A Day at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH)

I woke up this morning and it was raining,  Looking up in the mountains I could see that the rain here was snow up there.  I arrived at the hospital for 9 AM rounds only to discover the building quite empty as a "National Holiday" had been declared because of the snow and the hospital was closed.  Apparently, driving can be quite dangerous in the mountains, though conditions were not bad at all here.

Though there was no outpatient clinic today, we did round with Dr. Tashi and the surgeons.  Approximately 80% of the cancers here are hepatobiliary, pancreas, gastric, or GE junction.  As there is no medical oncologist, Dr. Tashi also supervises the outpatient unit and orders much of the chemotherapy. Rounds were quite international.  In addition to myself and Annette (the superb oncology nurse from the NCI working with me on trip, we had a surgeon from Japan here for 4 months, 3 Bhutanese surgeons, a Japanese GI nurse, and a Bhutanese nurse from the floor who pushed a cart with the charts and a bottle of liquid hand soap on top which we could use to wash our hands between patients.  Of interest, film Xrays were in the chat (no PACS here) so we could look at them with paper copies of the CT images.  Fortunately, the common language used on rounds was English (some of the patients spoke English as well as it is taught in all schools) though Dr. Tashi spoke to some of the patients in Dzhongha (the most common of the 18 different Bhutanese languages).

Following rounds we returned to the Oncology Unit.  WE have 10 beds in the oncology unit which serve as both inpatient and outpatient beds.  Outpatients come in and get there chemotherapy in a bed and then return home.  3 beds are reserved for palliative care.  On rounds we identified 3 patients (2 with gastric cancer and 1 with esophageal cancer) who were not going to be candidates for palliative chemotherapy and recommended palliative care.  By lunch time all 3 were transferred into the oncology unit.  Our charge is to spend about 10 days getting them on a stable palliative care program and them transfer them to a regional hospital nearer to their home (we are at the flagship National Referral Hospital).  There is no home hospice care, with the regional hospitals serving as an inpatient hospice for these patients. 

We did speak for awhile with Tszering, the head nurse for the oncology unit about palliative care and communication of bad news to patients and family.  Culturally, full information is shared with the family, including the diagnosis, prognosis, and recommended treatment.  With the patient, however, the word "cancer" is not used (it is used with the family).  We explain that the patient is sick, tell them how their surgery went, and explain that they need more treatment with chemotherapy (the word chemotherapy is used).  Full chemotherapy teaching with management of side effects  is given to the patient and family.  When I told Tszering that in the US we told everything including the cancer diagnosis and prognosis to the patient and could only talk to family if the patient gave us permission, he thought this was very strange. 

The surgery being performed is high quality (I saw a patient today who was recovering from a Whipple procedure for Ampullary Cancer), though we do not have Hickman catheters.  Vessicant administration is tricky.  We likewise do not have home infusion pumps, or home nursing, so any chemotherapy requiring prolonged infusion is admitted.

We have been asked to put together two lectures one related to palliative care and one on Targeted Therapies, so I will have to begin to pull those together.  They don't use monoclonals or TKI's yet, due to the cost in part, but are interested in learning about them and the clinical uses and results we have from them.

That's about all for today.  I am downloading pictures from the hospital and will post them later.