First Day at KCMC Hospital - Don and Thompson

The first day at the hospital was an overwhelming experience. I thought that conditions in Bhutan were challenging enough and walking into the hospital had a familiar third world feel and look to it, but the conditions here are much more stunning in volume and in severity and in lack of modern conditions.

Because Thompson finished his EMT training this past school year, he will shadow me for the month, so on our first day we headed off together at 7:15.

We have been assured he is welcome to participate in anything as long as he has a white coat on, but we want to be very ethical about this, so he will have no unsupervised independent patient care. One of the medical students did lend us a spare coat, so he can sit in on medical student lectures and circulate on rounds. Mostly, he will be observing, putting up x-rays, talking with patients, photography and note-taking – and just generally absorbing a hospital environment few people in the Western world have or will ever experience.




The volume of patients on the ward is phenomenal, the orthopedic ward should have 50 patients but currently has over 80 (we are told that at times it will be over a hundred patients on the wards), tightly packed in, maybe a third of them lying in the hallways on ancient-looking hospital beds or low army cots just 8 inches off the concrete floor. Patient rooms have as many as 10-12 people in them. Only about half of the beds (and none of the cots) have mosquito netting.

X-Ray Rounds are first, at 7:30, to show the x-rays from patients who were admitted over the weekend and from upcoming operations, or x-rays that had been requested to be seen at X-Ray Rounds. Morning Report = the intern, residents and AMO (Assistant Medical Officers) report to Dr. Maya, the Department Chief. It is very formal and ceremonial.

Thompson and I spent the entire day with Dr. Mashala (a first year resident and Thompson thinks he looks just like Turk from Scrubs), rounding to see every patient. It took all day.

One of the frustrating things is that patients are not treated for weeks, and sometimes for months, despite having been referred here for “expert care” and admission to the hospital ward.

For example, on the ward there are probably between 20 and 30 patients awaiting intra-medullary rods for the fixation of femur fractures, and while they wait they have been put into traction. Traction consists of a metal pin placed through the tibia just below the knee with an attached rope (like nylon cheap rope) that hangs off the end of the bed, attached to a single hunk of iron hanging at the end of it. To prevent the patient from slipping down the bed, the foot of the bed is raised on wooden blocks, meaning the patient lies head-down for months at a time. At home, these would be fixed within 24-48 hours and patients would never be in prolonged traction before the surgery.

There are ward rooms that are supposed to be “clean” and rooms that are “septic” but there is plenty of infection even in the “clean” rooms.

Today (Tuesday July 6) was our second day. We spent all day in the orthopedic clinic, which probably sees 50-100 patients, without appointments. The patients wait all day to be seen. For most of the day, Thompson and I were alone with an AMO student (sort of the equivalent of a physician’s assistant student in the US) who was brand-new to orthopedics. I don’t think we saw any patients who spoke more than a few words of English (which is about what we do for Swahili). We saw cases today including a gunshot wound to the lower leg (a game park warden, we think) 10 months ago that had gone untreated this entire time, and is infected. The shot shattered his tibia, which is still un-united. We saw a boy who had fallen off a bicycle two weeks ago, coming in with a likely dislocated hip. Another man who walked in on homemade crutches (all the crutches are homemade), with an untreated hip fracture from 10 days ago. We also saw a case of multiple osteochondromas, which are benign stalk-like growths coming out from the bones, and a case of multiple enchondromas (benign tumors on the inside of bones). We also saw a case of a severe osteosarcoma of the shoulder (a malignant tumor) that will have few if any treatment options here. We saw multiple cases of osteomyelitis, fracture malunions, and lots and lots of back pain and joint pain. And that was just one day.

Thompson spent part of the afternoon sitting in on the medical student lecture, held in the urology library, on diabetic ketoacidosis. During that time I went to the operating room to assist one of the residents with open reduction and internal fixation of a comminuted (i.e. shattered) patella fracture.

It’s impossible not to compare health care here and in other places we have seen, or in the States. The disparity is far too much. I will have more to say about this later but right now it is too much to adequately process.