Going to Work
Bhutan had always been high on my list as a place to go, but honestly, I had been hesitant about doing any medical work this year and to be here as a US citizen, you need to either be volunteering or pay the large tourist fee. I was hesitant to work becuase as it is easy for me to say yes to work and this year was a chance to say no, so filling up the year with work felt counterproductive to accomplishing the goals we set forward as a family. The second reason was my hesitancy of international health projects in general. While working internationally before I saw both amazing, sustainable projects that were changing lives, and others that only served the egos of those who “volunteered” and may have done more harm than good. I was hesitant to make the wrong choice for the wrong reasons.
The opportunity in Bhutan seemed like the perfect balance, it was short and would allow my family to see a place we wanted to go and the project looked sustainable and well run. I wouldn’t be coming into “change” anything or “bring my skills” as much as I was as a member of well-coordinated fire line, doing my lifting and handing it off to the next volunteer while the Bhutanese created a health care system that would be best for them.
What I didn't count on was how much our family would embrace this time. How after six months we have had space and time to be together and being in one place for this time, and with me having work, it gave us all space to pursue our individual passions and interests. My dad always quoted his Minnesota relatives by staying “once you stop plowing the fields, you might as well be in the dirt,” and the meaning and purpose in my work hit me like a blast of fresh air.
I am still trying to unravel all the feelings and thoughts about my time in Bhutan. It is mixed with life, death, large personal career choices, friendship, and relationships. The people I meet, the stories I heard, the things I experienced were like a concentrated drink - meant to be diluted in a gallon of water but given to me at once. I can already feel life pulling the pieces apart, shedding light on the experience changing the colors and taste. Part of me wants to hold on to the whole things as tightly as I can, never leave, never let go, but the river flows and so must I, and thus I am left reflecting on what this all means.
This is the front of the new hospital, directly behind this sign is the emergency department - you can see the ambulances in the background. The adorable little guy on this sign is the 6th King (K6 for those of you in the know). On either side of him are K4 and K5. The fact Bhutan provides free, universal health care to its people is a significant source of pride for the country, and in general I was struck by the gratitude people had for the health care. My patients did not have any expectations for perfection, endless patients and gratitude for their Bhutanese doctors and for volunteers willing to come to spend time.
I was asked a few times near the time I was leaving what I thought of the care in Bhutan - if I would trust the ED for my family and friends. It is an interesting question and made me reflect on what is the same and what is different and what we all want in our health care.
In the end, people are people, they don’t want to be sick or die in any culture or community. People don’t understand how healthcare works anywhere in the world, and often we distrust what we don’t understand. We have never understood medicine and probably never fully will, just before it was one doctor or healer telling you what they knew. As humans, we are programmed to rely on relationships so we could trust this relationship for our health. But now our health care is made up for systems of care, systems that try to bring forth data and expertise to the problem at hand and systems are inherently flawed and harder as humans to trust. This is true in any community and your ability to trust the system, and therefore the care of your health depends on if you have a navigator of that system you trust, be it a primary care doctor, nurse, family member, friend or specialist who has gone the extra mile.
The system of care in Bhutan’s emergency department has a lot less fancy toys and less clean protocols than in the US. But in that space of less, the art of healing is no less. There are a lot more smiles, less blame for deviation and more conversations about care and what patients want. In a world of little to no malpractice less harmful and costly modalities like ultrasound have been allowed to grow and flourish in a way I could only dream of in the US. Appendicitis rarely got a CT, trauma cases that are stable, even with a positive FAST are allowed to heal without the CT as they likely will not need intervention anyway. We titrated peripheral pressors for a few days with a bedside look at the IVC without a central line. We femoral blocked hip fractures and let them get back in the car with family if they chose to drive back to India to have the surgery closer to home instead of opioids and an ambulance ride. The arrow in the aorta, the NSTEMI, metastatic cancer all got on a commercial flight to India instead of a $100,000 air medical transport who's risks again struck too close to home when we lost a crew back in Alaska just a few days ago.
But just like from the patients perspective of care being so reliant on the relationship, the care delivered in Bhutan comes from an intensely caring group of doctors and nurses.
The care is remarkable because of the nurse who calmly, on her own, bagged a patient that just arrived intubated as she troubleshoots the suction that is not working, the monitor who’s battery died and the donated vent machine which is different from the other three in the room without ever looking flustered or frustrated. Nurses who balance not only the needs of the usual demands of doctors in their department, or other departments and of the patients, but also the first responder students and a never-ending string of volunteer doctors like me who write medications the wrong way, never know the antibiotics at hand and need to be explained that “giddiness” means “dizziness.”
The care is remarkable because doctors who come in after a night shift or on their day off to hear a lecture and learn something new. Doctors who work with half staff to give each other breaks when their staffing is cut or let their female colleges go home one hour early to keep breastfeeding. Doctors who will come in and help on busy shift out of the kindness of their heart, and maybe the bribe of a beer or a dinner. Doctors who make a life-saving diagnosis by hearing an S3 gallop in triage or can diagnose and treat without labs or imaging available for hours.
So would I trust my loved ones with the care in this developing country? Absolutely. They had the necessary tools like gloves and clean needles and what they lacked they more than made up for in skill, dedication, and compassion.
K5 is known as the King of the People and the care I witness in the ED was really truly the care of the people and an honor to be a part of.
There is a gift in caring for those in need. A desire to see what is truly wrong and try to make it better and clarity that comes in stepping back in time. This old ECG machine reminded me of just that. These perfectly balanced little suction electrodes trying so carefully listen to the heart of the patient and translate that into something meaningful in the form of lines on a paper. It seemed a perfect metaphor for my time in Bhutan.
The pathology, oh the crazy pathology. They really don’t have HIPPA so I could probably actually share a lot, but a few of the cases and images are being written up for publication, and I don’t want to spoil the show. This one was in the papers, so I figured it was public - I love how they even have the patients face to help identify him.
It seemed like every week there was a different case that was good enough for the NEJM clinical images section. This guy got shot right through the arch of his aorta into his spine, after landing at multiple wrong “archery fires” to try and find him, the helicopter found him and brought him to us. He was amazingly stable, but the type of surgery he would need was only done in India, so a commercial air flight was arranged the following day- with him in the back. One of our doctors found this “follow” up in the Indian paper, and we were all relieved to see he was doing well.
There were so many like this, the women in VT who’s bedside echo showed a hydatid cyst the size of a grapefruit in her septum. The three-hour code of aconite (monkshood) poisoning. The rheumatic fever, the TB, the autoimmune diseases. The stokes were often hemorrhagic, and extensive and would wait in the ED for 2-3 days until a medicine bed was available. Sats in the 80’s were good, sats in the 40’s were sometimes the best you had before intubating. I was saved by the buggie for the first time in my career and now really know how good the tracheal rings can feel.
But when I think of all of my patients, there is one that comes to mind. This amazingly sweet 82-year-old woman in with pneumonia and hypoxia. She ended up staying 4 days in the ED waiting for a bed, and on the first day, she smiled this huge broken tooth grin. She, like all the patents in the department, was never in gowns (we don’t have them) so she sat in her traditional clothing, necklaces, and beads for the four days she was with us. Later that day I want to check on her, and she grabbed my white coat and just started talking. She smiled and nodded and kept talking, without me understanding a word. But I smiled back and bowed and held her hand until she was done and she gave me one more squeeze and off I went to the other patients. This same thing continued to happen for the next 4 days, always telling me some elaborate something, me never knowing what she was really saying and she was steadily improving. The team started to tease me about my favorite patent, and they were right, she made my day. On my last day before she went upstairs, she did something different, she kept holding her belly. I was worried. What had we missed? I pressed, and she was soft, did not seem tender, I could feel her aorta as she was very thin, but she looked good. So I did what we always do in the ED and don’t understand - got more data. I went and got the ultrasounds machine and looked all over - what was bothering her? I could find nothing wrong. Her liver, spleen, heart, gallbladder, aorta all seemed fine. I finally asked one of the students to help translate for me, what was I missing? Turns out that she was saying I am like one of her children to her (which would result in her holding her abdomen and smiling) and thanking me for listening. I laughed and thanked her for sharing her care and stories with me. She reminded me of how much more healing we sometimes do with holding a hand or sharing a smile. I then mentioned she was a little dry and keep drinking lots of water and she asked “so more alcohol, more tobacco, and more Doma?” I smiled and said, no just water and maybe tea and was glad I this time I had the translator and wondered what else I had nodded yes to before.
Every day I would walk out of the ED and past this sign. Turns out, the psychiatric ward was mainly an alcohol detox area where we could usually get patients a bed, but the proximity between the ED and this outpatient center was well planned. It was a good reminder to me of how every safety net will involve the vises of our society and that mental health, that like physical health can fail us all at some point in our lives.
I was asked to sit in on this ED redesign meeting. They are expanding the emergency department. This is the architecture and head of the department discussing issues such as emergency OR suits, the role of triage, ways to address boarding and flow issues. Many of the same challenges as when we looked at redoing ours emergency department. Some were different. TB patient needing UV light and fresh air, changes to VIP care, and unsure how far out we can build because they are still looking for the original building designs.
This was looking towards the emergency department every day. Ambulances ready to go, family and workers enjoying the sun.
I took this picture the last day we were in Thimphu. Fairly early on I began to realize that Bhutan and Alaska have a lot in common. Both have about 700,000 people, one major referral area and great challenging transports for patients. Both places have learned they have to learn from others, but ultimately figure out how to care for their unique patient populations.
There is no stable EMS system - EMR as they call it (Emergency Medical Responders). Just over a year ago BEAR was established, a helicopter service connecting the country in ways it had never been connected medically before through the passion and sheer willpower of a US doctor who spent over a year here. He is a "larger than life" character whose stories deserve a book of their own, one I hopes he writes soon.
But you can’t have a helicopter service and hospital without having medical ground transportation as well. This was recognized and EMR training class is well underway, but there were no protocols to go off of, no scope of practice. What would they carry on the ambulances? What should be taught? What was sustainable? How do you help without harming? How to do you make it culturally appropriate and functional?
These questions were being talked about by the Bhutanese nurses and doctors but also by the ICU doctor from Hawaii and the Melanie and Shankar, two US trained doctors now in Bhutan for 2 years working in the emergency department.
As the challenges in Bhutan came up, the more and more it seemed like the Alaska EMS protocols might fit this community better than more urban ones. I emailed the EMS director back at home who kindly shared the work of the Mat-Su Brough EMS with us, and so began my odyssey to create a draft set of protocols and procedures for Bhutan’s new EMR program.
This work was challenging, fun, and took way more time than I realized. How do you do ALCS if you can’t see the rhythm strip as you might only have an AED on board? How do you draft protocols that help and minimize the risk of hurting? How do you take this lifetime of learning and knowledge that still does not answer all of the questions and put them on a piece of paper for a protocol? As I frantically ran to print off 3 final drafts to leave in the department before we left town, it was gratifying to leave a tangible piece of me here, with a hope and a prayer that it is a seed from which the EMR system, and therefore more united emergency health care system can gown in Bhutan.
The education is a big part of the job of the doctors rotating through the emergency department. We also taught them what Jeopardy is - which I think was about as exciting as anything else. Much like practicing medicine in Alaksa, it was a fun challenge to take what you have learned or know and figure out how you would do the same things without the same resources.
The final day in the emergency department I had the best meal I have had in Bhutan. One of the nurses organized the party and everyone chipped in for a whole feast (note the large bottle of hot sauce). Homemade momos, chilies, lentils - I could have kept eating all day. I found a favorite part of every day in the department was lunch. The staff makes a great effort in breaking with each other, so everyone, nurses, doctors, techs all take the time to sit and eat together. There were two “shifts” so half of the department would eat for 15-20 min and then the other half would. You sometimes got called out for a code, or some other emergency, but really the in 45 minutes everyone had eaten and the sanity and comradely it brought to the ED was tangible. I never break to eat at home, just putting food in my mouth between reviewing charts and never with the rest of the staff, we think it will impact the flow of the department too much. But my experience here has made me question all of that, the chance to pause, to care for ourselves made me feel like I had so much more for others. I loved hearing the nurses stories about home, tips for cooking, mutual challenges and joys over raising kids, good days and bad days at work. Every day the department would make a huge thing of rice, and sweet milk tea and everyone would bring a dish to share. By doing this, every day everyone got to share a bit from everyone else. If you forgot food, no worries, the team would feed you and when you walked out that door, back to the crazy of work full of death, sickness and life, you knew you were surrounded by a team that was feed and who would have your back.
Sitting there amongst friends at this final farewell was bittersweet. It was a touching goodbye, but I felt as though I had gained so much more from them than I had given, it felt as though I should be the one making the lunch, but I also knew if I had, it wouldn’t have tasted so good.
When I think on back on what I want to take from this experience, I think of this mandala. The blue medicine Buddha in the middle - calm with a hand in the position of the future and holding the medicine of the present. It reminds me of my wise attending who in the middle of chaos would say, “Anne do what is right for the patient and remember the rest is noise.” This Buddha is focused on the patient, on healing, surrounded by the beauty and chaos and noise of sickness, emotion, systems of care and all that we bring to illness and health. I also love the clear space around the head, like a protective shield to think with clarity when it is needed most.
May I always strive for the clarity and compassion I have seen and experienced this past 6 weeks.
May I continue to learn from layers of our past and from those who understand and experience the world differently than I do.
May I continue to accept death as a part of life, but never lose hope in the power the body and mind to heal.
May I always continue to be amazed by the journey of medicine
May I be grateful for and learn from the honor of caring of another life.
May I always strive to give more than I take from my team that stands at my side.
May I find calm and clarity among the noise.
May I always do what is right for my patient.
May I always carry a piece of Bhutan with me.