Orthopedic rounds
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Friday, July 15, 2005
This child I saw in clinic is wearing several silk amulet threads to ward off evil spirits.
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Ortho OPD
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.
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.
Thursday, July 14, 2005
What to Wear in Bhutan: Men
The gho is an ancient Bhutanese garment worn by men and boys. As in some cultures (Scotland, Fiji, others?) the men's garment is a tailored-looking skirt below the waist - which soon looks totally second nature to us. They are very comfortable, warm in winter, and stylish. Don wears gho about half the time to work, and the kids will wear a uniform gho in school. By royal decree, all citizens wear gho and kira when in public and to their places of employment, but they don't always wear them when at home, or running errands; this time around I have seen many more Bhutanese men in western clothing out on the street, and there are many shops selling jeans and T-shirts. Or, to be casual, a man might pull his arms out of the sleeves and tie them around his waist. Nevertheless, for men the gho is as correct a clothing as trousers/dress shirt/tie or a business suit. It is a long robe, with complicated seams, and putting it on is at least a two-person job - and I'm so lousy at helping Don that usually one of the Gadho's household helpers who has a free minute comes over and assists. Underneath it you would wear a T-shirt or short-sleeved shirt and shorts. Then you have either long white cuffs pinned to the inside of the sleeve, or a loose white shirt that is basically just a connected pair of sleeves. To put on the gho, tuck the right front panel into the left, line up the hems, and hold it at the sides. Then fold the extra fabric towards the back, and hoist up the front until it hangs straight at the knee. Fasten the waist with a tightly tucked long woven belt with fringe (the kera), and make sure in the back that the sides are neatly tucked so that they hang vertically. Turn back the sleeves so a nice crisp deep white cuff is showing. The top part of the gho, as it blouses over the kera, makes a pouch/pocket. Finish off with dark or argyle knee socks and dark dress shoes.
If you are going to an official place, like court, or the Parliament, or to a temple, then you need one additional item: a raw silk or linen scarf called a kabney, with very long fringe. This is draped over the shoulders and tied on the left shoulder.
If you are going to an official place, like court, or the Parliament, or to a temple, then you need one additional item: a raw silk or linen scarf called a kabney, with very long fringe. This is draped over the shoulders and tied on the left shoulder.
The RIHS graduates in their formal best. Men: gho and kabney, Women: kira, wonju, tego, and rachu.
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What to Wear in Bhutan: Women
What not to wear is easy: no shorts, nothing tight or revealing, and nothing above the ankles if you're over the age of 6. For women, the kira is the traditional dress. It is simply a long rectangle of cloth, usually with horizontal woven patterns, fastened on the shoulders with clasps or pins, and arranged so that there is a deep pleat vertically all the way down the front. Under it is a long-sleeved blouse called the wonju, and the kira is fastened at the waist with a belt similar to the men's but wider and with more embroidery. When correctly worn, one selvedge of the kira will be on the right leg, almost meeting the edge of the pleat. It is such a wide piece of cloth, folded in such a way that there is no possibility of any leg showing even in a stiff wind, and it's quite comfortable to stride in. Over the kira is a boxy silk, linen or brocade jacket called the tego, and the sleeves of the wonju are turned back over the tego to show a deep contrasting cuff. The kira should be worn so that it brushes the ground - shoes are barely visible. Most women wear dress shoes, heeled sandals, etc.
The "new" fashion in kira which is becoming more acceptable is the half-kira, which as its name suggests is just from waist to floor. This is typically worn with a nice tego, even in floral or other bright pattern, and fastened closed with a little brooch or pin.
For formal occasions, the kira are often hand-woven and quite elaborate. One's best tego and wonju will be of beautiful patterned silk, and in place of the men's white kabney is a narrow, tightly woven strip of red cloth called a rachu, usually with gorgeous yellow embroidery.
Women with infants tie them on their backs with a wider rachu that crosses over in front and is knotted with long fringe - I see children up to about age 2 being carried this way. A stroller, of course, would be quite useless here.
The "new" fashion in kira which is becoming more acceptable is the half-kira, which as its name suggests is just from waist to floor. This is typically worn with a nice tego, even in floral or other bright pattern, and fastened closed with a little brooch or pin.
For formal occasions, the kira are often hand-woven and quite elaborate. One's best tego and wonju will be of beautiful patterned silk, and in place of the men's white kabney is a narrow, tightly woven strip of red cloth called a rachu, usually with gorgeous yellow embroidery.
Women with infants tie them on their backs with a wider rachu that crosses over in front and is knotted with long fringe - I see children up to about age 2 being carried this way. A stroller, of course, would be quite useless here.
Wednesday, July 13, 2005
Memorial Chorten, the major Thimphu landmark between HVO Guest House and the town proper.
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Library Card: Anatomy of an Errand
Forrest and I set off from the house at mid-day, with rain threatening. There is a white fog drifting down from the sky visible at the far edge of Thimphu and the lightest drizzle in the air, so we take raincoats. The errand is simple enough: place an order with a tailor for curtains to be installed in our home in America; buy the fabric for said curtains at one of the many local fabric shops and deliver it to the tailor; purchase Forrest a stylish metal pencil-box at a stationary shop I have seen, and finally check out of the public library the second of the Tolkein trilogy which we brought with us and misplaced, so that the boys can continue their reading in sequence. We leave Thompson in charge (nominally) but the housekeeper is also home, and Jamtsho and his two older sisters and an assortment of adults at the Gadho's home, so Halle and Jacob will be kept busy, fed and looked after while Forrest and I walk down into town.
We stroll "the short way" across the weedy field, down the road to Chorten Lam, and down Chorten Lam to the center of town. We have been told there is a tailor shop in the building next to the fabric store. No sign. We go upstairs and ask at a sewing room for tankhas - a man is precisely pressing and seaming the gorgeous brocade around a painted image, but our Dzongkha and his English are equal in their lack, and we do not find a tailor shop there. Asking at several more fabric shops we finally are pointed across the street (Oh! Across the street!), where tucked under a dingy restaurant we find several men at work at the black Singer sewing machines like something out of the 19th century. None of them speak any English, and finally someone is fetched whose English is nearly as limited but who admits to being the tailor. He has tied the sleeves of his gho down around his waist and is wearing a checked short-sleeved shirt and a camouflage vest; his mouth and teeth are a gory russet from doma. Curtains, curtains, I finally make him understand what I am after (it is confusing because I am asking them to sew what here would be used to cover doorways, not windows), and he annotates my drawing with measurements and explanations in Dzongkha, and then he comes with me to the fabric shop back across the street.
There I become a mere appendage to a detailed transaction between himself and the fabric store clerk, a short, thin woman with a faint black mustache. They discuss, bring out the calculator, discuss some more. Don and I had set aside a bolt of fabric days earlier and it is pulled out; coordinating fabric for the panels and "flowers" at the intersections of the panels is selected and they negotiate how much is needed and she flourishes gigantic, fiercely sharp brass scissors to cut the pieces with a staccato zzzp. He and I arrange for the curtains to be picked up on Monday; I receive his price without bargaining (250 Nu per curtain, plus cost of the fabric? Very reasonable, it seems), and then he is off, across the street, with a large bundle of fabric, to make my odd request into a textile reality.
Now I need to pay the fabric shop for what has been carried out by the tailor. They add it up twice, take off some for a volume discount, and come up with a figure that exceeds what I have in cash in my purse. Luckily I have anticipated this and brought three travelers checks to cash at the nearby bank. They will wait for me to cash them and come back, so Forrest and I head to the Foreign Exchange counter at the Bhutan National Bank. I don't understand how this bank works, because every time I go the waiting area is absolutely full of people sitting in bus-station seats, but the foreign exchange counter never has a line. Unfortunately, I realize at the counter that I have grabbed three travelers checks signed by Don, not by myself. Forrest and I roll our eyes at my mistake. There is nothing to do but go back home, get the correct ones, come back, change them, and then pay the fabric store. We walk up to the store to assure them we are still planning to pay, and then hire a taxi to take us home, wait for us while I go inside (where we drop our heavy raincoats, thinking we are done with the rain), and drive us to the bank (ka-ching, 60 Nu), where it is... raining. I change the checks, run to the store, settle my bill there, and then Forrest and I embark on the other parts of the errand, keeping to the edge of the sidewalk under the eaves of the stores to stay somewhat dry.
The sidewalks of Nordzin Lam, Thimphu's main street, gradually run uphill from the lower traffic circle. Due to the change in grade, and to the non-standardization of buildings, there is hardly a stretch of sidewalk a block long that is not interrupted by steps up or down, ramps, open sewer, torn-up/being repaired sections, jutting corners, strange metal rods sticking up for no apparent reason. The sidewalks are flagstone with the spaces between them (sometimes) sealed with cement, and littered with doma splats, crushed bottles, crumpled paper, wrappers, wilted produce, and dogs. The rain does little to wash them clean.
We walk uphill, frequently having to leave the sidewalk and walk in the street, until we reach the stationary shop. Forrest selects a suitable pencil box, and then we go to the King Jigme Dorji Wangchuk National Public Library. It is one reading room in front, a fiction/childrens room with a separate "women's section" entirely for romance novels from India, and two tiny alcoves for the nonfiction and the reference. The books are as shabby and outdated as can be imagined. I fantasize about sending a box of brand-new books as a gift to the library... I wonder if it would arrive or be ripped open in some foreign airport customs office and distributed among the staff. Our entire family passed a quiet hour at the library a few days ago, reading as a break on our walk down from the other end of Nordzin Lam, so we know that the Tolkien is on the shelf. But in order to check it out we must join the library, and we are sent to the membership desk. I purchase a year's membership (oh well) at 550 Nu (this is too steep for most people, I wonder?). For this price I could surely purchase the book, which for all I know is available in "BookWorld" near the clock tower, but it's probably better to support the struggling library enterprise by buying a membership. This entails a form I must fill out, a fancy blue membership record receipt written from a carbon-paper book (all receipt here are done in duplicate books with actual carbon paper in them, which I find fascinating), a separate pink money-received receipt from a separate carbon-paper pad, an entry in a bound logbook carefully recording my name and the amount I have paid, recording all this information in yet another book, and then filling out two card pockets which are what is used to check out the books themselves... we select our books, bring them and the card-pockets up to the desk where the books are stamped with due date and their cards properly filed in my card-pockets, which are then filed in wooden fileboxes. Forrest is impressed with all this detail and with so many things to keep track for the diligent membership clerk.
After all this effort, we are exhausted, and refuel with ginger biscuits, mango juice, and a bottle of Thai-labeled Gatorade; a taxi takes us home (ka-ching, another 30 Nu).
We stroll "the short way" across the weedy field, down the road to Chorten Lam, and down Chorten Lam to the center of town. We have been told there is a tailor shop in the building next to the fabric store. No sign. We go upstairs and ask at a sewing room for tankhas - a man is precisely pressing and seaming the gorgeous brocade around a painted image, but our Dzongkha and his English are equal in their lack, and we do not find a tailor shop there. Asking at several more fabric shops we finally are pointed across the street (Oh! Across the street!), where tucked under a dingy restaurant we find several men at work at the black Singer sewing machines like something out of the 19th century. None of them speak any English, and finally someone is fetched whose English is nearly as limited but who admits to being the tailor. He has tied the sleeves of his gho down around his waist and is wearing a checked short-sleeved shirt and a camouflage vest; his mouth and teeth are a gory russet from doma. Curtains, curtains, I finally make him understand what I am after (it is confusing because I am asking them to sew what here would be used to cover doorways, not windows), and he annotates my drawing with measurements and explanations in Dzongkha, and then he comes with me to the fabric shop back across the street.
There I become a mere appendage to a detailed transaction between himself and the fabric store clerk, a short, thin woman with a faint black mustache. They discuss, bring out the calculator, discuss some more. Don and I had set aside a bolt of fabric days earlier and it is pulled out; coordinating fabric for the panels and "flowers" at the intersections of the panels is selected and they negotiate how much is needed and she flourishes gigantic, fiercely sharp brass scissors to cut the pieces with a staccato zzzp. He and I arrange for the curtains to be picked up on Monday; I receive his price without bargaining (250 Nu per curtain, plus cost of the fabric? Very reasonable, it seems), and then he is off, across the street, with a large bundle of fabric, to make my odd request into a textile reality.
Now I need to pay the fabric shop for what has been carried out by the tailor. They add it up twice, take off some for a volume discount, and come up with a figure that exceeds what I have in cash in my purse. Luckily I have anticipated this and brought three travelers checks to cash at the nearby bank. They will wait for me to cash them and come back, so Forrest and I head to the Foreign Exchange counter at the Bhutan National Bank. I don't understand how this bank works, because every time I go the waiting area is absolutely full of people sitting in bus-station seats, but the foreign exchange counter never has a line. Unfortunately, I realize at the counter that I have grabbed three travelers checks signed by Don, not by myself. Forrest and I roll our eyes at my mistake. There is nothing to do but go back home, get the correct ones, come back, change them, and then pay the fabric store. We walk up to the store to assure them we are still planning to pay, and then hire a taxi to take us home, wait for us while I go inside (where we drop our heavy raincoats, thinking we are done with the rain), and drive us to the bank (ka-ching, 60 Nu), where it is... raining. I change the checks, run to the store, settle my bill there, and then Forrest and I embark on the other parts of the errand, keeping to the edge of the sidewalk under the eaves of the stores to stay somewhat dry.
The sidewalks of Nordzin Lam, Thimphu's main street, gradually run uphill from the lower traffic circle. Due to the change in grade, and to the non-standardization of buildings, there is hardly a stretch of sidewalk a block long that is not interrupted by steps up or down, ramps, open sewer, torn-up/being repaired sections, jutting corners, strange metal rods sticking up for no apparent reason. The sidewalks are flagstone with the spaces between them (sometimes) sealed with cement, and littered with doma splats, crushed bottles, crumpled paper, wrappers, wilted produce, and dogs. The rain does little to wash them clean.
We walk uphill, frequently having to leave the sidewalk and walk in the street, until we reach the stationary shop. Forrest selects a suitable pencil box, and then we go to the King Jigme Dorji Wangchuk National Public Library. It is one reading room in front, a fiction/childrens room with a separate "women's section" entirely for romance novels from India, and two tiny alcoves for the nonfiction and the reference. The books are as shabby and outdated as can be imagined. I fantasize about sending a box of brand-new books as a gift to the library... I wonder if it would arrive or be ripped open in some foreign airport customs office and distributed among the staff. Our entire family passed a quiet hour at the library a few days ago, reading as a break on our walk down from the other end of Nordzin Lam, so we know that the Tolkien is on the shelf. But in order to check it out we must join the library, and we are sent to the membership desk. I purchase a year's membership (oh well) at 550 Nu (this is too steep for most people, I wonder?). For this price I could surely purchase the book, which for all I know is available in "BookWorld" near the clock tower, but it's probably better to support the struggling library enterprise by buying a membership. This entails a form I must fill out, a fancy blue membership record receipt written from a carbon-paper book (all receipt here are done in duplicate books with actual carbon paper in them, which I find fascinating), a separate pink money-received receipt from a separate carbon-paper pad, an entry in a bound logbook carefully recording my name and the amount I have paid, recording all this information in yet another book, and then filling out two card pockets which are what is used to check out the books themselves... we select our books, bring them and the card-pockets up to the desk where the books are stamped with due date and their cards properly filed in my card-pockets, which are then filed in wooden fileboxes. Forrest is impressed with all this detail and with so many things to keep track for the diligent membership clerk.
After all this effort, we are exhausted, and refuel with ginger biscuits, mango juice, and a bottle of Thai-labeled Gatorade; a taxi takes us home (ka-ching, another 30 Nu).
Monday, July 11, 2005
Hangen family with 3 of the 4 ortho techs from left to right, Karma, Sonam Choden, Sonam Jamtsho
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Tonight's Top Ten List
Actual ways to get injured in Bhutan and be seen by the American doctor
10. Backache from carrying heavy loads. Bhutanese are very prone to backaches and this tends to clog up our clinic when we have more important things to see. We do have a number of paraplegics and quadraplegics from spine injuries who stay in the orthopedic ward for a very long time, because there is no place for them to go in their villages.
9. Hit by taxi. Not surprising given the quality of the local driving.
8. Hit by arrow during archery tournament. Targets are 140 meters from the shooting line, and spectators line the entire path of the arrow, leaving only a 10-meter wide corridor. Straight shooting is rewarded with songs. Even a slight error can mean disaster, but this actually does happen to people in the crowd.
7. Gored by ox. Ox and cows frequent the roads and paths, many have long horns. Most are friendly and slow-moving, but...you get the idea.
6. Fell off roof. I don't know why people here have a propensity to imbibe their alcohol while sitting on the roofs here, but it's not uncommon for us to see people after a fall from a roof, and we ask no further questions.
5. Hit by stone. A woman was admitted with a broken upper arm. I asked "what happened," and was told by Sister Wangchoezem, the head nurse, "Hit by stone." "How was she hit by a stone?" I asked. The reply: "A stone hit her arm, sir." "But," I persisted, "how did it happen that the stone hit her arm?" "Oh, she was hit by a stone." I gave up and put a metal rod in her humerus without further clinical information.
4. Fell into open fire during epileptic seizure. I've had three patients so far this month with this scenario. Unfortunately one of them was a small baby who was tied to her mother's back at the time her mother had a seizure; the baby was badly burned on her hand. Today we released burn contractures and made it so she could open her wrist, use her thumb and index finger, and grafted some skin from her groin area to fill in the missing skin.
3. Suprachondylar elbow fracture. At home, I may see only a few of these per year, in children. In Bhutan, we see these every few days. This is a fracture of the end of the humerus bone right above the elbow joint. We manipulate them back into place, and under X-ray guidance pin them in place. On earlier trips to Bhutan we did not have X-ray to help us and probably didn't do a very good job. I don't know why they're so common here, but I have an idea that it may have something to do with both genetics and nutrition.
2. Dawa Transport bus accident. Riding the buses here is very risky. A few times a year, an entire busload of people will go over a cliff. Those who survive have multiple fractures, which creates a backlog of fractures to plate/rod/cast.
1. Fell into Indian toilet. This prize-winning injury happens when people slip while using a squatting floor toilet. Some of these have metal edges which are sharp, and the usual injury is a cut through the Achilles tendon. We see a couple of these a month, and I have seen them on every trip to Bhutan.
10. Backache from carrying heavy loads. Bhutanese are very prone to backaches and this tends to clog up our clinic when we have more important things to see. We do have a number of paraplegics and quadraplegics from spine injuries who stay in the orthopedic ward for a very long time, because there is no place for them to go in their villages.
9. Hit by taxi. Not surprising given the quality of the local driving.
8. Hit by arrow during archery tournament. Targets are 140 meters from the shooting line, and spectators line the entire path of the arrow, leaving only a 10-meter wide corridor. Straight shooting is rewarded with songs. Even a slight error can mean disaster, but this actually does happen to people in the crowd.
7. Gored by ox. Ox and cows frequent the roads and paths, many have long horns. Most are friendly and slow-moving, but...you get the idea.
6. Fell off roof. I don't know why people here have a propensity to imbibe their alcohol while sitting on the roofs here, but it's not uncommon for us to see people after a fall from a roof, and we ask no further questions.
5. Hit by stone. A woman was admitted with a broken upper arm. I asked "what happened," and was told by Sister Wangchoezem, the head nurse, "Hit by stone." "How was she hit by a stone?" I asked. The reply: "A stone hit her arm, sir." "But," I persisted, "how did it happen that the stone hit her arm?" "Oh, she was hit by a stone." I gave up and put a metal rod in her humerus without further clinical information.
4. Fell into open fire during epileptic seizure. I've had three patients so far this month with this scenario. Unfortunately one of them was a small baby who was tied to her mother's back at the time her mother had a seizure; the baby was badly burned on her hand. Today we released burn contractures and made it so she could open her wrist, use her thumb and index finger, and grafted some skin from her groin area to fill in the missing skin.
3. Suprachondylar elbow fracture. At home, I may see only a few of these per year, in children. In Bhutan, we see these every few days. This is a fracture of the end of the humerus bone right above the elbow joint. We manipulate them back into place, and under X-ray guidance pin them in place. On earlier trips to Bhutan we did not have X-ray to help us and probably didn't do a very good job. I don't know why they're so common here, but I have an idea that it may have something to do with both genetics and nutrition.
2. Dawa Transport bus accident. Riding the buses here is very risky. A few times a year, an entire busload of people will go over a cliff. Those who survive have multiple fractures, which creates a backlog of fractures to plate/rod/cast.
1. Fell into Indian toilet. This prize-winning injury happens when people slip while using a squatting floor toilet. Some of these have metal edges which are sharp, and the usual injury is a cut through the Achilles tendon. We see a couple of these a month, and I have seen them on every trip to Bhutan.
WEL * COME * NITE
Just above the hospital is Bhutan's nursing school, the Royal Institute of Health Sciences. Young people come to the RIHS either out of the equivalent of 10th or 12th grades, and go through a 2 or 3 year program to be trained as nurses, hospital techs, emergency medical workers, etc. Four RIHS students who are being trained as ortho techs work with Don and he gives them twice weekly lecture/instruction period prior to rounds in addition to training them on the job in clinic. Although the rest of the public school system just had mid-term exams and is resuming school next week, this is the month that new RIHS students arrive for the start of their program, and we have been invited to attend a talent show put on by the current students to welcome the incoming class.
This proves to be a fascinating glimpse into southeast Asian youth culture even beyond the borders of Bhutan. We arrive after the start of the program, and there are seats left for us on the front row, next to the American HVO physical therapist and her son. The stage of a large pink lecture hall has been decorated with colorful clothing, banners (the big one says Wel-Come Nite), cellophane-wrapped fluorescent lights, and blinking strings of Christmas-type lights. Two students have the responsibility to yank the two large black curtains closed and open between acts, and there is a decent set-up of microphones, speakers, and sound system for the different acts, with one male and one female MC to announce the show.
The first number is called "Dzongkha dance," and proves to be a group number with 6 women in beautiful traditional kira and bright silk blouses performing a type of Bhutanese folk dance called dzong dancing. It is quick-moving, with flowing arms, expressive, with a little shuffling kick-step on every beat, danced to a Bhutanese pop song. Their hands are mesmerizing to watch. The next one is a male solo, a student who sings a crooning song in Dzongkha to the accompaniment of an electric keyboard. He is wearing a gho with bright white cuffs, black knee socks and black dress shoes that are the style here for young people, with extra-long squared-off toes. We hear several solos like this during the evening, some with the keyboardist and some with an acoustic guitar accompaniment. I am interested to see what the next performance is, a "Nepali dance." It turns out to be a well-choreographed dance performance to a Nepali pop tune by a young man in black jeans and Western dress shirt. A "Hindi dance" has no saris in evidence, but two young girls in stylish jeans and T-shirts (no midriff in evidence, of course) taking a Hindi pop song and choreographing a Bollywood-style music video dance - distinguished from Bhutanese dancing by much more shoulder-shaking and some pointing at the audience.
Although the program is mostly Dzongkha dances (groups of women, or men, or in the big finale, 6 of each) and songs, there are enough of these well-received "Nepali" and "Hindi" numbers to suggest that television, films, the internet, and CD sales have blurred some of the cultural borders among young people. The MCs comment on how music is a universal language. After the show, we talk with other guests until someone points out that the remainder of the audience is waiting patiently in thieir seats for us to leave first. The knowledge of etiquette is assumed here and we learn often by trial and error.
The next day is an important day in the Buddhist calendar, the anniversary of the Buddha's first sermon, and one of the ortho techs named Sonam Jamtsho invites us into the RIHS campus to see the prayers being said, to view the inside of the small compound temple, and to eat lunch in the dining hall. While we sit and talk in the dining hall before lunch, 28 students with their ceremonial scarves around their necks sit in two long lines facing each other, on mats, and sing Buddha's sermon (in Dzongkha) with a bell to keep the beat, a tub of incense in the center sending up curving gray ribbons into the air. We see many of the students who performed in the show, and we have an opportunity to learn from Sonam more about the students and where they come from. Surprisingly, everyone I speak to is from eastern Bhutan (the less "civilized" and more rural side, but also the side with easier access to northern India). Western Bhutanese, Sonam explains, aim for higher education programs that will lead to "office jobs," while for eastern Bhutanese farm kids, the RIHS is a significant step up and a great honor. Although they have been taught Dzongkha (i.e. the dialect of western Bhutan) in school, along with English, they have all grown up speaking the eastern dialect called Sharchop, which is linguistically very different from Dzongka, and many of them also know Nepali and Hindi too. Buddhism and youth culture (especially pop music) are the common denominators among the RIHS students.
Lunch is served from a long marble counter onto which are set the huge aluminum pots of today's food. Sonam tells us that the fare is usually red rice, with some kind of accompaniment: Mondays and Thursdays egg, Wednesdays and Fridays meat, and Tuesdays and Saturdays emadatsi (chilis in a cheese sauce). But since today is a special day there is a broader selection: red rice, emadatsi, scrambled egg with chilis, hardboiled eggs rolled in spices, yellow dal soup with potatoes in it, and big baskets of papadam (the crispy Indian "pepper" tortilla that often comes as appetizer in Indian restaurants). No one, including ourselves, uses any silverware. We are asked to go through the line first, and then the rest of the 170 students line up with their own bowls and cups, get their food and go outside to eat it. Outside the door there are four sinks for students to wash up their plates so they can take them back to their dormitory rooms clean. Sonam tells us that one young man each month has responsibility to be "mess captain," and when his month is finished, he nominates a person he thinks will do a better job than himself. That self-deferential and dignified manner is so typical of the Bhutanese, regardless of where they come from, and is something I so enjoy about the people we meet.
This proves to be a fascinating glimpse into southeast Asian youth culture even beyond the borders of Bhutan. We arrive after the start of the program, and there are seats left for us on the front row, next to the American HVO physical therapist and her son. The stage of a large pink lecture hall has been decorated with colorful clothing, banners (the big one says Wel-Come Nite), cellophane-wrapped fluorescent lights, and blinking strings of Christmas-type lights. Two students have the responsibility to yank the two large black curtains closed and open between acts, and there is a decent set-up of microphones, speakers, and sound system for the different acts, with one male and one female MC to announce the show.
The first number is called "Dzongkha dance," and proves to be a group number with 6 women in beautiful traditional kira and bright silk blouses performing a type of Bhutanese folk dance called dzong dancing. It is quick-moving, with flowing arms, expressive, with a little shuffling kick-step on every beat, danced to a Bhutanese pop song. Their hands are mesmerizing to watch. The next one is a male solo, a student who sings a crooning song in Dzongkha to the accompaniment of an electric keyboard. He is wearing a gho with bright white cuffs, black knee socks and black dress shoes that are the style here for young people, with extra-long squared-off toes. We hear several solos like this during the evening, some with the keyboardist and some with an acoustic guitar accompaniment. I am interested to see what the next performance is, a "Nepali dance." It turns out to be a well-choreographed dance performance to a Nepali pop tune by a young man in black jeans and Western dress shirt. A "Hindi dance" has no saris in evidence, but two young girls in stylish jeans and T-shirts (no midriff in evidence, of course) taking a Hindi pop song and choreographing a Bollywood-style music video dance - distinguished from Bhutanese dancing by much more shoulder-shaking and some pointing at the audience.
Although the program is mostly Dzongkha dances (groups of women, or men, or in the big finale, 6 of each) and songs, there are enough of these well-received "Nepali" and "Hindi" numbers to suggest that television, films, the internet, and CD sales have blurred some of the cultural borders among young people. The MCs comment on how music is a universal language. After the show, we talk with other guests until someone points out that the remainder of the audience is waiting patiently in thieir seats for us to leave first. The knowledge of etiquette is assumed here and we learn often by trial and error.
The next day is an important day in the Buddhist calendar, the anniversary of the Buddha's first sermon, and one of the ortho techs named Sonam Jamtsho invites us into the RIHS campus to see the prayers being said, to view the inside of the small compound temple, and to eat lunch in the dining hall. While we sit and talk in the dining hall before lunch, 28 students with their ceremonial scarves around their necks sit in two long lines facing each other, on mats, and sing Buddha's sermon (in Dzongkha) with a bell to keep the beat, a tub of incense in the center sending up curving gray ribbons into the air. We see many of the students who performed in the show, and we have an opportunity to learn from Sonam more about the students and where they come from. Surprisingly, everyone I speak to is from eastern Bhutan (the less "civilized" and more rural side, but also the side with easier access to northern India). Western Bhutanese, Sonam explains, aim for higher education programs that will lead to "office jobs," while for eastern Bhutanese farm kids, the RIHS is a significant step up and a great honor. Although they have been taught Dzongkha (i.e. the dialect of western Bhutan) in school, along with English, they have all grown up speaking the eastern dialect called Sharchop, which is linguistically very different from Dzongka, and many of them also know Nepali and Hindi too. Buddhism and youth culture (especially pop music) are the common denominators among the RIHS students.
Lunch is served from a long marble counter onto which are set the huge aluminum pots of today's food. Sonam tells us that the fare is usually red rice, with some kind of accompaniment: Mondays and Thursdays egg, Wednesdays and Fridays meat, and Tuesdays and Saturdays emadatsi (chilis in a cheese sauce). But since today is a special day there is a broader selection: red rice, emadatsi, scrambled egg with chilis, hardboiled eggs rolled in spices, yellow dal soup with potatoes in it, and big baskets of papadam (the crispy Indian "pepper" tortilla that often comes as appetizer in Indian restaurants). No one, including ourselves, uses any silverware. We are asked to go through the line first, and then the rest of the 170 students line up with their own bowls and cups, get their food and go outside to eat it. Outside the door there are four sinks for students to wash up their plates so they can take them back to their dormitory rooms clean. Sonam tells us that one young man each month has responsibility to be "mess captain," and when his month is finished, he nominates a person he thinks will do a better job than himself. That self-deferential and dignified manner is so typical of the Bhutanese, regardless of where they come from, and is something I so enjoy about the people we meet.
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