An infant died during our morning rounds this week.  He was the fifth child to die in a week at JDW Referral Hospital.
       "We are the only referral hospital in Bhutan," Dr. Mimi, the head of the department, and one of three pediatricians in the hospital, explained. (We all go by our first names with the appellation "Dr."  I am called "Dr. Dave")  "We get all the sickest children."
       The senior resident Dr. Jimba and I were making our rounds in the ward.  Dr. Mimi was busy in the PICU.  We came upon a baby I shall call Sonam ( --- no chance of violating HIPPA - which doesn't exist in this country anyway; half the population, both males and females, are named Namgay, Tsering, Sonam, or Tashee).
             He had been in the hospital since long before my arrival.  He was born with congenital hydrocephalus. He had a ventriclo-peritoneal shunt to drain the fluid from his brain placed in India, but it had failed.  He had two revisions, which had also failed.  Dr. Tashee (the male neurosurgeon, not the female pediatrician Dr. Tashee) had approached me during my first week here, in the PICU, to ask my advice regarding intra thecal amikacin to treat a shunt infection.  The baby had had recurrent infections.   He was barely conscious.
               Dr. Tashee and Dr. Mimi, had both explained, "We have discussed the prognosis."   I had met his young parents.  They were quiet, calm, and respectful, like almost all the parents here.  They never had any questions.  They probably had asked them all already.
              Now the patient was in a bed in one of the 6 bed units on the Pediatric Ward.
                "Dr. Mimi has discussed it with the parents,"  Dr. Jimba explained.  "We should not perform CPR on this child".  I asked Dr. Jimba if this meant "Do not resuscitate" and he said Yes.   I said that we also include a "Do not intubate"  (DNI) order as well.
                 Dr. Jimba said "We don't have such orders here".  Doctors simply discuss the patient's prognosis with the parents, every day.  Then they reach an agreement.
       I looked a the baby. He was on oxygen by nasal CPAP but his pulse oximetry was now in the seventies.   He was in respiratory failure.  He had bandages over his hugely swollen head.  His chest was sunken.  He looked grey.   I listened to his lungs.  We reviewed the situation with the parents.  We went on to the next patient, moving clockwise to the other half of the room, past the one TV set in the unit, which was hardly ever on.
       Minutes later, one of the nurses, who are called sisters (or brothers) here, asked us to come quickly.  The child's breaths were agonal.  He was dying.   Dr. Jimba explained what was happening to the parents.  The father gave the baby a few drops of a clear potion.
        "This is to help the child on his way to his next life," Dr. Jimba said.
         Two sisters fiddled with different sized ambu masks, but I told them to put the masks away.  I asked them to call Dr. Mimi, so that she would know what was going on.  She was unavailable, we were told, minutes later.  She was trying to resuscitate a dying child in the PICU.
          I sat with the baby as he passed away.  I told Dr. Jimba and the parents that his heart had stopped.
         Anyone who believes in the stereotype that the Bhutanese do not show their feelings have never sat with parents of a dying child here.  The young dad cried has he held his baby.  His mother wept, hugging the father's shoulders.  Of the deaths I have witnessed it was among the most heart rending.
         Traditionally, everyone has at least one monk in their family, Dr. Jimba explained.  One of the sons has usually fulfills that role.  As family size shrinks from an average size of 5 or 6 to 2 and the culture modernizes, this tradition is fading. But everyone usually has their own monks to call upon.  This family was no exception.  Three men with shaved heads, sandals and red robes entered the room.
They began to chant by the baby's bedside.  An aunt joined the family.
        We continued our rounds.  The next patient was a two year old boy who had been in the hospital for a month.   (There are no "quality assurance" people here heckling us every day to kick  patients out, because "the insurance company will deny payment."   Health care is free.  There are no insurance companies.)   The boy had an undiagnosed weakness of both lower extremites, so that he had stopped walking and difficulty crawling. The weakness was preceded by a non specific viral illness. He was in no pain.   He had lost his patellar reflexes. A lumbar puncture was negative.   He had been waiting for an MRI of the spine, but the one MRI machine in the country was unavailable for two weeks.  Nerve conduction studies are difficult to get here.
        Dr. Mimi had asked for a "neurology consult".   This is in quotes because there are no neurologists in Bhutan.  There was a HVO neurologist, Dr. Doug, from Colorado who was here for a month.  (He so impressed the Bhutanese medical staff that they asked him to move here.  They offered him five times the salary of the average Bhutanese doctor, but that is still ten times less his income as a doctor in the States.) He does not see children, however, so he asked me to consult.
               After reading everything I could find about pediatric neuromuscular disorders (in the western literature - the vast majority of medical literature is published in the west)  I concluded that the child had Guillain Barre syndrome - perhaps the chronic form called chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).  The cerebrospinal fluid is supposed to have an increased amount of protein in Guillain Barre, but the CSF can be normal in certain cases, said Dr. Doug, with whom I discussed the case.  The one problem was that the weakness is supposed to be ascending, from the toes to the head.  The boy had neck weakness, as well,  but no paraplegia of his respiratory muscles.  He was having no problem breathing, or eating.  His cardiac function was normal.  Still I thought that G-B was the diagnosis.  I proposed the currently accepted treatment,  daily intravenous immune globulin, for five days.  Dr. Mimi agreed.  I thought I was pretty smart.
      The boy did not get any better.  Finally he had the MRI of his spine.  It showed an inflammatory lesion of his third and fourth lumbar vertebra.  The disc space was normal.
      An orthopedist was consulted.   Like most of the surgical specialists here, he was wearing a white coat instead of the tradition kho.
       "This is typical tuberculous of the spine,"  he explained in a soft spoken but confident manner.   "We see this all the time.  Probably someone in the family had TB."
         Yes, the mother said, the father had had TB.  We hadn't bothered to find this fact out.   This diagnosis is not in the pediatric literature on neurological disorders.  I realized, not the for the first time, how biased the medical literature is towards the developed, resource rich nations.  The orthopod suggested triple therapy for TB.  No, it wasn't necessary to biopsy the spine.  He didn't even feel a PPD skin test was necessary; the appearance on MRI was so typical.  The neck weakness was due to a second tuberculous lesion in the cervical spine, he said.   We could get an MRI of the C spine to prove it.
           In the bed across from us, the monks were still chanting.  One of them was supporting the parents with his hands.  They were quietly weeping.  The other families in the room all knew what was happening.  The sisters had brought in a partition to give the family privacy but the much of what was going on was still clearly visible.  The other families were curious but quiet and respectful.  They kept their distance.  The sisters asked us permission to remove the tubes and wires from the baby's body.  Dr. Jimba went to fill out the death certificate.
            Dr. Mimi came to help him.  The child in the PICU had died as well.  He had been transferred here with some form of meningoencephalitis, a a viral infection of the brain and spinal fluid.  Then he suffered aspiration pneumonia, respiratory failure, and arrested.
          I was reminded of an infant we had rounded on the previous week.  She had been diagnosed twice with pneumonia at a regional hospital, then was thought to have congestive heart failure.  She was transferred to JDW.   The diagnosis was problematic, because she had no heart murmur.  Her chest X-ray looked normal to me.  But still he seemed to do a bit better, on two medicines, aldactone and lasix, used to treat heart failure.  His oxygen saturations increased.  She had also been placed on two more antibiotics.
           However, the next morning, Dr. Jimba arrived exhausted for my weekly Thursday morning lecture.  He was on call when this patient arrested.  She could not be resuscitated.   Dr. Mimi thought that the infant perhaps had botulism.  The family is Nepali.  It is common practice among parents of this ethnic group to feed their infant's honey, which may carry botulin spores.  In the U.S. we warn parents against giving baby's honey until the first year of life at all their well child visits.  However, well child visits in Bhutan do not exist --- only sick visits, and vaccination clinics (see previous post).
        "All these children who have died (except the infant whose death I had witnessed) are from the South, from the border region.  They get a lot of meningoencephalitis."  Dr. Mimi explained.   "When they get sent to us, they are very sick."
            Many of these young children develop seizures.  They are all treated with combinations of dilantin, phenobarbitol, and sometimes diazepam.   There is no EEG machine with which to diagnose epilepsy.  They are treated empirically. Without the laboratory facilities to identify viruses, it is impossible to tell what the pathogen is.
              These patients are in addition to those who come in with seizures from cisticercosis, scrub typhus, or japanese encephalitis virus (three infections which can be diagnosed here).  A baby with JE virus has been on a ventilator for two months.  She moves her eyes to look at us but has lost all use of the rest of the muscles of her body. Then there are the patients with nephrotic syndrome due to diseases like mesangial proliferative glomerulonephritis -- rare diseases that would probably not even be handled by the nephrologists at my medical center back home.  These patients would be sent to Childrens Hospital Medical Center in Boston.   Congenital heart disease (CHD), is diagnosed clinically with the help of sometimes echocardiograms that are read by technicians, not cardiologists.  The three pediatricians here send about 40 children a year to India for surgery for their heart conditions, but take care of these children themselves until they are ready for surgery.
         
          I'm not sure if it is the culture, or being away from everyone and everything to which I am accustomed, but I have never been so aware of the yin and yang of life.
          My roommate is a good and decent person.  Yet he is quiet, serious.  We play no TV nor music.  We can go for long periods without talking as he works on his lectures.  On the other hand,  my wife - herself a warm and gregarious person with many friends - tells me, in the evenings after work,  "You are a talker!  I'm tired after work.  I like to just watch a show on TV.  But you need to talk!"
          So this, along with having a roommate for the first time since medical school, is an adjustment.  We both see the good and difficult sides of ourselves, I am sure.
           Bhutan itself is among the "greenest" in the world.   Yet there is garbage everywhere and gutters with open sewage running down below our apartment.
            At JDW Referral Hospital, the pediatricians are among the brightest I have met everywhere.  Yet without the diagnostic tests, specialists, medications and facilities we take for granted, they sometimes by necessity take a "shot gun" approach.
            Hygiene has improved dramatically in Bhutan, but I still have seen cockroaches and flies in the PICU.  (They don't tend to kill them because Buddhists value all life.)  Signs everywhere in the hospital warn against spitting doma, the potent beetle nut lime mixture that turns teeth red, chewed nearly universally here.  A sign on the doors at the entrance to the nursery warns to keep the doors closed, to keep mosquitoes out.   In the outpatient pediatric department, garbage is swept up in big piles at the end of the day.  Each exam room has a table with a sheet and a pillow which are not changed between patients.  Families and children wait in long queues to be seen --- obviously a breeding ground for contagion.
          They usually arrive at the exam room without having there temperatures or weights measured.  They have histories of fever without temperatures having been taken at home --- since no one owns a thermometer.  The patients then have to be sent to "Chamber 6" - the treatment room - to have these important measurements done.  Last week, the day the boy with the VP shunt died, I was supervising a new intern.  We were seeing complicated patients -- like a baby with prolonged jaundice, who had been put on thyroid replacement for hypothyroidism which might have been transient.  (There is no newborn screening to pick up inborn errors of metabolism).  He was on about 5 other medications.  We saw another baby sick with vomiting, peeling skin, and large lumps popping out of his body, which turned out to be abscesses.    
              I was trying to teach him how to look in ears.   All children have waxy ears here.  It's the hard dry kind that is hard to clean out.  Yet it is essential to look at the tympanic membranes to diagnos an ear infection (otitis media)..  Here children are sent "to ENT" for ear cleanings.  Judging by the number of kids who have waxy ears (about 100%), I think there is a lot of guess work when it comes to diagnosing otitis.
            Dr. Mimi had told me that sick babies should have their temperatures taken before they arrived at the exam rooms.  I went out and talked to the young woman at the intake window, and the nurse.  She pointed out that she was the only nurse there that day, and there was only one working thermometer in the clinic.  She had to do updrafts, and rehydration therapy as well.    There is a shortage of nurses.   Yet Bhutan does have the money to send patients who need expensive cancer chemotherapy and liver transplants to India.
              And there is no evident shortage of uniform guards - most of them young women, who line the stairwells between every floor. There are usually three of them, together.  Why the guards?  There are no security problems.   The prime minister led the "Move for Health" march last weekend without any guards.   He passed a law that no politicians should have any security personnel when they move around the country.  The fourth king himself (K-4, he is called) frowns upon having security when he takes bike rides or hikes.  (Instead the army will practice surveillance on the king, and set up check points.  "The king has just passed" they will radio to each other.)
          "They should get the guards to take the temperatures!" Rebekkah,  a nurse anesthetist volunteer suggested.
          It is a country of contradictions.  
          I talked to the Cuban medical officer stationed in the OPD. Did he have this problem?
No.  But I'm not sure how often he takes temperatures.  
         The previous prime minister had close ties with Cuba.  To help with the doctor shortage here, he contracted with Cuba to have them send physicians here.  They are put up in hotels until they are oriented and learn enough English, then paid to practice here in various capacities for a year.
         I had a suspicion the Cuban doctors were the ones prescribing antibiotics for children with colds. I could not tell for sure, since I can not read anyone's signature.  Antibiotics are for bacterial infections, not viruses.  They don't not help, and may cause harm, leading to side effects and antibiotic resistance.        
One of lectures I have given was on pneumonia, and upper respiratory infections (colds, or URI's).  Unfortunately, none of the pediatric attendings could make it.
       I had pointed out that cold and cough medicines do not help children with URI's either.  They have have never been proven to help.  These drugs can cause serious side effects.   One of them, phenylpropanolamine, has been banned in the U.S. The WHO guidelines call only for the use of saline nasal drops and warm liquids for kids with colds.   Yet over the counter (OTC) cough and cold  medicines are still regularly prescribed here.  
           The doctors say that the parents here want to get a medicine from the doctor.  I told the residents I have worked with that this was the situation in the United States.  But one can simply explain to parents that colds and other viruses will go on their own, thanks to our immune systems.  The body heals itself.  Sure enough, the residents have found out that I was correct.   The parents here as smart as those back home.  They left the resident and me with prescriptions for salt water nasal drops only, without complaint.   And, I pointed out, this will save the Bhutanese medical system thousands of dollars.
          This is an important issue for a nation that only spends 3.5% of its budget on health care, yet promises free health care for all!
          The Cuban physician on duty, Dr. Gabriel was a friendly enough fellow, though he wore a mask, and refused to shake my hand, presenting only his arm to me.  There is a widespread fear of spreading infection here.  With good reason:  my roommate has been sick.  The volunteer Dr. Larry upstairs has been sick.  The pediatrician Dr. Tashee was out sick last week.  Dr. Jimba was out sick.  The intern had been sick.   The OPD is a regular rainforest of infection.
         He denied prescribing antibiotics for colds.  
         At 1:30 pm, I checked outside the door of our exam room.  The intern and I were the only ones left in the OPD.  The nurse and the Cuban doctor, and the intake staff had gone home early.  The clinic is supposed to run until three pm.  All doctors are civil servants here.  They work, officially, from 9-3.
         "They must have had CME"  Dr. Tashee explained, when I saw her.
          And I had to leave, for a hypnosis consult with a patient who turned out to be 96 years old.  More on this in the next post….