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.