November 2013

After flying out of Bhutan, we had a couple of nights in Bangkok. Due to the fact that Paro's airport is purely visual and doesn't have a control tower we had to have a grace period before the groups flight back to Aus in case of rain or fog meaning that we couldn't leave Paro.
We used this time to relax for our last few days together and I took the opportunity to see parts of Bangkok I missed last time. First up was Jim Thomsons house, a beautiful traditional Thai style country house set in lovely gardens, right it in the middle of the most manic city I've ever been. It belonged to the founder of the Thai silk industry who went missing while hiking in Malaysia. It still houses his impressive collection of art and artefacts and was extremely interesting. The contrast to surrounding Bangkok was also the weirdest experience.
With Barbs local knowledge we had a great lunch in the locals section of MBK and picked up a few bits and bobs (like a phone charger-seriously who forgets to pack one?...me apparently)

Back at the hotel I was surprised with about 10 emails from mum (love her!). After confirming that, you know...everyone was ok, found out about the cyclone in the Philippines. James, Beth and I had a flight booked early the next morning to Nha Trang, exactly where it was headed in the next 24hrs and with people being evacuated already, naturally decided to change our plans. That arvo was fun (sense the sarcasm) trying to get onto insurance companies, airlines, hotels and various embassies and consulates. All worked out nicely, with an extra night in Bangkok planned, we were Hua Hin headed on the coast, 2hrs drive from Bangkok.
That night we hit up patpong and I'll say no more.
The next day was full of massages, rooftop pools, and burgers (the first thing that wasn't noodles or potatoes in 3weeks). After dinner (pretty sure we keep the restaurant across the road in business while we were there) we waved the majority of the group off to the airport. Saying goodbye was hard, we'd all got so used to each other's company, had the most amazing experience together and I couldn't have asked for a better group...can't thank everyone enough.
We changed hotels for our last minute extra night . No one really knew what we were in for, we just booked it because Adam who we'd travelled Bhutan with was staying there so it made sense. It was beautiful! The most amazing pool, gorgeous hotel and right on the river. We pulled a sneaky and piled 3ppl into a 2 person room and it ended up being a bargain! Late night swims and a couple of piña coladas later and I was convinced everything happens for a reason.
After a very hot bus ride to Hua Hin the next day and we spent the next few days relaxing as much as possible, literally doing nothing and soaking up the beach. We had a ahem 'interesting' night out and did some great people watching. In the interest of full disclosure it's worth mentioning that one day here just didn't happen as far as Beth and I were concerned. One missing persons report, multiple calls to the embassy (again!), dealing with the police, multiple hours and the biggest freak out ever later...James was actually ok.
Back in Bangkok, after another super hard goodbye I spent the next couple of days holed up at the hostel or a fab Internet cafe in Siam paragon writing my 4000 word assignment for Bhutan. With that done and dusted I headed out to Asiatique, a night market on the river for Loi Krathong, a massive Thai festival.
I've never seen so many people crammed into boats and in one area. It was absolutely beautiful though, 'krathongs' are released down the river decorated with flowers and lit with candles and incense. There were also tons of floating lanterns marking Bangkoks skyline. The idea is that you let go of all your anger, hatred and bad deeds with the Krathong and let your negative thoughts float away. There was a 'water parade' of sorts with lit up boats and barges and it was a fantastic, atmospheric night.
Battled the crowds back, ready for a VERY early train into Cambodia the next morning.

Stay smiling xx

Between our hospital shifts we were also exposed to many other areas of Bhutanese healthcare. We spent a morning at the traditional medicine hospital, an outpatient service for treatments such as needle therapy, hot compression therapy and steam therapy. Herbal medicines are dispensed by specialised traditional medicine doctors. This is very popular in Bhutan, often as either a first or last resort. It is often utilised for chronic pain, however doctors will not treat anyone currently receiving treatment of another method (usually western medicine) for risk of incompatibility. One interesting thing was the claim that their medicines have no side effects as they mix herbs and other natural products to cancel out the side effects of others. Although good in theory, I had to wonder where they stopped, eventually something would have to give. We walked through the 'museum' of the different products used and it was fascinating to see things that are grown all over he world, often classed as weeds having such varied uses. There is an allegorical tree of medicine, following much the same outline as western medicine with branches of assessment, pathophysiology and treatment. Treatment is then based on diet, behaviour and medicine. Currently a new hospital is being built that will have the capacity to treatment people differently depending on the season, another aspect of traditional medicine.


Another morning was spent at a basic health unit on the outskirts of Thimphu. This is essentially a very basic version of primary healthcare. It consisted of one tiny room, with one desk and table. Staffed by basic health workers the majority of cases were family planning, vaccinations, peri natal checks, coughs and conguntivitus. Workers here can distribute some medications, and contrary to the hospital setting, I have never seen so much panadol handed over. The level responsibility compared to their level of training though was questionable with one child being diagnosed with pneumonia based on just respiratory rate and a newborn baby being given amoxicillin (a very strong antibiotic) to take at home with no information, assessment or monitoring. Overall it was an incredibly positive experience, the workers interaction with the community is extremely vital and beneficial and for the most part it is a viable alternative to hospital. The documentation was fabulous and care was much more patient centred than I'd seen anywhere else.

We visited the community health clinic focussing on child and maternal health, the separate psychiatric ward and the HIV/AIDS and health information drop-in centre. All of these provided valuable insight and were much more developed than I expected. One major difference was the role of family, this is prevalent all through the system, with family taking a major role in patient care. All patients have an attendant there 24/7 who look after all their personal care, assist nurses and in terms of mental health are the primary carer. In Australia, family is often viewed as annoying, demanding and just getting in the way and it was important to see how valuable they can be in a patients recovery, as well as how useful they are in a human resource poor healthcare system.

Finally was health assessment at the local Chortan. Teamed up with students from RIHS we set up stations to measure height , weight, BMI and blood pressure before using this information to give advice. It was one of the most manic but wonderful things. No one was prepared for how overwhelmed we would be, the community was so involved, we ran out of paper slips almost immediately and there were so many people. Although busy and thus time consuming, everyone was so thankful and patient. It was an amazing morning, that really reiterated the importance of health promotion and community health.

Immersing myself in Bhutan's healthcare system has been an absolute rollarcoster. There have been incredible and happy experiences but also a lot that I've questioned. I've learnt things that I never imagined, not only facts, but about who I am as a nurse. I've met some amazing people and this last fortnight is something I'll be drawing on well into the future.

Photos from the hospital:

Flew out of Paro this morning and I'm back in Bangkok. Still loads more of Bhutan stories to come! Already had pad Thai, a Chang and been to pat pong market...couldn't be more cliched but it's good to be back!

Stay smiling xx

The main purpose for our trip to Bhutan is to, as nursing students learn about and from their healthcare system. Our first exposure was info sessions on Bhutan, GNH and their healthcare system at RIHS.

Gross national happiness:

GNH is born out of Buddhist teachings that became a legal code in 1729 based around the concept that if you cannot create happiness for yourself and more importantly others then you have no purpose to exist. In 1987 their 4th king stated that it's more important than GNP. It's a holistic measure of the quality of the country based on serving others, nature, and recognising your own innate personal wisdom and brilliance. There are 4 pillars 1) socioeconomic development 2) culture 3) environment 4) good governance. The end goal is to promote the common good and conditions to sustainably peruse wellbeing.
We learnt a lot about what different demographics ranked as being most important to happiness, with financial security consistently being at the top. Conversely to what we believed it would be in Aus, leisure time was always down the bottom. As part of GNH healthcare is easily accessible and free. It's been shown that 98.6% of the population are happy with the system, I don't know the aus equivalent but I can't imagine it would be that high!

Healthcare in Bhutan:

• **Disclaimer: nursing rant, it may be ridiculous and not mean much to non medical people and I have tried to be minimally gory, but apologies in advance***

Health delivery only became prevalent in Bhutan 1961 with the introduction of the first 5yr plan and the development of 65 basic units and 22 hospitals. Before this their health indicators were among the lowest in the world and relied on drs from overseas. In 1974 RIHS was established enabling them to begin to self rely on manpower.
Currently there are 181 drs, 723 nurses, 572 health workers, 31 hospitals and 181 basic medical units throughout Bhutan. There are currently 555 people to a bed within the health system.

Their present system is essentially a 6 tiered referral system.
Firstly is the outreach programs consisting of 1200 volunteer health workers who are trained in hygiene, water education, immunisations and family planing and can give basic meds
Next is the basic health unit, there are several of these in each Geog (equivalent to a state in aus), they can treat minor illness and injuries. If a patient cannot be treated they are referred to the district hospital where there are 3drs, 20 beds and qualified nurses, next is the regional hospitals (east, central and west) for complicated cases and where some specialities are available.
Finally is the national referral hospital in Thimphu. Here there are resources such as CAT/MRI and sub specialists. If someone cannot be treated here, e.g needs open heart surgery they are referred to India.
It was at the national referral hospital we did x2 observational nursing shifts. We had a tour of the hospital one afternoon and it took me a long time to realise what I thought. It was like walking through a movie set. It wasn't as crowded as I expected and a lot bigger, but it was very dark, rundown and eerie. There was so many infection control issues, something that came up again and again, no patient privacy with up to 8 people in a room. However I did have to question, just because it's older equipment then I'm used to, does that make it bad? The nurse:patient ratio is as high as 1:18 but if that's what they have learnt from the start, maybe it works.
In a county that until so recently has no major health services, surely this is better than nothing. I left a bit dazed and determined to go into the shift the next day with an open mind.

My first shift was on the ENT (ear, nose, throat) ward, that changed to dermatology when I arrived. I was then told by my buddy student nurse that it was an overflow medical ward, and the first case I dealt with was paediatrics. Basically it was the bit of everything ward.
The first thing that struck me was the lack of formal handover, staff came and went but no one seemed to know what was happening with each patient. The teamwork is amazing with all the staff helping change the beds from the nurse in charge to the students and helped me realise how well team nursing works in Australia too. Watched quite a few dressing changes, and was struck by how the knowledge of sterile procedures is there, they have reusable packs, sterile gloves and attempt to maintain a sterile field, the lack of awareness of WHY they are doing something means it's often broken. For example, there was some blood on the floor which the nurse wiped up with gauze then put back into the sterile field, before asking me to get the gauze because she couldn't touch the canister. To clean and sterilise equipment such as kidney dishes it's dropped in a massive bucket of bleach. Everything is reused, including gauze and EVERYTHING is dressed with bedatine, gauze and tape.
This lack of understanding why and the possible consequences of what they're doing came up again and again. My second shift in emergency saw a patient being given morphine and when asked the administering nurse had no idea about the side effects and dangers of the drug. At the end of the first shift, we were all struck by how resourceful they are, doing so much with the minimal resources they had. Catheters are used as tourqinets And the plastic wrapper off gloves as emesis bags.
However as we learnt more, we realised that the resources are there. It might not be new and flash but they do have access to what they need. It's the education that's lacking. There is a very strict hierarchy in the hospital of surgeon knowing the best, doctor next best and nurse the least. This means that nursing assessments are non-existent because 'the doctor will do that' and no one wants to step over that line. It's slowly changing but the concept of a COLDSPA pain assessment or questioning the characteristics of chest pain was so foreign.
On that note, one of the most disturbing things we all found was the lack of pain relief administered. It's a widespread belief that it's addictive and that pain is an emotional experience that is non existent if you are properly psychologically supported. This saw post-op patients on no pain relief, nothing given in emergency and knees being relocated without anything. It's is believed that the surgeon knows exactly what pain will be experienced and will write up the right drug, however patients are clearly in excruciating pain, and maybe given only voltarin once daily.

It is interesting to learn how Bhutanese culture and Buddhism is so ingrained into health delivery. One diabetic elderly patient with a leg wound so extensive and necrotic I had to leave the room (and I've got a stomach of steel) refuses to have it amputated despite the fact it will never heal and she's in excruciating pain. On questioning we realised that she believed that should she lose her limb, she'll be disabled in her next life. Among others this case increased my awareness on how we can't push our beliefs on others in the absence of full knowledge and understanding.

Reading back over the last bit I've written it sounds so misleadingly negative. It's not all bad, it's a new and developing system and workforce and they are moving in the right direction. Our student buddy nurses from RIHS were absolutely incredible, both in going out of their way to help and show us and make sure we were ok and also in their scope of practice. 2nd year students were performing skills so advanced, such as cannulation and taking blood from a newborn it was impressive. With such a HR shortage, their skills are needed to ensure the running of the hospital. It was the lack of knowledge behind what they were doing and the background of their patients that shocked me. They are taught assessment and pathophysiology at RIHS but with no support in the hospital and a system that degrades nurses knowledge, they are unable to put it into practice.

In the next couple of days we're heading out to satellite clinics and conducting heath assessments at the local Chorton. Cannot wait to get as much out of it as I can and again an even greater understanding of an amazingly varied, new and constantly developing healthcare system. If never been so sure this is what I'm meant to do, or been so inspired to put the knowledge I'm privileged to have into practice.

It's taken me a while to write this, because I honestly didn't know where to begin. I'm still pinching myself everyday and can't quite believe it's real. Bangkok was dark and sleepy and with a 3am wakeup call our first 18hr day travelling from bangkok-paro-thimpu was a blur of amazing Himalayan views from the plane, naps, markets that turned me into a vegetarian for the next fortnight, dzongs, headaches, decorated trucks and just beginning to get a sense of this incredible place.
The next morning after a solid 12 hours shut eye was the Amazing Race, trying to find out way around Thimphu and managing to go the the new and old cinema and the new and old bank neither of which were the right ones.
The Chorton was definitely the highlight, seeing an entire community come together to pray and immerse themselves in faith amid a kaleidoscope of colour and life was mind blowing. Contrary to calm temples and dzongs it was very evident that the Chorton was a part of people's everyday life with people catching up, sharing meals and watching children play.

That afternoon working on our presentations was a rude reminder that we are actually here to 'study'. Whoops. Also managed to put together the most incredible performance that you will ever see of the anthem, kookaburra sits in the old gum tree (in rounds!) and happy little vegemites, ready for the welcome dinner that night.

Walking into the Royal Institute of Health Sciences I have never felt more welcomed in my life. The staff and students of RIHS organised a dinner and bonfire with traditional entertainment that although important and meaningful, I had chills receiving the traditional white welcome scarf, very quickly became friends singing dancing and learning from each other as though we'd known each other for years.

The next day was back at RIHS in the morning for info sessions on the Bhutanese healthcare system, gross national happiness and public health in Bhutan. We then toured the Thimphu referral hospital where we are doing nursing shifts later in the week.
The following day we visited the HIV and health information drop in centre, drug and alcohol drop in and community health centre focussing on child and maternal health.
I'll leave all the nursing/healthcare things for another post, it's an essay in itself and it's taking me a while to sort out how I feel about it.

That afternoon we visited the school of traditional arts, where students are selected and their entire education is based around either painting, sculpture, woodcarving, mask making or embroidery in an effort to preserve Bhutanese art culture. The attention to detail and skill was incredible, finishing some courses took up to 5 years.

It's very hard to capture what makes Bhutan so special, I could say it's because they've never been colonised, or because of how stunning the landscape and architecture is, how hard they work to preserve their culture or how with a population of under 750,000 people are either related or went to school together, but there's something else I just can't put my finger on so stay tuned.

I am continually reminded how lucky I am not only to be travelling to such an interesting and not so accessible country but also how unique the opportunity to work with and assimilate into such a unknown and protected culture is. The chance to see first hand, learn from and integrate into Bhutan and their healthcare system to this depth is so rare and something that will change how I live and work into the future.

It's currently about day 5..I've honestly lost track and this barely scratches the surface of the first couple of days so there's more on the way! I'll also add some photos when I can, didn't think through the camera to phone logistics without a computer!

Stay smiling xxo