The Dragon Path

 





 

The four day trek from my work site in Thimphu to the airport in Paro seemed to be the fitting end for this very eventful month.  Fortunately,  I was able to contact Tashi Wangdi, the lead guide from our 2013 REI Chomolhari Trek and he was happy to put together a trip with just one week notice.  Not an easy task--this is not a normal backpack with hi-tech light weight gear, but a full scale expedition with 5 staff, 8 ponies, baskets of fresh veggies and a huge propane tank, and an absolute need for a guide to take us over the criss-crossing maze of ancient trails that join the two towns.  With a little gentle persuasion the roster was filled out with two other HVO couples: Eric and Rita, an orthopedist and OB-GYN from Wenatchee, and Joe and Robin from Rochester, MN, an ER doc and free-lance writer turned elementary school ESL teacher.

Monk and friend at our lunch stop on day one, Phajoding monastery.  He held tight to his favorite dog, as 5 others followed us up the hill and for the rest of the trek.

 

By tradition, the guide picks the cook and the cook picks the rest of the staff to be sure they can all work together harmoniously.  Our team, who we dubbed the Merak Mafia, are all childhood friends from Tashi's home village in far Eastern Bhutan.  They grew up at 11,000 feet four hours' walk from the nearest road, and together attended a decrepid boarding school, sleeping on the bare floor with poor food, a constant infestation of lice and fleas and Indian teachers prone to corporal punishment.  Despite this, they perservered, and earned the priviledge of high school by making highest marks.  Tashi was able to gain a scholarship to university and excelled at English and geography, two topics which have served him well.

 

This trek is listed as"moderate" but don't be fooled.  The first day involves a quad-searing climb from 8300 feet, just above Thimphu, to the highest pass at 13,900 feet in the space of about 6 miles. 

 

Fog hits at Pumela Pass, 13,400 feet.  As we pass by an eerie sky burial site on a high peak, heavy rain and then hail and wind reduce visibility to about 50 feet.

Eric, Rita, Joe, Tashi and me.

No one stops for photos at Labana La Pass at 13,900 and we get a brief view of the camp far below before fog closes in again.  Rita, Eric and I are guided in by the sound of the bells on the grazing ponies.  I turn around just short of camp when I realize Joe and Robin are somewhere behind walking in the dense fog and deepening dusk.  With the help of my high-powered whistle and call and response of "Marco...Polo!" we find each other.  Now thoroughly cold and wet we hustle to camp for dry clothes and hot tea.  In spite of a pre-bedtime warm-up in the cook tent, a shot of whisky and a hot wtaer bottle I wake up freezing at 2:00 am and put on all my clothes in my sleeping bag, including fleece, puffy jacket and wind pants.

Rita contemplates a nice hot breakfast.

Our camp, viewed from high above.

 

 

Our pack string catches up.  Always stand to the high side of the trail!

Hanging prayer flags on a pass.  Careful, Joe--it's a long way down!

 

Me and my buddy.

Tashi, Dawa and Sangay with a mastif puppy they found at an abandoned yak-herders'  camp.  Sadly for Dawa, who had already named the pup Pela, the owner showed up and took possession.

Leki, our awesome camp cook, demonstrates the proper technique for making Bhutan's famous chili-cheese dish, ema datsi.

 

 

 

Okay, this is gonna burn.

Dawa the horseman shows that he is a serious pyromaniac.

Bonfire entertainment:  The Merak Mafia treated us to a night of Bhutanese dance and song, maybe fueled a little by the Special Courrier whiskey.

High ridge on day 3, a very long 12 miles of up and down.  These aren't "real" mountains since the snow doesn't stay year round.

Dawa the horse-whisperer.  The day before the trek he walked his pack string all the way from his home in Paro to our start point in Thimphu over a short cut.

At Jili Dzong with Tashi, our lead guide, spiritual master, translator, naturalist, historian and mom ("Don't eat as much as you want, eat as much as you can.")    A trek isn't just a walk in the woods, but a travelling lesson in Bhuddist philosophy, Bhutanese history, cuisine and culture and the creation of a very special bond between five American volunteers and five hard working Bhutanese.

 

At Jili Dzong I asked a question and rolled the dice for the monk.  They came up six, three and one.  The total of ten indicates a very auspicious possiblity of a return to Bhutan.

Wrapping up

Young boy with a scalp avulsion from a traffic accident, awaiting flap closure by the visiting Australian Interplast team.

 

 

One of the most obvious challenges to medical care in Bhutan is the simple lack of adequate personnel.  With only about 200 doctors to serve a population of over 700,000 every one of them wears multiple hats and is stretched to the limit.  The Urologist does endoscopy and ERCP, the General Surgeons drain subdural hematomas and remove kidney stones, the neurosurgeon takes call and does appendectomies, and so on.  Ex-patriot volunteers and visiting teams take up a little of the slack, but often there is no one waitng to take over when they leave.  For example, the only ICU specialist in the country is a young doctor from Germany who is staying about a year as a volunteer; when she leaves there is no one to replace her.   The same goes for hematology, nephrology and many other specialties Plastic surgery teams come in for a whirlwind of cases and then there is a vacuum until the next "camp."    Equipment and personnel to fix and operate it have the same issue.  Our CT scanner, the only one in the entire country, was down for two weeks, and ultrasound is such poor quality as to be not much better than simple clinical judgement.  The operating room is our de-facto scanner.

 

 

A recent case, though, illustrates how things are certainly worse in nearby coutries.  An 83 year old woman came to our oncology clinic, having been brought be her family from Nepal where medical services are severely disrupted by the recent earthquake.  She had presented with neglected late stage breast cancer, with liver metastases on CT scan.  Biopsy did not include tumor markers, and she then underwent cytotoxic chemotherapy, which was probably not indicated considering her debilitated state.  It was given through a peripheral line on the same side as her cancer, and she suffered severe tissue necosis from extravasation of the drug.

 

 

Here our surgical oncologist has a better understanding of appropriate therapy.  I did a small biopsy of the tumor to get tumor markers, and she will likely be started on anti-estrogen therapy.  She can go to the local hospital for wound care and may eventually have a skin graft on her arm.  Due in part to the emphasis on appropriate palliative care by recent HVO volunteers, hopefully she will receive logical, ethical and compassionate end of life care. 

 

 Now, it is time to back up a step and put a major effort into public health education regarding early detection and treatment of malignancies so the meager resources that are available are not spent almost exclusively on patients who will not survivie their disease.  There is reason to be hopeful:  in the last week I have had numerous visits from local women who had heard there was a breast specialist in town and wanted to get a screening physical exam; some had even made the effort to travel to India for a screening mammogram.  Also, our junior surgeons have told me they are eager to learn more about breast surgery and wish I would be here longer.  The technology does exist for major health campaigns using radio, TV, internet and public gatherings, and the public is eager for knowledge and reasonably trusting of western medicine.

 

Historically, single physicians have made huge differences in medical care in this tiny nation, simply by doggedly pusueing a particular goal. In the last 40 or 50 years there has been huge progress in eliminating leprosy, iodine deficiency and polio.  Vaccine rates are actually very good, malaria is all but gone, and infant and maternal mortality is falling steadily.  Now non-communicable diseases such as cancer and heart disease represent the challenge of the future.  It is hard to imagine not coming back and at least trying to help.



 

 

I take a beating from the "sin stick" at Tari Goempa Monastery.

Photo essay

Dr. Tashi Tobgay, a neurosurgeon recently returned from relief work in Nepal, came to my talk on Hereditary Breast and Ovarian Cancer, and earned a pink ribbon medal to add to his collection.

The new digs, an apartment know as International House, which I share with my roomie, pediatrician Jenna Holmen.

Neighbor on a hot tin roof.

Game of darts, near the trailhead to Tango Goempa

Shortcut to the Goempa, up the rails where construction materials are being hauled to reconstruct the monestery for the first time in over 300 years.   It got a bit sketchy half way up, but I wasn't about to walk back down.

Monks at the top.  Some will meditate alone for three years.

Nice little bridge at the start of the hike to Cheri Goempa.

Picnic with Tashi--he brought rice and chilis for two, and I shared my PB&J.

Nerve center of our litle apartment.

Kids getting dropped off for school at Etho Metho.

Crossing guard--a very good idea.

A talk for the interns.

My faithful crew of hardworking and sincere interns.

Orienteering

I feel like I have spent most of my first two weeks here in Thimphu feeling a bit lost in time and space,  but things are finally making a little more sense.  For example, if you come to the Jigme Dorji Wangchuck National Referral Hospital and want to find the operating room, go through the main entrance and up to the second floor (which you might call the third floor, but entry is floor zero); go past all the signs to the operating room and turn right at the little sign for Microbiology.  Then another right down a narrow unmarked hallway and through the white painted plywood door into an anteroom full of shelves of shoes.  You made it!  Just be sure you remove your street shoes or you will be stopped and scolded.

Want the Cancer Registry?  Go down the long set of emergency ramps to the first floor and turn left into the doorway labeled "Blood Bank."  At the first office on the right, push through the crowd of people to a door wedged open with a red chair covered in shredded plastic.  If you see a shy woman in a bright blue silk jacket you made it.

Way-finding around town is no easier.  Even the capitol city, with population 80,000, has virtually no street names, and the locals don't use them anyway; there are no address numbers on houses and businesses.  Forget what you see on google maps--all directions are given in relation to known landmarks like the stadium, memorial chorten or large hotels.  Turn at this shop, go up the little alley, around the corner (was that left, or right?)...   If you are looking for a specific destination wear comfortable shoes and prepare to ask many people and go in many meandering circles.  Keep your eyes on the ground at all times while moving, lest you fracture your femur falling off a three foot curb or into a gaping hole in the sidewalk.

Who needs a show of force with such pleasant security guards?

 

Herding cats.

Hospital schedules and rounds are barely controlled chaos--I introduced the HOD to the term "herding cats" which he immediately appreciated.  Some days our crowd of 3 attendings, two residents, 3 interns, a gaggle of nurses and one sweating, befuddled HVO volunteer (me) actually all start together at 8:30 as planned.  Then phones start ringing, and the crowd from the hallway finds a way past security to ambush us.  Patients use any special connection to avoid the huge lines at the outpatient clinics--first a long line to the "sorting hat" to get a number token to a certain clinic, then hours waiting with the 70-90 patients lined up to see a single doctor.  An oncolgy nursing assistant pounces as I am dropping off my purse in the work room, "My sister from out of town has fever and chills and terrible headache for one week.  I gave her a liter of saline.  Can you see her?"  I've asked other volunteer docs about the best strategy--order labs and direct to the clinic?  See the patient only if it is simple?  Resist all advances on the theory it will only encourage more of the same?  As far as I can tell, no money changes hands on any of these exchanges, and there may or may not be an entry in a medical record (carried home by the patient).  But what goes around comes around, and maybe someday I will want to jump a line, too.

Lobby line

Science starts with counting.

Control central for Bhutan's national cancer registry

 

 

I wouldn't normally be confused with an IT expert, and in fact in most cases I'm the one asking for help.  But earlier this week I had a chance to test my skills on the brand new National Cancer Registry.  Just started 6 months ago, there are over 450 patients logged.  The data at this point is little more than tumor site, date of diagnosis and some demographics, but if science starts with counting then this little room in the hospital basement is where counting starts.  The one and only resgistrar painstakingly copies material from scrawled paper charts onto a data sheet, and then enters the codes into the computer.  I sat with her for over an hour, trying to figure out how extract and filter the data--so far no one had actually tried to produce a report.  I alternated between the help file and trial and error, back and forth for over an hour.  Picture Han Solo steering the Millenium Falcon with smoke coming out of the dash...  Finally, I hit the right combination and Viola!!  A list of all 40 breast cancer patients!  Fist pump!  I made a cheat sheet for the registrar, and even though she speaks almost no English she had been watching me closely and with just a few hints she was able to duplicate the process. 

Medical Records

 

Piles of data to enter.  Dr. Tashi Dendup and the regstrar contemplate the challenge

 

 

Later in the week I returned to the catacombs with the HOD (Head of Department), Bhutan's only Surgical Oncologist, Dr. Tashi Dendup.  With him driving at the console I led him through the steps, and then we quickly expanded our tricks to multiple filters, excel spreadsheets, etc.  With yellow-jacketed paper charts stacked four feet high behind us we were able to glean information without turning a page.  The reports at this point only give a hint of information, but also serve as a way to do quality control.  For example, less than 10% of the records include tumor staging, critical to determining progress or planning interventions.  Also, there is no follow up data of any kind.  We brainstormed possible ways to use the national census data or death records to at least document year by year whether patients are dead or alive.  The registrar will need training to find staging information, but this can be done.   Hint:  the nice neat charts on cancer survival in Bhutan that you might see on the WHO website are just extrapolations from data in India.  Soon, we can do better.

Recycled bottles line floor to ceiling shelves in pathology.

 







 

 

 

News Flash: Rock 'n' Roll

In case you are just waking up to the news that there has been another major earthquake in Nepal I want you to know that all is well here.  I was just finishing up with a breast lumpectomy when there was a sudden rolling surge--at first I thought the anesthesiologist was joking around and rocking the OR table, but people in hall started shouting "earthquake!"  and there was a lot of scurrying and yelling.  It was over in about 15 seconds, but obviously people here are very nervous!  About an hour later the electricity suddenly went out, fortunately just after we had finished with a lap chole.  This may have been unrelated as power outages here are not too uncommon.  Lucky for that flashlight app on the cell phone I could find my way to the dressing room.

Quick quiz:  What would you do if you were in the OR with a patient under general anesthesia and there was a very strong earthquake? 

Changing the tires while riding the bike

This tourist from Thailand stopped me to ask for help with his DSLR camera.

The simplest things can turn into an impossible task.  One of the (many) issues with breast cancer here is that many patients are diagnosed at an advanced stage and would benefit from receiving chemotherapy before surgery.  To give the proper agent you need a good core biopsy that can be tested for tumor markers (estrogen receptor, HER-2, etc).  Currently, diagnosis is always make with fine needle aspirate (FNAC), scraping off just a few cells with a small needle, directed by palpation by the pathologist.  Unfortunately, this is generally not adequate for special stains and so the patient goes straight to mastectomy in virtually every case.  Core biopsies are used for diagnosis in over 98% of cases in our hospital in Salem, and in the case of a palpable mass I can accomplish this in aobut 10 minutes in my office and have the answer in 24-48 hours.

At about 10:30 this morning I saw a 27 year old woman with a 5 cm mass in her breast which had appeared over 8 months.  The FNAC was read as "favors malignancy."  I wouldn't want to do a mastectomy with a lack of definitive diagnosis, not even in this low-resource environment.  So, I recommended core biopsy.  Is there a core biopsy device in the hospital?  Where is it stored?  Where can I do the procedure and who will help?  The patient had an entourage of mother, brother, friend, concerned friend of brother, who all trailed down to pathology to wait.  The procedure room was full. Other patients kept arriving for FNAC of cervical nodes, thyroid, etc.  Finally, about 1:00 pm we had the room.  Patient gets on table; my short list of supplies has not arrived (lidocaine and a scalpel blade.)  Patient gets off table another gets on.  A runner is sent to a different building for the supplies (requested over 2 hours ago.)  I finally prep the patient, only to find the core device is a tiny, flimsy 20 guage needle meant for prostate.  It will not enter the rock hard mass.  By 2:00 pm the patient is back in clinic getting scheduled for an open biopsy in the operating room later this week.

And so it goes.  Can I convince the surgical oncolgist to order the appropriate device?  Will it be used when it arrives, or is it easier to just keep doing things the same way?  In the case of overwhelming workload and high acuity of illnes where is there time to step back and come up with a better plan?

Washing clothes and getting clean.

The one thing this experience really has going for it is the ready-made community of other Health Volunteers Overseas staff.  In fact, the hospital is full of a little United Nations of volunteers:  A pathologist and an ENT surgeon from Cuba, hematologist from Australia, pediatrician from Germany, and at least a dozen from the United States in various specialties.  Some, like me are staying only a month; others have brought their families and are here for one or two years.  They range in age from last year of residency to post-retirement.  Information flows readily:  where to change money and use internet; how to set up lectures for the residents; where to find bathrooms with sinks and TP in the hospital; where to eat out and buy fresh fruit.  All of us seem to share the same mixture of frustration and guarded optimism.

This weekend four of us took an overnight trip to Punakha, the next major town to the east, over 10,000 foot Dochu La pass on the National Highway, a ragged, potholed, sometimes paved marvel of engineering that twists and turns and switchbacks throught impossibly vertical terrain.  Imagine taking this ride (3 hours from the town closest to Thimphu) in the back of a lurching ambulance at 15 mph with broken bones or an acute abdomen!

Tea time at the Nolanda Monastery, where visitors provide the useful service of letting the older monks practice their English.  They have internet service, where they can update their Facebook pages and watch foreign movies.  These three aspire to a lifetime of studying Bhuddism, although they would like to travel to England or Australia.

 We visited monasteries and temples and the fantastic Dzong (fortress), and slept like logs in lovely soft beds.  We got a little better understanding of the importance of Bhuddism in everyday life here, and the quantity of resources that are devoted to it.  Many boys and girls start in the monastery or nunnery at the age of eight, and then at 18 chose to stay or join secular life.  Meanwhile, they are supported almost entirely  by donations and as part of the government structure.  The fantastically elaborate temples and religious buildings are continually updated and repaired.  Every monk has a cell phone though--provided by their family to stay in touch, or earned by money given for performing special rituals and blessings.

Who am I to decide the relative value of all of that versus a readily available 14 guage core biopsy needle?

Ghos and Kiras dry in the sunny fields of chilis.