Day One

Duly licensed to practce medicine and surgery in Bhutan.

It's hard to sleep with sun pouring in the window at 5:30 am.  The guesthouse cafe doesn't open until 7:30, so I made do with a breakfast of instant coffee, muesli, OJ and a soft boiled egg (cooked in my hot water pot).  I took a long stroll uphill in the warm early sun, passing streams of school kids in matching kiras and ghos, their school uniforms, passing the time until my meeting time with Dr. Tashi at the hospital.



At 8:45 a short walk brought me to the giant, sprawling National Referal Hospital. The front lobby was a seething mass of patients and families queueing up or waiting in row upon row of metal chairs.  following hte signs, I made my way to the Oncology Unit where I was greeted warmly by the head nurse, Reeta.  While we waited for Dr. Tashi t show up, I got a quick tour of the chemo unit--8 beds side by side in large open room, bare green plastic mattresses gleaming.  The last bed was occupied by an elderly woman with pancreatic cancer and a DVT; she is here only for morphine, and prefers to be here in the unit with a family member at her side rather than try to go home.

H&P and admit orders.

As we waited in the consultation room, patients started showing up with rumpled piles of records in their hands and sat in te plastic chair in front of me, the one in the white coat.  With Reeta translating I waded in--a 68 year old woman partly through chemo therapy for advanced rectal cancer, with bleeding, pain, fatigue; a 40 year man one year out from resection of gastric cancer, needing more pain meds for his retroperitoneal recurrence; 30 year old man with groin pain after surgery a year ago from testicular cancer.  Dr. Tashi showed up, we chatted, and he continued with me observing.  18 year old with neuroendocrine tumor of the pancreas, underwent Whipple 2 years ago in India, now with massive liver mets; 32 year old doing well 3 years after mastectomy for breast cancer; a man with asymptomatic liver hemangioma referred from the medical clinic.  The exams consist of having the patients open their clothing briefly to expose the approprite part; there doesn't seem to be an exam table or private area available.

Out paitent medical record, brought in by the patient.

Next, we did rounds on the surgical unit with the two other surgeons, both named Dr. Sonam.  Reminded me of "Chief's Rounds" in residency--all orders are given verbally to the trailing nurse, no notes are written,  Each ward has 8 beds, mixed with men and women.  It is a grim collection:  obstructed gastric cancer, transected common bile duct from a lap chole at the army hospital; transected duodenum from traffic accident, with multiple drains tht look suspiciously bilious; deeply jaundiced elderly man with common duct stones (we discuss whether to operate today, as ERCP is not available; it seems that a decision is not reached); a young woman recovering from resection of hydatid liver cysts; and one lucky fellow cured of his ruptured appendix.

Down in endoscopy, a thin young man lies quietly, wide awake, as a gastroscope slides down.  No monitors, no sedation, not even topical anesthesia.  Within minutes the next patient lies quietly waiting her turn.  Were apron, gloves and scope changed?  Not sure--I had my back turned for a moment.


As quickly as the day started it's over; the clinic closes before 3:00 pm and I'm out in the bright sunshine, starving, wondering what to do next.  My little throw-away Nokia rings.  Dr. Sonam is admitting a patient for appendicitis; I might as well check it out and see what happens in the operating room.