I start my workdays at 8 am on Tuesdays and Fridays, when I give lectures to the four orthopedic techs. They are quite shy, and overly polite, and speak in very soft voices. We meet in a small room with a single desk. I sit on one side, and they gather around the other side. This month we are tackling anatomy and physical exam - this means actually examining each other's shoulders and knees - which they found challenging at first because of cultural norms! But we are getting through it.
Rounds start at 9, beginning in the female ward, followed by the aseptic ward (i.e. non-infected cases - as these are in the minority, they get their own ward room), and on to the male ward. On earlier trips to Bhutan, I have been the only orthopedist available in the country. But now, our program has grown to the point that we have two trained Bhutanese orthopedic surgeons in Thimphu. This means that I don't need to be a workhorse all the time, but can play the role of consultant and even student, as there are certain types of cases that they have far more experience with than I. In addition to the orthopedic surgeons joining us on rounds are two male orthopedic PAs (physician assistants), who have been trained by the HVO volunteers over the past number of years, the four orthopedic techs, and several physical therapists as well as the ward sisters and brothers (ie nurses and health assistants).
A typical ward room holds between twenty and thirty patients in an open room with no barriers between the beds. Privacy is out. Flies and unusual odors are in. The beds are very old, just slightly better than an army cot, with a very thin mattress. Oftentimes family members of the patient will sleep in the same bed or on the floor nearby. Patients tend to be admitted for lengthy periods of time, since once they go home to the villages they do not tend to return for follow-up.
Health care is entirely free in Bhutan, and as far as I can tell, runs almost entirely on donated supplies and money from the government of India, WHO, Save the Children, UNICEF, and groups from Denmark and Norway. Supplies are very limited and equipment is minimal, but is certainly improving at a steady pace. We have three or four antibiotics to choose from. Surgical patients generally do not receive any pain medicines. It is the norm and patients just accept that surgery hurts.
Rounds take about an hour, and then we head to the Ortho OPD (OutPatient Department) in chamber 16, where dozens of patients are lined up to be seen. We see between 60 and 100 patients a day, generally between the hours of 10 and 2:30. Surprisingly, this seems like a relatively relaxed pace - with no insurance, no pre-approvals, and minimal paperwork and charting. There are also no appointments and people expect to wait the full day. People show up to the hospital to a triage desk downstairs, where they are directed to various chambers. This triage process is imperfect; for example, today I saw a patient with abdominal pain (but also back pain) who probably had a bleeding ulcer, another patient with a kidney infection, and one with a breast mass.
About half the patients speak enough English so that we can communicate directly. For the rest I use an orthopedic tech or PA as a translator. We never know what's going to walk in the door. Today, we had a patient arrive with a traumatic dislocation of his hip that happened over a month ago. Apparently he had X-rays at a district hospital where they visualized all of the leg except for his hip. We will operate on him on Monday. In addition to fractures and postoperative patients, we see a number of burn-related injuries and contractures, as well as numerous cases of osteomyelitis (ie. bone infections), septic arthritis (joint infections), and congenital anomalies (birth defects). We also see ordinary cases of low back pain, tendonitis, and sprains. One of the consequences of free health care is that people in Thimphu are very willing to access it.
On occasion, one or more of us will be pulled out of the OPD by the hospital superintendent to see a VIP patient. Last week, two of us went to wait (!) by the casualty (ER) door for the king's aunt, who we were told was arriving from the Indian border town of Phuntshoeling. We waited for 45 minutes before she arrived, and she only had a minor knee sprain - I was pretty annoyed by this waste of resources while all our other patients waited upstairs, but it was interesting to meet her and her entourage. Briefly, she is half-Russian, half-Scot, but grew up in India, where she met and married the queen mum's brother. Apparently there was a suspected plot to overthrow the king in the 1960s (this would be the present king's father), and this lady and her family were exiled to Nepal for many years.
The Buddhist workday is great! We oftentimes finish around 3pm, which leaves me plenty of time to walk up the hill, take a nap, read, and go for a run prior to dinner.
