'm going on frequent flier miles, so I am traveling East, not West, to Bangkok. Outbound via Heathrow, inbound via Arlanda (for the uninitiated, Stockholm) More to come.

The Final Bhutan Post

Yup, this is it. Last one. Life is too complicated for me to be able to go back out for a month, at least for now. Maybe when I retire...

Picking up from the last posting, which was about National Day, December 17th. It's hard to talk about the patients. It is very depressing in some ways; the ICU had about a 50% mortality. We did manage to pull through a fellow with pancreatitis; he spent about 10 days on a ventilator and amazingly avoided pneuomnia. The amount of alcoholic liver disease is staggering, as is the number of head injuries and strokes. The World Health Organization says that non-communicable disease will be the next big problem in developing countries. They are very, very right.

Most of this is a bunch of interesting random stuff, to give a flavor of what life was like. I also got invited to some parties and festivals, which are worth recounting.

Dogs: last year, I said there are dogs everywhere. There still are. Mostly, they get along with us humans just fine. However, the husband of the physiotherapy volunteer was spontaneously attacked and underwent rabies prophylaxis Here's a picture of some unusual behavior; I really don't know what this was about:

No idea what they were doing hanging out on the median divider.

Shopping and markets: One of the neat things about doing volunteer work in a country is that you get to live there, as opposed to tour there. Shopping is a bit different. I've shown pictures of the markets in previous posts. Here are a couple more:

Just past those two buildings is the open air market. As you get closer, you see that the streets are jammed with people, there are dozens of stores, and they sell just about anything/everything that a Bhutanese might want.



This part of the open air market sells grains: rice, corn, wheat, barley in many different shapes and sizes. For a carb freak like me, it was like walking around heaven.

 The hospital: I thought that a couple more pictures might round out what it was like here:

Lab waiting area. This is before it gets crowded, when there is literally no place to sit and people are packed shoulder to shoulder.

This is the corridor in front of the ICU. There are no waiting rooms. People sleep on the floors. There are a couple of alcoves, and folks will bring mats and food and literally camp out. I wish I were joking, but cooking fires are explicitly prohibited. Apparently it has been an issue among visitors.



The picture is a bit small. This is a picture of just inside the main entrance to the hospital compound. The people sitting on the sidewalk are vendors; folks standing around are customers. Doma (betel nut), soft drinks, snacks, fruits. It's chilly, but acceptably warm in the sun.



Around town: Here's several pictures from around town that were just fun. I ultimately found myself pretty limited in my excursions, so these are all from Thimphu. My cardiopulmonary endurance was just fine, but my left leg was sufficiently weak to interfere with being really ambitious. Next trip is to a nice, flat, river delta. Flat ground poses no problems.

So, you guys think they worry about detailing cars in the US??? This is typical for Bhutan and India. Indian trucks have Hindu themes; Bhutanese are Buddhist. Lots of overlap in the iconography, though.

I thought this was cool. Young guy just contemplating life and enjoying the sun. Rocks on the roof are ubiquitous, even in/on more substantial dwellings.

Traditional older Bhutanese dwelling.



Monastery



Another picture of the monastery. The building was several hundred years old. Unfortunately my visit collided with two busfuls of Indian tourists. I waited til they left.

What a hoot. I love the name. Good store.



Last year I said the that the city was quite pedestrian friendly. Throughout the city there are thoroughfares like this, where walkers can slither between buildings and avoid long detours needed to stay on a paved road. A little weird at night, feels isolated, but they are safe (except for dogs.)

The last four or five days were a social whirlwind. Christmas eve was spent at the apartment of a couple of Indian nurses, one of whom is Christian; he threw a Christmas dinner.  He should not be a nurse, but should own a restaurant. Wow, what a great meal!

The next night I went to a puja, which is a festival. The puja to which I was invited was held by Tandin's family, the head nurse in the ICU. She grew up on a farm outside of Thimphu. We walked down through the dry rice paddies to her home, where we were plied with a variety of appetizers, suja (salt tea), and beer. This was one of the most unhealthful meals I have ever eaten, putting German cooking to shame. One dish was slabs of cheese with sugar, covered with melted butter.  After the appetizers, we had the main course. You weren't allowed to leave until your triglycerides were 1000, your glucose 400, and couldn't stand because you had drunk so much. Unfortunately, the pictures I took did not work out that well. The meal, by Bhutanese standards, was quite good, with all sorts of meats and chilies and tons of rice. A couple of interesting items. First, this puja is a yearly thing, a rededication of the home and being thankful for the harvest. When we left we were given a kg. or so of rice. Second, there were many people at this festival, friends of this family through different sets of contacts. "Affinity groups," if you will, were in separate rooms and didn't mingle. I guess that is custom.

The last night I was in Bhutan I was given a going away party by the nurses and a couple of the docs.  As usual, everyone was quite gracious, friendly, and I think genuinely sorry to see me go. They are good people; I shall miss them.

So that, dear reader, is that. The trip home was uneventful and without disruption. I have been home for just shy of two weeks, and in some respects it is as though I never left. However, I will always have the memories of two months as a doctor in the Himalayas, adopted and cared for by some of the nicest people I've met.

Bye.