Just one GNM?

Despite a huge shortage of Nursing Staff in the hospital, I understand that only one GNM has been posted to MRRH. I think the administration really needs to bug up and insist on more staff. Many districts have more that the number of nurses they actually need, going by the workload!

Hospital Based IMNCI

The ARI /CDD Program, DoPH, is in the process of  preparing manuals for the Hospital based IMNCI( Integrated Management of Neonatal and Childhood Illnesses) which is likely to be implemented beginning later this year in some of the district hospitals in the country. Two hospitals each in the east, west and the central region have been selected to initially start the program.

We recently met in Paro to finalize the manuals for the same. This strategy is aimed to equip the general doctors and clinical officers in the district hospitals with basic management skills in Pediatrics especially in the absence of a Pediatrician. The initial training in this regard is expected to begin sometime in October this year.

Easing Nursing Services

The Labour  Ministry's announcement to train 268 GNMs in India by 2013 should come as a good news for the  health sector and the nursing fraternity. This should have come long before we planned to build these large state-of the-art hospitals like JDW or MRRH which are  now fully  functional but with a large shortage of nursing staff.

With this announcement, I guess atleast the shortage can be reduced by about 50 percent in few years time.

Mongar Hospital has acute shortage of  nursing staff in most of the wards including the ICU. NICU and Cabins could not be started solely because of the nursing shortage.

UNICEF Rep visits MRRH

Dr. Gepke Hingst, UNICEF Representative in Bhutan , visited the hospital on Friday and spent time in the MCH following up on the Pentavalent Introduction. She was interested to know if anything adverse or otherwise happened after the re-introduction. She also had a brief discussion with me on main areas of Pediatric Morbidity and Mortality. She found some time to go around the new hospital complex as well.

Welcome the Pentavalent

June 11th 2011, will yet be another great milestone in the history of the country's health sector. Once suspended in 2009, Pentavalent will make a come back tomorrow with a nationwide launch. Having five antigens in one injection, Pentavalent will protect children from Diptheria, Tetanus, Whooping cough, Hepatitis B and Hemophillus Influenzae infections.

The health sector across the country is well prepared for the launch. I as a Pediatrician, would like to urge all parents to come forward at vaccinate your child with Pentavalent. Children due to get the 6 week dose of vaccine will be eligible for this and will have to complete 3 doses ( 6 weeks, 10 weeks, 14 weeks).

Hospital Meeting

The hospital conference hall went buzzing on Saturday afternoon when a meeting to discuss some  of the Departmental problems  was called. The Hospital MS chaired the meeting.Most doctors, Unit In charges and administration staff were present.Some of the problems faced by the laboratory and OT were highlighted.

Major chunk of the discussion was on the work-load currently faced by the laboratory in the background of  acute shortages or absence of some of the essential Laboratory services.

Microbiologist talks to the staff

Dr Tshokey, the country's first clinical Microbiologist, who recently joined JDWNRH, made an hour long presentation on the antibiotic resistance, the theme of this years WHO day . More than 40 staff including the doctors attended the lecture. A prolonged discussion followed after the presentation. Besides, Dr Tshokey also visited the Laboratory and inspected the Microbiology department.

STI/HIV/AIDS: External Consultant reviews Program

A UNICEF fielded external consultant and the PHL In-charge, Binay Thapa, were here to meet relevant people involved in the cited subject. It was basically a part of the piloted assessment program in the country. The MS,some Specialist Doctors, laboratory staff, PMTCT focal person, and other relevant staff attended the session that lasted two hours. It was an interactive meeting with active involvement of all who were there.

Pentavalent will be back

Pentavalent Vaccine, initally started in September 2009 and suspended till date due to reports of adverse events, will be back to the immunisation schedule begining June 10 this year. The adverse events were investigated thoroughly and concluded that pentavalent is not the cause of those adverse effects.

Health workers under Mongar Dzongkhag are attending a two day workshop, which ended today, to the same effect.  It was mainly to improve communications to the general public regarding the re-introduction.

Sunday Picnic

Residents of Doctors colony were off  to Ligmethang this Sunday for a  Picnic. Though the weather did not favor us much, it was fun filled day. The kids especially enjoyed the time at the river side. They also enjoyed the quick sight of the  Kurichu Dam later part of the day.

Sunday Trek

Seven doctors( me included!) and including Dr Sam Baker, a US based HVO Volunteer, went out on a half day trek, up the slope of Kilikhar to the ridge overlooking Drepong, made to the Pokchulung Lhakhang along the ridge, and then down via Kadam , in about 4 hours. It was fun!

Ended with a delicious lunch at Taras ( canteen owners) place.

BHMC Deputy Registrar briefs the staff

Mr Nima Sangay, Deputy Registrar of the Bhutan Health and Medical Council, briefed the hospital staff on the salient medico-legal aspects of medial practice. The discussion covered areas like medical certificates, death certificates, documentation, medical negligence etc.

Fruitful discussions followed during the course of his presentation.

Maternal and Neonatal Mortality Meet

The EMOC focal person convened a meeting of the neonatal and maternal mortality review committee today at the doctors lounge. We discussed the neonatal deaths for the last quarter of 2010 and the first quarter of 2011. There have been 4 neonatal and one maternal death in this period. Staff from the maternity ward also participated.

The committee members include the MS, DHO, Pediatrician , Gynecologist and EMOC focal person.

WHO day Observation

We observed the WHO day today at the Hospital Conference hall from 2 PM onwards. After the MS read out the Message of the Regional Director, Dr Krishna, Pathologist discussed on the concepts and mechanisms of drug resistance. I briefed the floor on the messages of the WHO and its startegies on antimicrobial resistance worldwide.

An interesting revelation of the anti-microbial resistance pattern at the hospital was also shared with the gathering.

Worth reading

According to The Lancet, non-communicable diseases (NCDs), mainly heart disease, stroke, diabetes, cancers, and chronic respiratory disease, are responsible for two out of every three deaths worldwide and the toll is rising. A landmark global alliance between leading scientists and four of the world's largest NGOs brings together evidence from a 5-year collaboration with almost 100 of the world's best NCD experts and proposes a short-list of five priority interventions to tackle the increasing global crisis. Reducing tobacco and salt use, improving diets and physical activity, reducing hazardous alcohol intake, and achieving universal access to essential drugs and technologies have been chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility.

http://www.citizen-news.org/2011/04/emerging-global-mandate-to-save-36.html

Meeting Peripheral Health Workers

A two day workshop on infant feeding is  underway at the DYT Hall. Variety of other issues including the child mortality and maternal mortality related issues were discussed.

The MS also spoke on rabies and its management with public health perspective. Other local health issues are expected to be discussed on the second day.

Abstract of our report on Child Mortality

III. Some Vital issues

With the exception of three cases who died in the hospital, rest of the deaths occurred at home  This means that the parents have not sought medical attention during the last moments of the child’s life and the illness leading to their death. We believe that many of these deaths could have been prevented if the child was in the health care facility. Delay or denial of seeking medical attention is still an important contributory factor leading to morbidity and mortality in our country. This is a direct reflection of overall   low literacy rate, ignorance, poverty and  social problems.

Female Literacy is a vital contributory factor to the quality of child care and health seeking behavior of a family. To our current knowledge, there is no better tool than this. Unless female literacy improves to comfortable levels, it is difficult to expect a rapid decline in childhood mortality.

Decline in childhood mortality is parallel to socioeconomic development in the country. Presence of roads, transportation facilities and telephone coverage obviously facilitate better healthcare. A smoke filled home due to lack of electricity is a direct risk factor for a child’s health as it can contribute to Pneumonia  and other respiratory illnesses.

Alcohol use is widely prevalent in our society including the female population. Alcohol directly contributes to poor maternal health, complications of pregnancy, low birth weight, child neglect, broken families and several social problems that have a direct impact of children’s health. Out of the 29 deaths stated above, at least 3 of them were associated with an alcoholic mother, who failed to bring the child for medical care!

Community Participation is indispensable in the success of any public interventions. This is surely discouraging seeing the large number of home deliveries, home deaths and failure to seek medical care. Every family is informed of the need to deliver in the health care setting or call a trained attendant and every one is informed of the presence of health facility in their locality, yet, many of our people do not come forward. Therefore, it is not appropriate to directly blame the health care delivery system alone, which in our opinion, is doing its best at the prevailing situation.

Family planning and limiting the number of children is the personnel choice of an individual couple. Such decisions are made by the clients after appropriate counseling and information from health workers. In other words, its purely informed choice. Opting for a permanent family planning method like vasectomy and tubectomy is again the choice of the family or the couple, knowing the availability of other temporary and alternative methods. No couple is forced to opt for any family planning methods by the health workers.

Declining births and declining deaths ( in older age group) is part of a  demographic cycle that every nation passes  through and it may best be regarded as a part of the nations over all socio-economic progress. Whether the current birth rate and the trend of decline is a concern for country’s future in terms of population size or not , is a debatable issue. We feel that that this should be left to experts in population studies to study the pattern of population growth over the last century and accordingly predict the pattern for the future.

WHO Day, April 7

Update on Clinical Use of Blood.

A half day session on Appropriate clinical use of blood was organized today. It covered all aspects of blood transfusion related topics covering major specialties. A prolonged discussion followed on some of the practical aspects faced in the hospital from time to time.

A working lunch was served, funded by the DMS.

Check this out!

http://www.bhutanobserver.bt/%e2%80%9cdangerous%e2%80%9d-indigenous-healers-thrive-despite-modern-hospitals/

Eye Camp

Dr Dechen, Eye Specialist and Pediatric Ophthalmologist from JDWNRH, Thimphu is currently stationed at Mongar for the eye camp. Lot of patients are availing the services at the moment. OPDs appeared packed for the last few days. A group of visually handicapped students from Khaling have also been brought in for operation.  I also took the opportunity to screen them for congenital heart diseases.

Meet to discuss Under five deaths

Following  the concerns raised during the recent Mid Term Review Meeting   and upon the high command of the Hon’ble Prime Minister and subsequent directives from the GNH Commission, the health sector of the Dzongkhag formed a committee to study the detailed deaths reported in the  year 2009. The committee consisting of the following relevant people met on 25^th March and discussed in detail the issues and concerns pertaining to the  high reported child mortality in the district.

1. Dr Tapas Gurung, Medical Superintendent ,MRRH.
2. Mr Tsering Dorji, DHSO , Mongar Dzongkhag
3. Dr P. Bhandari, Child Specialist, MRRH
4. Dr Sonam Gyamtsho, Gynecologist, MRRH
5. Mr Kuenzang Thinley, Focal Person, Emergency Obstretic Care.
6. Hem Kumar Nepal, In-charge, Neonatal ICU

Under five mortality for 2009 was 34/1000 Livebirths , which is the fifth highest in the country. Gasa, Lhuntse, Wangdue and Trashigang have mortality rates higher than Mongar. A report to the same effect is being prepared.

Briefing on Acute Encephalitis Surveillance

A brief awareness on the above subject was recently conducted at MRRH and Samdrupjongkhar hospitals as part of the initiation of  Encephalitis Surveillance in the country. Five hospitals including JDW Gelephu and Phuntsholing apart from the above two are in the list. This is to gather the prevailing scenario of Meningoencephalitis cases prior to the re-introduction of the Pentavalent vaccine later this year or early next year.

Post Graduate slots

Please check this link...may be of interest to doctors and nurses!

http://www.health.gov.bt/announcement.php

Super-speciality services at MRRH

Although it will be decades before MRRH will have the so called super-specialists, some of such facility is already available and being done with whatever expertise available. In my personnel opinion, MRRH does much more than its mandate: Examples:

• Dialysis: ideally a Nephrologist required, but being succesfully done by the Medical specialist and the dialysis team of nurses.
• Endoscopy: Ideally a Gastro-enterologist required, but again being done by the Medical specialist. 
• Echocardiography:Job of a Cardiologist! but done by medical and child specialist here!
• Neonatal  Intensive Care:Job of a Neonatologist, but being managed by Pediatrician and NICU team of nurses.

The picture shows endoscopy being performed at MRRH.

Acknowledgement

I would like to thank all the Maty ward staff (MRRH)for their invaluable support rendered to me in conducting the Cardiac Study in all the neonates born in 2010. Extra thanks to Sis Kesang, Sis Chimme, Br Kuenzang and the nurses who spent time filling up the forms! I would be glad to share with you the results of the study once compiled at a later date.A total of 500 neonates have been screened for congenital heart disease.

Yet another facelift for MRRH!

Colorful new Hospital Gate!

This is what Hon'ble Lyonpo has to say on the corruption in our Ministry

http://www.health.gov.bt/newsdetail.php?newsId=626&from=news

Check out this article in Business Bhutan!

Health officials cheat country off millions

By tenzing_LAMSANG | 22 January 2011 | 5 Comments

A plastic bucket worth Nu 600 was bought for Nu 7,500. Rot is spread across most departments in the health ministry with faulty tendering, favoritism, buying poor quality equipments, excessive ordering, overpricing and collusion
http://www.businessbhutan.bt/?p=4199

On Long Leave and no updates please!

I am on a month long leave and will not be able to update you on MRRH. Will catch up once back to station.

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!