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.