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.