Operating with one hand tied behind your back: A day in the OT with Dr. Sonam

Dr. Sonam plays candy crush while waiting for turnover.

The Bhutanese medical lingo is infused with a special flavor of British English, filtered through the Indian education of most of the doctors.  So there is no OR, but rather the OT:  Operating Theatre.  I am addressed formally as "Madaam"  (rhymes with aplomb), and the male doctors are "Suh".  More informally the support staff refer to each other as "sista' and brotha'".

Our first patient had been admitted the night before, as usual for gallbladder surgery, but on applying the monitors in the OT she was found to be severely hypoxic and hypertensive.  Our advertised 9:00 start drifted toward 10:00 as the next patient was fetched and prepared.  I felt like a brand new intern trying to "assist" Dr. Sonam:  first, a scrub with a bar of strong smelling soap, then finding right side up on a heavy, wrinkled cotton gown, which had to exchanged due to a large hole in the sleeve.  Double gloves, but no closed gloving technique.  Dr. Sonam preps with a cottan swab dipped in a metal bowl of iodine.  Drapes are heavy multilayer green cotton, arranged and folded just so, and held with towel clips.  All the laparoscopic equipment is reusable, or at least re-used:  unguarded metal trocars with little caps that flip up and down for 5mm and 10mm instruments; others are yellowed plastic, the irrigation is hung in a plactic bottle and squeezed by the anesthesiologist for more pressure.  Once started, Dr. Sonam works slowly and carefully, stopping to dip the tip of the scope in a thermos of water (hot or cold?) to clear the lens.  I crane my neck to see the one monitor, which suddenly looses color and goes to black and green with flickering red lines.  Dr. Sonam sighs, and the anesthesiologist jiggles the power cable until color returns.  Nevertheless, a gallbladder is safely removed.

Next up:  two patients for cystoscopy and removal of ureteral stents.  No IV or monitors; the anesthesia is "local and vocal":  lidocaine jelly and gentle reassurrance.  As the scope clears the prostate and enters the bladder I see brown toes curl tight, but there is no sound.  The stent is pulled clear, demonstrated to the patient over the drape, and tossed aside.  Next, a petite young woman walks in and hops on the bed and the process is repeated.  Feet in to feet out is not more than 6 minutes.

We nearly suffer a "cancellectomy" as electrolytes are re-checked and high risk consent signed for an elderly, emaciated man with obstructing gastric cancer.  While we are delayed, we retire to the staff lounge and Dr. Sonam treats me to hot milk tea and a bowl of microwaved dry noodles.  As more staff arrive for lunch small dishes from home are shared around the table and soon my Ramen is doctored up with leafy greens, sausage and chili.  My fingers are crossed, hoping for no inter-cultural exchange of microbes.

Back in the OT at last, our patient is no sooner asleep and prepped than the incision is made without any preamble or interruption of the multiple conversations taking place among the 10 or so people in the room.  Again Dr. Sonam proceeds with not much more to work with than a knife, a fork and a spoon (okay, no fork or spoon, but only two varieties of retractor and some vicryl).  In just a short time he has a nice gastro-jejunostomy and we are done for the day, exactly 2 minues before the usual quitting time of 3:00 pm. 

I'm sure this is roughly how surgery is done over much of the world.  At least Bhutan has the benefit of well trained, compassionate doctors, willing to do their best with one hand tied behind their backs.  Will I soon be giving it a whirl?

Street shoes stay outside, just like in the temples.

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.

Bhutan 101

I had planned to write up a very brief overview of Bhutan to save you all the trouble of burrowing around on Wikipedia and Lonely Planet, but first a word about yesterday's devastating earthquake in Nepal.  The destruction is hard to comprehend, especially in a country when infrastructure is severely lacking even in the best of times.  Recovery will be long and very difficult, and hopefully the world will jump in immediately to help.  I don't expect a direct effect on my trip to Bhutan, as I am entering via Bangkok, and the quake was only felt as a level 4 in Thimphu, 250 miles from Kathmandu.  However, many tourists arrive in Bhutan via Kathmandu so airport closures and delays may have a ripple effect on the region.

Although there are many similarities in geography and culture between Nepal and Bhutan, there are also important differences.  Population density in Bhutan is 19 people per square km; in Nepal it is 208.  Bhutan received 115,000 foreign visitors in 2013, and Nepal 800,000.  Summiting peaks (anything over about 18,000 feet) is strictly forbidden in Bhutan, and all tourists must travel with government approved guides, obviously a huge difference from free market tourism Nepal.  This was a major issue in the massive storms last year that left hundreds of trekkers stranded in Nepal, often with very little central information about where people might be.  In addition, Nepal has seen considerable political strife over the years, while Bhutan has a stable and benign government and has seen great strides in heath care in the last two decades.

Bhutan was essentially closed to outsiders before the 1970's.  It has never been conquered (not that the Tibetans didn't try), never been Christianized, and still does not allow foreign missionaries and accepts only a very few NGOs.  Only a few thousand tourists a year visited  in the early 1990's, but tourism is now seen as a major economic force and numbers have more than doubled in the last 5 years.  TV and internet arrived in 1999 and 2000; cell phone towers now dot the rural mountains and valleys far from any motorable roads, erected by hand and pony labor and powered by solar panels. 

The population of Bhutan is 754,000 in a land area 1/6 the size of Oregon.  The roads you see on the map above are literally the only ones that exist on which you can drive a wheeled vehicle and most are barely a single lane wide and suffer frequent landslides and bridge washouts; 70% of the population lives in rural areas on subsistence agriculture, often several days' walk from the nearest road.  The topography is so steep that the international airport in Paro had to get special permission to build a shorter than normal runway because there is no more available flat land!

Quick heath factoids:  ( comparable numbers for the United States are in parentheses.)
Life expectancy at birth M/F:  68/69  (76/81)
Per capita health care spending $253 ($8895)
Population > 60 years old:  7% (20%)
Maternal mortality per 100k births:  120  (28)
Deaths by age 5 per 1000 live births:  36 (7)
DPT and measles vaccination rates at age 1:  96%, 94%  (94%, 91%)
Daily tobacco smokers:  3.3% (18%)
Obesity M/F:  4.7/6.6%  (30/33%)
Hypertension and diabetes:  28%, 12%  (17%, 10%)
Leading cause of death: Heart disease, lung disease, stroke  ( heart disease, dementia, lung cancer)
Average number patients per doctor (2007):  USA 390; Haiti 4000; Bhutan 20,000; Liberia 33,000.

Want more?  http://www.who.int/gho/countries/btn.pdf?ua=1,  http://www.who.int/gho/countries/usa.pdf?ua=1, http://bigthink.com/strange-maps/185-the-patients-per-doctor-map-of-the-world 

In eight weeks, on the day after my 56th birthday and the day before my practice partnership closes for ever, I will hop on an airplane and start the long journey literally halfway around the world for my long-awaited volunteer stint in Surgical Oncology at the Jigme Dorji Wangchuck National Referral Hospital in Thimpu, Bhutan. When I return I will jump into a new practice and re-start the rest of my career.

 The seeds for this journey were planted in 2008 when my Dad and I traveled to Bhutan for a cultural tour with REI.  I literally fell in love with the beautiful Himalayan Kingdom and its warm and gentle people.  But even with stars in my eyes I could see that this was a country with many needs, and also many advantages compared to other "low resource" countries:  Minimal infrastructure for transportation, communication, sanitation, health care and education, yet a stable and benign government, mostly unspoiled natural beauty and resources, strong cultural values, and a commitment to the future guided by the principle of "Gross National Happiness."  More about Happiness later...

I had a very strong desire to come back to Bhutan to contribute in some way, hopefully in medical care since that is pretty much my primary skill.  But at that time there were very few NGO's operating, and none that I could find that could use the skills of a General Surgeon.  After a flurry of emails, letters and web searches I had to put my desire on hold.

In 2013 I returned to Bhutan with my husband, Jeff, for a much-anticipated high altitude experience: The Chomolhari Trek.  We were able to get way off the beaten path, not that any path in Bhutan is all that beaten, and travel above the snow line and far into the countryside.   I was also able to arrange a half-day visit to the Referral Hospital in Thimpu, where the country's lone surgical oncologist took me for a tour and started my education about the challenges of treating surgical disease and cancer in a country with very few roads, only one full service hospital, no radiation facilities and not a single mammogram machine; also precious few doctors and no medical school.

About this time the organization Health Volunteers Overseas, who had been working in Bhutan since the 1990's in areas such as orthopedics, pediatrics, nurse anesthesia, internal medicine and mental health, started up an Oncology program and I saw my opportunity.  I applied and was accepted as the first operating surgeon to volunteer, joining a steady parade of Medical Oncologists and Palliative Care specialists.   My exact duties are not all that clear, and it may be in large part up to me to pitch in where I can:  giving classes or lectures in the brand new residency program, wielding a scalpel, working on public education campaigns, seeing clinic patients, and who knows what else.  Mostly I will be learning and observing and submerging myself in a totally new experience.

Stay tuned, as I really have no idea how this will all turn out!