Happy New Year 2011

I would like to wish each and everyone a very Happy and prosperous New year. May all your dreams come true and you and your loved ones enjoy a peaceful and productive new year.

Telemedicine Workshop

We had a one day Tele-medicine workshop for the Hospitals in the east which have been supplied with some basic equipment recently. All the District hospitals were represented  with a participant each with the exception of Dewathang and Riserboo Hospitals.

The workshop covered on the overall Telemedicine coverage in the country and provided hands on training for the participants on the web based consultation that is to be followed .

Mongar Hospital will now serve as the expert end for the Telematic centres in the east instead of JDW as practiced earlier. A digital camera will be procured for each of the centers  by the Program.

I have been identified as the Focal Point for Telemedicine in the east and we will collectively  try to see how we can make a difference with the use of ICT in our patient care.I am absolutely  optimistic in this path!

Pediatric OPD Closed:JDW

Kuensel reported that the pediatric OPD was closed on 24 and 25 December due to shortage of a Pediatrician. It is understandable and I can agree with the explanation given by the Hospital Director.Obviously, there is a big shortage of Pediatricians in the country with just 5 national pediatricians in the whole country including myself at Mongar hospital and one at Military hospital, Luntenphu.

Of course, closing the OPD was just not the right thing to do. JDW has plenty of GDMOs and they could have mobilised some of them for few days. Even experienced ACOs can handle the OPDs to a great extent!

Hopefully, the scenario will improve by mid next year as two more national pediatricians and a Burmese pediatrician are expected to join us.

What about the specialists?

http://www.kuenselonline.com/2010/modules.php?name=News&file=article&sid=17770



So far nurses with degree were equated with specialist doctors and now even the diploma and certificate holders may soon be equated to specialist doctors....all in P3...hmm good news for the nurses!

National Order of Merit: Congratulations to the health officials who are the recipients.

It is a moment of pride for the health family as three of our colleagues have been awarded the National Award of Merit , by His Majesty , The King , on December 17th . They are:

1. Dr Mohanta, Pathologist, serving in the country for more than 30 years.
2. Kesang Jigme, Laboratory Technician, known for blood donations( more than 40 times)
3. Dupchu ,BHW of Narang BHU under Mongar Dzongkhag( played a crucial role when the fateful quake hit the eastern part of Bhutan, Narang  being the most badly affected)

Dr Mohanta was awarded the National Order of Merit (Silver) and the other two received Bronze.

Lalpatti effect!

You drive through the doctors quarters or walk up the steps  to the hospital from the residential complex, you will pass through these ovely flowers beautifying your way.....enjoy

And thanks to our present MS who is fond of flowers, plants and trees to beautify the hospital surrounding!

By the way , I dont know the name in English!

Hospital Gate construction underway.

Construction of a new concrete gate at  the hospital entrance is in full swing at the moment. It is expected to be complete in a months time from now. 

Meanwhile parking facilities have been disturbed by the construction temporarily.

Once complete, this will surely add on the asthetic

beauty of the hospital.

Telemedicine Workshop

A three day workshop on Rural Telemedicine and SAARC Telemedicine project is re-scheduled from 27-29 December at MRRH for the eastern region. Aprroximately 20 participants are expected including the Director General of Health.

A ToT to the same effect was conducted recently at Thimphu which was attended by our IT friend , Omapati, who will be one of the resource persons. I am looking forward to participate as well.

Snakes: They scare me!

For the first time in two years,we are managing a case of snake bite in the Pediatric age group. A 6 year old with a venomous snake bite was referred from Pemagatshel Hospital yesterday. Unfortunately no anti-venom was available there( reflects the dismal state of our essential drug supply at the moment throughout the country). The nearest hospital they could send the patient was to Trashigang where both anti-venom and a doctor on station, were available. Obviously there was a delay in the administration of anti-venom which is vital.

At the moment, the child is in the Pediatric ward with features of severe local envenomation and some systemic as well( deranged clotting). Ten vials of AVS have been given at Trashigang Hospital and hopefully he will not need further doses.There is apprehension that the limb might get affected by compartmental syndrome!Obviously there is no data available on the type of snakes prevalent in Bhutan.

http://emedicine.medscape.com/article/168828-treatment

Plight of the Junior Specialists.

Many Junior specialist are forced to work on the grade and salary of a GDMO or a nurse. While most specialists are given specialists cadre, some of the Junior specialists have been seriously affected by the position classification.  The ministry recently turned down applications for fast tract promotion submitted by some of us saying that no promotion is due before 4 years. At this pace, my personal concern is that we will reach our retirement age by the time we enter specialist cadre, but having worked all throughout as a specialists!

And this is unfair!

A year into Blogging!

Around this time last year, I started blogging as a novice. A year into it, I have derived immense pleasure in doing this as my leisure activity and also as a means to update our colleagues elsewhere about Mongar Hospital. I have received good feedback from those who have seriously read the threads and that is what keeps me going. But there are some mischievous readers who simply log in and mark everything as "funny"..obviously that is someone who must be jealous of my work or is not my wellwisher. I have no ill-feelings.

I am glad that through this blog, a dentist couple previously working in India, found a way to come to Bhutan. They found a job at JDW!

Thanks everyone and am glad that the page views have now crossed 3000! I welcome your comments and suggestions please.

Everyone Looks, but few actually SEE!

Dear Doctors, brothers, sisters, ward boys and girls in the delivery ward and NICU.

Thank you all for rendering your saving, healing and nurturing hands.

We would like to express our heartfelt gratitude for saving our baby daughters life and others who are admitted here. We will not forget the sleepless nights you have spent nurturing our babies. Really and truly, we remain indebted to the tireless service you all render in stabilizing the condition of patients who aspire to live their lives to the fullest span. We would also like to assume that the noble deed you commit never go unobserved in the eyes of the almighty. He would rather rejoice in heavenly abode above that: my son and daughters are realizing that service to the humanity on earth”. More over your profession is in the prophecy of the lord Buddha, whoever shall attend sick shall attain me.”

Thus, we admire your job and appreciate your services. Finally we wish you all the best and healthy lives bestowed with happiness and prosperity.

THANK YOU ALL…

Yours truly indebted parents,

Thinley Namgay and Pema Yangdon.

This note was left by parents of  a 1.2 kg baby girl who was delivered here, resuscitated at birth by a NICU nurse and was in the NICU for her initial 5 weeks and weighed 1.7 kg at discharge!

PS: The baby in the picture is no this baby though!

This is what somebody( must be our own staff)has to say in KOL!

Quote:

why is it trhat some staffs has to work soo hard when some are sitting,chatting eating in the name of dialysis.it is not fair when some wards has acute staff shortage .why the hosp management is not functioning ,it seems it has to have a fast action....

Unquote:
http://www.kuenselonline.com/2010/modules.php?name=Forums&file=viewtopic&t=699

.

Condolences and Prayers

The charming Chamkhar town was reduced to ashes in  matter of few hours. It will not be the same again. It was a lovely site to pass through and drive by the town till recently. It is extremely sad and tragic!

My deepest condolences to the families affected. Our prayers and always with you.

Visit to the Book Fair

A three day book fair is underway at the Mongar Sports Ground. Various stalls packed with visitors, mostly school children and teachers, were seen on the first day.

For otherwise calm  Mongar, this will be a good timeout!

If you havent been there, do so..you may find something for your kids!

Somethings needs to be done soon!

We have probably waited quite for sometime for availability of some of the essential medicines like Iron tablets. With no good pharmacy around , it has become practically impossible to give this basic medicine to many of our needy patients. We can turn down patients a few times but not always..and it is sometimes embarrasing for the doctors and staff to tell the patients that such and such is not available.

I wonder if the Ministry or the DVED has no solution at all?

We are equally affected by non availability of some antibiotics like cloxacillin and even chloramphenicol.

External consultant reviews the EMOC Project

An external consultant was today at the hospital meeting various stakeholders, to review the EMOC program and progress. He was accompanied by the Program Officer of Reproductive Health Program, Khina Maya.He met with the Pediatrician, Gynecologist , EMOC focal person and some other relevant people.

ILI update

The personnel from the PHL, JDWNRH, briefed the doctors and other relevant staff on the status of Influenza Like Illness Surveillance in the country. The findings of the past two years were presented to the audience.

Plans to start the Severe Acute Respiratory Illness ( SARI) Surveillance , was also discussed.Question answer session saw a lively discussion on the actual problems faced during recording and reporting.

Working Lunch and refreshments were provided for the participants.

EMoC Training

A Five day workshop covering the Basic Obstretic Standards and Emergency Obstretic Care along with some essential neonatal protocols, concluded today at Gyelposhing BHU.

Similar workshop for the second batch of staff will commence from the 14th of this month. The revised standards were published in 2009.

The picture shows how our friends from the BHUs managed their accomodation during the training...hmm.. something I too would love to experience! Looks tempting!

LAN finally!

Finally the so called LAN lines have been pulled to our chambers and duty stations. At the moment, they are busy fixing the lines and it will be a few days before we can have net connection at our chambers.

Internet connection at work is necessary:

• quick literature searches
• quick tele-consultaions
• updating oneself during free time
• social networking ofcourse!

Nice Lecture on Sepsis

Visiting HVO Volunteer and ER Specialist, Dr Jared Hubell, gave an hour long lecture on this common topic yesterday at the conference hall. It was a well covered and relevant lecure focussing the important aspects of diagnois and treatment. Dr Jared highlighted on the missing links that he observed during his short service at the ER in JDWNRH.

The 6 hour and the 24 hour bundle sepsis therapy he talked about was impressive. Question answer sessions followed the lecture. About 50 participants registered for the lecture.

Refreshments were served as well. Meanwhile, his better half Katherine, who accompanied him, handed over a large bag of childrens' clothes to be given to the poor and the needy.

Thank you two and have a pleasant stay in Bhutan!

Improving Efficiency!

I was particularly concerned about the delay in radiological diagnostics at JDW. It is said that dates for USS and Echo are given as later as 2 to 3 weeks! With five radiologists and several Technicians, I thought there should not be such a long waiting list for USS particularly.I believe , lot of time is spent on typing the reports. I understand not more than about 10-20 Echos are done daily. How can we improve this:

1.Reports can be hand written as and when the scan is over

2.Reports can be brief especially if normal study.

3.Or Standard formats can be utilised.

4.Deploying assistants to write reports as the scan is being performed is another way, especially with Echos.

5.Given the adequate machines, may be atleast 2 radiologists can devote to ultrasound along with other Technicians.

Just my thoughts anyway!

Biswakarma Puja

It was formally organised at the hospital colony with initiatives from Nagendra( Engineer ) of the Hospital.

Milestone for MRRH: Dialysis begins

Begining today, MRRH will probably be able to cater to the need of renal dialysis to patients of eastern Bhutan. Two patients , who were till date being dialysed at JDW, were successfully dialysed here today.

This is definitely a great achievement for Mongar Hospital. This is going to avoid lot of referrals and un-necessary travels for the patients .

It will be handled by the Medical specialist and a team of five trained nurses.

It is definitely a proud moment and my heartiest congratulations to all involved in this mamoth task.

Check Mongar Hospital Group in Facebook for more pictures!

Consequence of Local/traditional treatment

Recently , Kuensel made headline on the death of a child following some local treatment. It is not uncommon for us to see this almost everyday in our practice. In my personnel experience, a lot of children are subjected to such forms of treatmet like sucking and incissions, before actually coming for medical attention.

From my personnel point of view, this practice should be strongly discouraged as it seems to have plenty of harmful effects than any benefit to the patients:

1. Leads to delay in seeking medical care.
2. Introduces infection through sucking or incissions.
3. Can lead to dangerous and life threatening bleeds if cut /incissed over a vessel or if the patient has a bleeding tendency.
4. Can lead to transmission of dangerous blood borne infections like HIV/Hepatitis B
5. Can lead to pain and unnecessary discorfort in an already sick patient.
6. Leads to ugly bruises and scars especially if done in a visible part of the body.
7. Patients might be forced to pay some money for an attempt which will not provide any relief.
8. Gives false sense of security to the family, thereby further delaying medical attention.

I have here posted a picture of a child who came to me today and complained of headache. He was having an upper respiratory infection. The three bruises on his forhead were created in turn by his father, mother and a sibbling to relieve his headache. Now will this family need a hospital?

Food for thought!

At last , computers for specialists!

Thanks to the Telemedicine Program. Specialists in Mongar Hospital will now have computers in their chambers, and they have already arrived and had been fixed in some chambers. This will enable steaty practice of Telemedicine and internet for patient care.

New face of Mongar Hospital

This is how our hospital looks after the recent completion of the Hospital Parking .

Hospital Management Training

A ten day training on this area is scheduled at RIHS, Thimphu for hospital administrators working in various hospitals across the country. DMOs, CMOs, Superintendents, Administrative Officers, nursing superintendents/incharges have been called for the training.

Dr Tapas, Medical Superintendent and Br Thinley Penjore , will attend the training from Mongar Hospital. Resource Personnels are expected from outside the country.

Annual Rimdro

Day long Annual Rimdro was organised at the Hospital complex yesterday. A lot of people,both from within and outside the hospital attended the ceremony.

German Doctor in MRRH

A German Gyenecologist( Dr Dirk) is presently at MRRH, working in the Gyne/Obstretic Unit . He will be here for a period of seven months. This will greatly ease the work load for our lone Gynecologist beside providing an oppurtunity to learn from each other.

Staff leave for training

Three staff from our hospital recently left for training abroad.

1. Kesang Wangmo for NICU, Bangkok
2. Sonam Dekar for Pediatric Critical Care, Bangkok
3. Lungten Pem for Diploma in Ultrasound, Chennai

The Team here in Bangkok (HIV/AIDS Training)

Seven of us are really having fun and enjoying the training also. The way they are is fantastic. Very much ahead and very very systematic. The visit to the isolation ward yesterday was awesome!

Health DG vistis MRRH

The Director General of Health visited Mongar Hospital on 1 st August. The hospital visit was conducted in the morning while the evening was spent with the staff on a dinner at the HVOs quarters. Petinent issues are said to have been discussed. I am away and not very informed about the actual discussions.

New batch of Nurses to Join soon

New batch of nurses who passed out this July will soon join the Ministry of Health. All the candidates seem to have cleared the joint interview and are now waiting for the appointment letters.

The news is not so good for Mongar as I understand that only about four of them are being posted to Mongar. This will hardly make a difference to the huge gap of nursing shortage existing in Mongar Hospital at the moment. Moreover, couple of them are going for trainings soon.

Off to Bangkok

I will not be able to update the blog for sometime( may be about 2 weeks) as I am going away to Bangkok to attend a training on HIV/AIDS. Please bear with no posts or few posts please.

Other people in the team include Dr Damber, Dr Subba, Dr Lotay,Dr Kinley( Ped), Dr Thukten, Mr Thupten(Pharmacist).

CME: Poisoining

Today, we had a CME session on Poisoning , in which the medical specialist, Dr Kesang, discussed in detail the approach to cases of Poisoning in the Emergency Department. Common poisonings were discussed including Mushroom Poisoining. A brief account on snake poisoning, use of charcoal and other emergency procedures were discussed.

Second round HPV vaccination

The second round HPV vaccination will be conducted nation wide tomorrow. Most of the recipients will be school girsl after the age of 12 years.The first round was conducted in May.

Some of us(doctors) from MRRH will be going for supervision of the activity.....

Updated: here is a picture from one of the vaccination sites!

ACC in action!

Officials from the Anti-Corruption Commission are stationed at MRRH for last couple of days and verifying all the equipment that have been procured and supplied to the hospital during 2007-2008, with the establishment of the new Hospital.

Clinical Case Conference on Tuesdays

Here onwards, the clinical case conference where in doctors of MRRH meet to discuss a puzzling case or an interesting case, will be done on Tuesdays instead of Thursdays. The regular CMEs will be done on Thursdays, provided participation is encouraging.

Meanwhile , the surgical specialist discussed a case of Gynecomastia in a young male (due to adrenal cortical tumor) toaday.

Improving Casualty Services

The doctors, casualty staff and the administration sat together for more than an hour to discuss some of the management issues in the Casualty particularly pertaining to patient monitoring, timely information to the specialists and more vigilance on the part of nurses and clinical staff caring for patients admitted to casualty.

Change of CME schedules

Henceforth, the weekly CME sessions conducted on Fridays till date, will now be conducted on Thursdays. This change was made as the OT staff felt that they are not able to attend on Fridays due to OT of two departments.

The Clinical conference amongst doctors will be done on Wednesdays.

CME: Evidence Based Medicine

An interesting discussion ensued following the presentation on this important and evolving area of Evidence Based Medicine by Dr Min, anaesthesiologist of our hospital. He covered all the vital aspects of this fascinationg area (which has always been one of my favourite topics).

About 35 participants attened the session.

Case of Anasarca

A case of anasarca in a 48 year old lady which has been a diagnostic puzzle in the medical ward was discussed at the clinical case conference at the doctors Lounge today. Most of the doctors attended the session including the medical superintendent.Diagnostic possibilities were discussed and further course of investigating this patient was outlined.

It was obviously not a straightforward case of kidney , liver or a cardiac disease. Appeared more like a disorder with multisystem involvement.

High Patient load

The last three days at Mongar Hospital has been extremebly busy, with all time high patient loads in all the out patient departments. The Pediatric OPD alone saw more than fifty outpatients today, stretching our work beyond capacity.

We believe that it is because of the many students and parents being free to come to the hospital as it is a summer break for most of the schools.

Road blocks affect ambulance movement

Two ambulances deputed on patient referral directly from Mongar to JDW were held last night at Nobding due to heavy rains and landslides. However, the roads were cleared early this morning and the ambulances could move to Thimphu after about seven to eight hours of delay.

Casualty Grand Round

From the 2nd of July , we have started doing a grand round daily at the casualty Unit. At 9 AM, all the specialists would gather there at the casualty and discuss all the cases that have been admitted there during the previous night. This is aimed at training the junior doctors , ACOs and the casualty staff on basic emergency management and also to reach a consensus management plan in difficult cases. This is possible through the inputs of all the doctors and specialists who are expected to participate daily.

We look forward for co-operation from all doctors and clinicians concerned.

CME: Reduced Fetal Movements

An hour long CME session was organised yesterday ( July 2nd ) at the conference hall on this important topic. Dr Sonam, the gynecologist conducted the session very interestingly. Overall, it was a very informative and educative session covering the etiology and management of reduced fetal movements in a pregnant women.

Like in the previous session of Ocular emergencies, the attendance in the session was dissapointlingly poor, with participants numbering to less than 20. If the trend continues, the CME sessions, which are mainly planned and informed in advance targetting the nursing fraternity, may soon become a thing of the past.

The clinical case conference attended by most doctors will continue as the participation has never faded.

Clinical Case Conference

A case of Thrombocytopenia in a young lady who was in her second trimester of pregnacy and whose illness started with a spontaneous abortion, was discussed at the doctors Lounge.Most of the doctors and specialists were present for the discussion.

The most likely cause discussed was gram negative sepsis with/without DIC.

Clinical case of Severe Myalgia

A nine year old boy from Dremtse, unde Mongar Dzongkhag is admitted with three days history of fever and severe muscle pain especially at the calves. There is marked tenderness of muslces all over the body.He does not look toxic but the pain is incapacitating. No documented fever after admission.
Total count 27,000 with neutrophilic Predominance, ESR 108. SGOT= 21, CPK Pending.
What is the most likely diagnosis? 1. Polymyositis 2. Viral myositis 3.Parasitic myositis like Trichinosis. 4.Others?

Please share your thoughts

Hospital without water

The heavy rains for the last two days has disrupted the entire water supply for Mongar hospital including the residential colony. We are finding tough time meeting the needs and it is especially tough for the hospital to run without a steady water source. It might take a few days to restore the connection again.

Briefing on Surgical checklist

Almost two hours of brainstorming was done on the implementation of the surgical checklist that was initiated recently in the referral hospitals. An audit conducted by the program for MRRH revealed that about 30 percent of the operated cases overall had filled the cheklist.

This was certainly thought to be a good begining and it was decided that its use will be further strengthened from now onwards. Some changes to the actual format of the checklist were also discussed.

Dechen Chophel and Tandin Wangchuk from the Quality Assurance Division, MOH were present for the discussion.

Quality Assurance meeting for Drungtshos and sMenpas

A workshop to this effect is underway at the conference hall, MRRH , conducted by the Quality Assurance Division of the Ministry of health. It is expected to last for three days and is being attended by sixteen participants.

MRRH to get better IT facilities

The hospital will soon get a new server and LAN cables to upgrade the internet and network facilities within the hospital. This has been made possible through the Telemedicine Program.

The previous server has been non-functional for over a year and despite having more than fifty computers in the hospital, there is no easy access to internet and email facilities especially for the doctors and the specialists. This has also led to the total collapse of Telemedicine services .

With the new facility, it is hoped that all specialist chambers , like in JDW, will be connected to internet through the LAN system.

It is hoped that this will revive the Telemedicince services that once existed in this hospital.

Talking Telemedicine

I am attending a Telemedicine workshop/consultative meeting at the RIHS ,Thimphu which will conclude tomorrow. Although I came with lot of enthusiasm, the number of participants called is dissapointingly low. Mongar hospital and JDW are well represented, but the district and peripheral collegues who are actually given the equipment, are not in the scene.

We are discussing the current status of the Telemedicine, which is widely viewed as a dying or defunct project, and ways and means to sustain and take it forward.

The only area which seemed to show some activity is the SAARC Telemedicine Link with PGI Chandigarh and SGPGIMS, Lucknow with weekly CMEs( althought the number of participants was discouraging).

We will come up with certain definite recommenations on day two and will probably give the way forward for telemedicine in Bhutan.

Good news for Mongar is that the whole Telemedicine equipment will get a facelift soon with a new server and a bette LAN facility.

Scene from the Archery ground!

The ongoing open archery tournament organised by the Mongar Sports Association...

The Mongar Hospital team is participating as well.

Upcoming workshops in the East

A short( probably a day long) workshop on life support for nurses will be organised soon at Mongar hospital , for nurses in eastern Bhutan.

Another workshop on vector borne diseases will be organised at S/Jongkhar soon, which is also for the nursing staff. Final dates are yet to come out.

As usual, this time of the year ,nearing the financial closure, are more busier than usual, as the programs wake up to finish the last available budget in their respective areas!

Mushroom Poisoning

Two cases from the same family( father and son) have been admitted to Mongar Hopital with symptoms of severe poisoning following intake of wild mushroom. They were referred from Trashigang Hospital.

Both patients have features of liver toxicity with very high transaminases.While the father is improving, the child is critically ill.

Food for thought!

Indigenous unit on life support:

Posted on Friday, June 11 @ 02:01:41 EDT by chencho -->

Mongar Hospital 11 June, 2010 - Shortage of staff in the indigenous medical unit of Mongar hospital has become a major challenge to serve the growing number of patients visiting every day.Karma Chezom, 96, of Wengkhar was up early morning and rushed to the regional hospital at around 9 am last Monday. She took a prescription form and showed it to the dungtsho (traditional physician). She got the medicines at around 3 pm after waiting for five hours.
Currently, there is only one Dungtsho and a sMenpa in the unit. The problem gets worse, when one them is out on medical leave.
About 30 to 50 patients, including both OPD and herbal steam treatment, from the eastern districts visit the hospital everyday.
“The unit functions during government holidays, if it falls between Monday to Friday, to maintain the treatment course, especially for those undergoing herbal steam treatment,” said Dungtsho Tandin Phurpa. “We’re facing a difficult time handling the large number of outpatients, given the manpower shortage.”
According to the hospital’s administration officer, the requisition was forwarded to the ministry, but nothing has happened so far. As per the royal civil service commission’s requirement the regional referral hospital has slots for two dungtshos and sMenpas each.
More than three thousand patients visited the unit in the past six months, ever since the herbal steam bathing facility started in November last year. The unit has 14 beds for patients needing steam bath treatment.
Records indicate that steam bath patients are usually those suffering from post-traumatic pain, swelling of hands and legs, neurological disorder, obstinate skin diseases, joint and back pains and gout.
By Tshering Namgyal

Poor show on CME

Despite advance notice and information, the attendence , at the CME session today was dismal . While our people continue to cry that they don't get CME credits, they actually don't turn up when it is organised. This is the paradox!

However, all the doctors were present in the session which encouraged us to continue.

One Day H1N1 workshop

A one day workshop on this topic is being organised at the Conferene Hall of the Hospital today. This is for the hospital staff including the nurses and the technicians. Dr Gembo Dorji is the principal resource person.

Incidentally, following reports of the outbreak or H1N1 at Kanglung, a student from there has been admitted to the isolation ward for suspicion of the same disease.

There was a recent report of increased number of flu cases at Riserboo Hospital as well.

Meanwhile all of us must take adequate precautions to prevent the spread of this infection.

Farewell Yuka!

The hospital gave an official farewell to YUKA AIDA , Japanase volunteer nurse, who worked in the NICU for the last two years. She was in the country as a JOCV volunteer through the JICA Program. She will be leaving Mongar next week and flying out of the country in another week or so.

Meanwhile a new hospital administrative officer has also joined Mongar Hospital and four maintenance staff who had been on contract have resigned.

Mongar Hospital now

It had been sometime since I visited the canteen . I found some time yesterday to go for a quick tea and a plate of momo with a senior colleague and friend.

And as I stepped out of the canteen, the hospital looked a bit more different than what I used to see earlier. And just caught this picture for you all.

And can you suggest whether that lone old tree should stay there or should be done away?

Restoring Sight to Hundreds: the best gift you can think of!

In the last four months, more than 250 patients with cataracts and other ocular problem.s were operated during the mobile eye camps conducted by the Eye Team from Mongar Hospital headed by Dr Bhim B Rai, eye specialist of the hospital. Besides conducting the camps at all the district hospitals in the east, the team also travelled to as far as Nganglam with sophisticated equipment required for the delicate operations.

This benifits most of the old and elderly patietns who have been blinded by cataracts, where the lense tissue opacifies as an aging process, taking away the power of sight, which is the worst handicap you can think of!

Congratulations to the team and do keep this up!

Maty Staff discuss CTG

The Maty ward staff along with the Gyenecologist and MCH staff discussed the CTG( Cardiotocogram), an invaluable tool for monitoring the fetal condition during labour. Some of the staff recently attended a short attachment in JDW on this subject.

Radiology Workshop

A four day Radiology workshop for the Technicians is underway at the Conference Hall of Mongar Hospital from today. Radiologists from the National Referral Hospital are around to resource the workshop.

Inviting CME Proposals

I would like to request all the specialists,doctors and staff of MRRH,to volunteer ( as Resource)for the weekly CME sessions on Friday. It has been very smooth going ever since we started having these sessions about three months back. Participation has been encouraging and we would like this to continue as usual. Please submit your proposals to me for forwarding to BHMC for approval of credits.

Thanking you for your encouraging participation so far!

Pentavalent gets a green signal

The expert WHO committee, which was involved in the investigation following the incidences of suspected deaths to Pentavalent, has concluded that the vaccine was not responsible for the reported deaths. This means that the vaccine will probably be re-started in the country again .

I think this is the reality and that the vaccine should be re-started sooner than later.

Nurse Assistants

Twelve nurse assistants, who recently completed their training for four months, have been appointed to work at Mongar Hospital. They will support the nursing staff in the ward, mainly on non clinical errands. Many of them are expected to go for GNM training to India sometime in the future.

CME: Maternal Collapse

Dr Sonam Gyamtsho, Gynecologist, presented on this rare but important subject of " Maternal Collapse", few of which have occured in our country in the past. Overall the important causes and management, highlighting on the multi-disciplinary team that is required, was emphasised. About 26 participants were present for the CME.

EMOC Workshop

A three day workshop will commence tomorrow at Bumthang to discuss issues related to EMOC and Neonatal care in the country. Program officers and all the EMOC focal persons will be attending the workshop at Hotel HOME.I will also be attending the same to discuss the neonatal part.

Another five day long workshop on Mental Health is already underway at Bumthang Hospital from today , mainly for the new group of doctors who have recently joined service.

Mongar Hospital staff selected for training

Two Mongar hospital staff have been selected for further training , through the open competition conducted by the Ministry of Health.

• JB Darnal,ACO for field course in Epidemiology(Thailand)
• Lungten Pema, Ultrasoud Technician for diploma in Ultrasonology( India)

Our congratulations to both!

Neonatal Equipment through JICA

The JICA office, through the neonatal nurse currently posted at NICU, Mongar , has supplied some essential neonatal equipment that was felt necessary for a long time.These include neonatal stethoscopes and saturation probes. These will be very useful for the unit.

Clinical Discussion: CLL

A case of 60 year old with anemia and splenomegaly that was confirmed to be CLL was discussed today. Clinical history, findings and a differential diagnosis was discussed by Dr Kesang, GDMO.

Away at Paro

I am away at Paro for couple of days for a workshop on Research Ethics and have not been able to update the site. Will catch you all once am back to station.

CME: Approach to Coma

A very comprehensive coverage on "Approach to coma cases' was made by Dr Kesang, Medical Specialist, on the CME session today. Common causes, relevant history and physical findings,and basic management aspects were outlined.

Alcoholic liver disease leading to hepatic encephalopathy as one important and common cause of coma in our set up was especially highlighted.

Clinical Meeting: HSP

A case of Henoch Shonlein Purpura in a 15 year old adolescent patient was discussed today at the Doctors Lounge,where most of the doctors were present. A detailed outline of vasculitis syndromes was also presented by the Medical Specialist, Dr Kesang.

Proposal of conducting such meeting weekly was discussed with the doctors present.

First Phase HPV Vaccination

The first phase of vaccination against Cervical Cancer commenced today with girl children between 12-18 getting the first of the three dose series of the vaccine.

I had the priviledge to witness the event at Lingmethang and Gyelposhing schools. Apart from some grins from the children, everything seemed going smooth. Meanwhile some other doctors including the Medical Superintendent have been deputed to supervise the event at various vaccination centres in the Dzongkhag.

The campaign will go on for another two days.

Making Mongar Hospital Academically Active!

It's already been smooth going since we started having regular CMEs on Fridays . More than 15 sessions have so far been organised which have helped the staff to fetch CME credits required for their promotions and career enhancement.

To keep the doctors and specialists engaged, we are also planning to have a clinical case conference every week ( Thursdays) on some interesting cases that we encounter in our practice.This will be mainly for doctors and ACOs although all interested can join. We have already had few such conferences where we discussed Chronic Eosinophilic Pneumonia, Fanconii Anemia and Hypertension in the Young.

The last discussion on Hypertension was particularly fruitful!

HPV Vaccination Awareness

Various doctors from Mongar Hospital visited the Schools around in an attempt to create awarenesss about the upcoming HPV Vaccination aimed at preventing against cervical cancer.

As there was lot of confusion on the consent issue, the DoPH has sent a letter stating that this is not necessary for vaccination. This will surely ease the job of the vaccinators and improve coverage.

First phase will kick off on 5th May!

Infection Control : Hospital Acquired Infections

This issue was discussed today at the Conference hall for over one and half hours.A presentation on Hospital Acquired Infection , which was investigated in the ICU was presented to the floor by Binay Thapa, Microbiologist. A prolonged discussion with recommendations were made by the doctors.

Clinical Case Conference: Hypertension in Young

An hour long clinical case conference on an important and very frequently encountered topic was organised at the Doctors Lounge today. Dr Kesang Namgyel, Medical Specialist , preseented a case of Hypertension in the young, which was followed by a detailed discussion on aprropiate evidence based management of this common ailment. The Junior doctors and ACOs were particularly sensitized on when and what medicines to start, how to follow up and when to consider secondary causes of hypertension. The presentation was followed by a healthy discussion covering common problems encountered in the management of Hypertension at our set up.

I am sorry for not being able to take a picture today!!

Staff Get-Together

Saturday evening was fun for many staff of Mongar Hospital. Initiated and organised by Dr Kesang, a drink-dance-dinner party kept the participants full of rare fun. It was organised at the doctors colony and nearly 60 staff came for the gathering. The only dissapointment was some rain in between though it failed to dilute our enthusiasm.

Must have such gatherings once in a while!

Disaster Preparedness

It could not have been more appropiate! Dr Hoffman, a Hand surgeon at the Kaiser Medical Centre in California, presently working as an HVO Volunteer in Mongar Hospital, made an excellent presentation on this issue sharing his recent and first hand experience at Haiti, following the disastrous earthquake.

While Bhutan also recovered from a major shake in September last, another major shake is forecasted any time in the future. Dr Hoffman made relevant suggestions that are practical in our set up and emphasized that pre-planning, a disaster management team , traiging and flexibility of roles are the cornerstone of a successful management strategy in case of a mass casualty.

Lets hope and pray that such a thing never happens again!

Infection Control Core Group Meet

The core group on Infection Control met at the doctors Lounge yesterday, for an hour to discuss the plan of action in the next three months. The budget for some of these activities has reached the office of the DHO. Monthly activities will be conducted. Proposed activities include a presentation on the recent ICU infection of two ventilated babies, visit to the municipal waste disposal site, meeting with the Dzongkhag Municipal Committe.

We will next be meeting tentatively on the 28th of April.

Internet at the Doctors Lounge

Finally after two years of proposing and re-proposing, the Doctors Lounge now has a computer and Internet Connection. This is will help doctors to browse the net and conduct some telemedicine during the free time they get in between patients.

HPV and H1N1 training( Vaccines)

A one day training on these areas was organised at Gyelposhing BHU for the participants from various BHUs. HPV was covered by Dr Sonam, Gyenecologist and H1N1 part by myself. While Vaccine for HPV has reached, Vaccine for H1N1 is still awaited. Tentative dates of vaccination is next month.

Seen on the picture is Gyelposhing BHU I.

ICU/NICU Meet

The ICU/NICU staff with the medical and the child specialist met for a 2 hour meeting yesterday at the Doctors Lounge. All the concerns put forward by the staff were discussed in detail.

Most of the talk was dominated by some petty issues raised by some disgruntled people.

CME: Head Injury

An hour long session on this subject was conducted today and was attended by a record 53 people. There was a good interactive session at the end of the presentation. All salient aspects of head injury and its management were covered in simple details.

The Resource for this important clinical topic was our Surgical Specialist, Dr Myat.

Casualty Meeting

A short meeting to discuss the problems of the Casualty Unit was held today. All the staff working in Casualty along with the nursing superintendent and two specialists( Medical and Pediatric) attended.

Another meeting was called separately to discuss the problem of ambulance movement and the authority to sign the movement orders.

Clinical Case Conference

We discussed an interesting and rare case of Fanconii Anemia at the doctors Lounge today. Almost all the doctors were present including Dr Hofman, Hand Surgeon on HVO deputation who is in Mongar on a short term.

With the reported incidence elsewhere, Bhutan could just be having a single case or two of this rare condition.

Staff Farewell

Senior EPI Technician, Mr Ngawang Pelzang, retired from service after 37 long years in the goverment service. All the Hospital staff gathered to bid him a farewell.

Good Luck ,Ata Ngawang!

Water Festival- The Burmese New year

This morning we had some fun at the doctors colony where we threw jugs and buckets of water at each other drenching ourselves. Our Burmese Specialists and all the doctors residing in the colony participated. It was some great fun!

Doctors and Nurse Assistants on Picnic

The student Nurse Assistants who are about to complete their four month crash course, together with the doctors and their tutors are off to Lingmethang on a picnic. The Burmese specialists and the Medical superintendent also joined the group. It s a good way of killing time in the weekend although the heat down there might be diluting their excitement!

And ofcourse , the doctors colony appears deserted today!

Japanese Festival

A 2 day Japanese Festival was organised at the Lower secondary school from yesterday. Many JICA volunteers working all over the country are participating in the event. Full day events including cultural program in the evenings were organised.

Mongar Hospital current has a neonatal nurse volunteer through the Program.

ACC Team at Mongar Hospital

A team of Anti- Corruption Commision officials were at Mongar Hospital inspecting the various equipment procured in the recent years. Detailed account of the visit and their purpose is not clear to me at the moment.

Eye Camp in Samdrupjongkhar

There will be a week long eye camp in Samdrupjongkhar begining this Monday. This will be lead by Dr Bhim B Rai, Eye specialist at Mongar Hospital. They will mainly be operating cataract cases and ofcourse provide other ophthalmological services to the needy patients during their stay there.

Training Neonatal Nurses

The Department of Public Health, MOH, is keen to train Neonatal Nurses at the Regional Referral Hospitals for a period of one month. A letter to this effect has reached our hospital few days back. This came as a big and funny surprise to me because the concerned people have not done any homework as to whether the regional hospitals have the set up and the facilities conducive for an attachment training. For instance, both the hospitals do not yet have a proper neonatal set up. In Mongar, neonates are nursed together in the adult ICU. There are only two formally trained neonatal nurses in the whole hospital( one of which is not currently working in the neonatal ward for health reasons). Most of the nursing is done by nurses trained in adult ICU.

And in this set up, how can we train neonatal nurses which is a highly specialised area? I have expressed my concern to the Program accordingly.

There is a remote possibility that we may be able to start a separate NICU after July -August this year provided that we are given sufficient number of nurses from the fresh pass-outs.

CME: BLS and ALS

A one and half hour CME on this topic was conducted today by the Anaesthesiologist. It covered some of the most vital aspects of basic and advanced life support including the latest recommendations. Practice drills will be arranged with individual units soon. About 40 participants
attended the session.

First Patient referral to Guwahati from Mongar in recent years

A young female patient with pulmonary embolism will be evacuated to Guwahati early tomorrow, probably to down town hospital. Approval for direct referral to Guwahati has been sought from JDWNRH.

Referral to Guwahati from Mongar surely seems a more convinient option than referring the patient all the way to Thimphu and then to India from there. This proposal has been submitted for discussion at the Annual Health Conference.

Specialists Visit District Hospitals

Some of the specialists( Medical and Orthopedic) visited Lhuntse Hospital today in-order to supervise the clinical care and streamline referral services from the Districts. In the process, they also attended huge crowd of patients who had turned up to the hospital. This will be of immense benefit to the public if it can be continued on a regular basis. It was purposely planned for the weekend in order to avoid disturbance of services at the referral hospital during other working days.

Quality Assurance Workshop

A two day workshop on Quality Assurance is scheduled for 4th and 5th of April at the Mongar Hospital Conference Hall. This is being organised by the Quality Assurance Division in the Ministry of Health. Similar workshop is being conducted in other districts in the east at the moment.

HPV Vaccination

The country will soon be introducing vaccine against Human Papilloma Virus, an agent causing cervical cancer in women. To this effect, there will be a one day training /workshop for healthworkers today i.e the 3rd April,2010 at Mongar Hospital.

Preparations are also on for nationwide H1N1 vaccination soon. A training to this effect was already conducted earlier.

PLWHAs

A three day meeting of counsellors and people living with HIV/AIDS concluded today at Mongar. Around 28 participants including patients and people affected by the conditions were present. Senior counsellors from the HISCs in Thimphu and Phuntsholing resourced and co-ordinated the meeting.

World Bank Team visit Mongar Hospital

Dr Gembo Dorji from the Ministry of health along with two consultants from the World Bank visited the hospital today and met with the specialists and relevant people from the nursing and laboratory services. They made visits to many units , departments and waste disposal sites .

They were here to review the progress of World Bank funded activities.

Publications??

I want to know if any of our senior colleagues have published research papers( original research)from Bhutan in any of the International Journals...Actually I want to know what is the proper procedure and how long it takes to publish an article provided it is accepted?

Any answers?

By Profession and Being Professional

Health is a highly specialised field where every service provider is trained and hence is a service provider in a particular area by profession. Nurse by profession, Technician by profession, Doctor by profession and so on. I have been particulary interested to watch people do their duties and decide for myself if someone, and including myself, is being professional in doing whatever we do. Well I cannot be the judge for myself. But I try to figure out how other people do their primary responsibilities...whether they are just something by profession or they are truly professional. It is hard to believe but seems true that most of us do not do our jobs professionally...I am particularly critical about the nursing services and the level of care they provide...for they are the backbone of any health care delivery system...It is sad to see that spotting a truly professional individual has become a rarity!

My personnel feelings only!