Auspicious Days and the Bhutan Four-Day Forecasts

In a culture where monasteries were built by lamas on winged tigresses, demons lurk in certain valleys, people drive counterclockwise against traffic around certain intersections, and footprints of Buddha in caves are noted frequently, there are certain degrees of superstition that must be accepted on a daily basis. This system of beliefs permeates the entire culture daily. That is why some of my operating days end at noon as described above.
As a matter of fact, we are leaving shortly before a horrible two-year drought of auspicious days. There are a flurry of foundations poured this week, lots of marriages, and lots of promotions and promotion parties. The real problems start next month.
The way it was explained to me we work off the lunar calendar here. This year we have only eleven months, although one month repeats itself twice. This does not happen very often. We therefore have to check the forecast to figure out what is happening.

For instance, according to the Bhutan national newspaper, The Keusel, the weekly forecast has not been very good.

Tuesday 10/25/05 Day of the Water Mouse

The elements of Water and Wind make the day favorable to conduct rituals, draw Mandala, enter a new house, and hold discourse.

A bad day to construct new statues, consecrate new structures, become a monk, perform rituals, wear new ornaments and clothes, marry, enter a new house,, conduct funeral rights, take the dead out of the house, and venture on a long journey.

Wednesday 10/26 Day of the Wood Ox

The elements of Fire and Wind make the day favorable to conduct rituals, become a monk, wear ornaments and new clothes, draw Mandala, enter a new house, hold discourse, employ domestic help, seek medical treatment, and sow seeds.

Not a favorable day to hold a celebration, conduct funeral rights, take the dead out of the house, or erect prayer flags. Roof the house, and give away household wealth.


Thursday 10/27/05 Day of the Fire Tiger

The elements of Earth and Water make the day favorable only for daily offerings.

Not a favorable day to hold a celebration, construct new statues, consecrate new structures, perform rituals, wear new ornaments and clothes, marry, enter a new house, conduct funeral rights, take the dead out of the house, erect prayer flags. roof the house, give away household wealth, and other important works.


Friday 10/28/05 Day of the Earth Rabbit

The elements of Earth and Fire make the day favorable to conduct rituals, till land, and name a village.

Not a favorable day to hold a celebration, construct new statues, consecrate new structures, perform rituals, wear new ornaments and clothes, marry, become a monk, enter a new house,, conduct funeral rights, take the dead out of the house, erect prayer flags. and venture on a
long journey.

I asked my colleague Dr Tshewang what a family must do if someone died last week. It has not been favorable to remove a dead person from the house for over a week. That could potentially create a problem. Of course, there are exceptions to the rules and ways to get around this. The obvious solution, remove the body out the back door head first (consult a lama first).

Although Friday is not a good day to venture on a long journey there are certain exceptions for international travel, especially when all the flights are booked. Unfortunately, we cannot stay here for the next two years waiting for an auspicious day to start our journey back to Fox Island. I believe we will be back here before the auspicious day drought ends as well. See you all soon after two days of R&R in Bangkok.

Would you let this guy operate on you?

Patients

My daily outpatient clinic is quite an interesting menagerie of patients.

Patient #1
A mother in a beautiful kira and jewelery from a nearby village walks in with her 9 year old son on her back piggyback style. He cannot walk. Never has walked. He was born in the village. No history. Appears that the child has a complex pterygium syndrome and webbing behind both of his knees so he is fixed at 90 degrees. This is complex problem at home and abroad. Could be fixed with complicated operation with help of plastic surgeon but none exists. Mom requests that I might do him tomorrow. I pass for now.

Patient#2
Soldier in camouflage fell off horse yesterday. He is off duty because of a previous foot injury. He was on a horse apparently getting to his house two hours away. He has a stiff neck. Xrays are horrible quality but show no evidence of fracture. Cannot get new xrays because they closed at 1pm. He wants to be off work because of his neck. No problem.

Patient#3
Indian couple. Man in impeccable grey double breasted suit, starched shirt, red tie, gold teeth, dress shoes. Wife in beautiful sari. She has knee pain for two years. Tried traditional medicine. Tried Ibuprofen. No sports, no inuries. Her exam is completely normal. She had a battery of tests from India that are all normal. They drove 6 hours today to see me. I decided to switch anti-inflammatories. They wanted to know if they needed to come back next week for a follow-up.

Patient#4
Pleasant twenty year old cousin half-sister of a VIP colonel in western clothes. She had an arthroscopy by a previous HVO volunteer. She wanted physical therapy. No problem.

Patient#5
Farmer in old gho wearing old leather climbing boots and knee socks. Hands look like they have worked the fields for a century. Bowlegged knees and knee pain. Recent treatment with gold needle acupuncture was only moderately successful. Takes a foul smelling poultice off his knee. Knee exam reveals he has more creaks than barn door. Xrays show severe osteoarthritis. No knee replacements possible here. I prescribe a short course of Ibuprofen. Tell him to take it with his big bowl of red rice and chilies in the morning. He is overjoyed and gives me a big red betel nut smile.

Patient#6
2 1/2 year old girl in a kira with her father. Limped since age one. Born in village. No other history. Exam reveals one leg shorter than the other. Xrays show severe congenital hip dislocation. Briefly explained the treatment of a pelvic osteotomy (re-constructing the socket) and femoral osteotomy (breaking the leg bone and repositioning it in the socket). He says that would be fine if I could do it tomorrow. He will check his astrologer and see if it is an auspicious day. If not he will wait until I return in a year. Maybe I will do it tomorrow.

Patient#7
Farmer in gho, purple track suit underneath, wearing flip-flops. Splinter in his hand that bothers him during rice harvest. He has had the splinter for two years. I remove splinter and he is grateful.

Patient#8
Hospital executive in very nicely tailored gho and knee high argyle socks. Right index finger hurts when he plays tennis. Exam reveals tendonitis. Racket modifications and archery restrictions are placed and he is happy.

Patient#9
4 year old with old diagnosis of clubfoot. Never treated for it. Walks on side of foot. He actually has cerebral palsy. Mother requests some type of treatment. I explain the procedure and she wants it tomorrow since the following year has not been projected as favorable for surgery by the astrologers. We book the surgery and hope that we can get it done along with all our other stuff by the time the OR shuts down at 3pm.

Patient#10
Indian scaffold worker fell today from bamboo scaffold. Dark skin. Large brown eyes. Lives in corrugated steel shack at job site. Back pain. Xray show compression fracture of T12. He gets a release from work but wants to return next week.

Patient#11
Student run over by HiLux truck. Smashed foot this morning. Xrays show foot fracture. Placed in cast and given note to get out of exams. Wants to know if he can play football in two weeks.

Patient#12-25. Same old stuff every clinic. Monks, Nuns, VIP’s, farmers, chidren in miniature gho’s and kira’s, Indian and Nepali workers, people that traveled days to see us, new and old trauma and neglected fractures, wild pediatric cases. Lots of low back pain. Xray closes at 1pm. Clinic closes at 3pm. If you are late for either you return the next day. No complaint box. No insurance co-pays. No Labor and Industry forms. Minimal hand written medical records. Pharmacy carries two anti-inflammatory medications and both work wonders.

Child with reconstructed burned hand is doing really well Now has five moving fingers rather than a fist. Mom really happy.

Girl who walked on her hands got up on her feet today. Very happy person.

Bear mauling guy went home.

Waiting to transport two patients with spinal cord injuries to India. Peak tourist season and no one wants to give up a reserved seat. The airplane will not accommodate a stretcher and we have to remove a row. Red tape,. New helicopter service $1500.00 per hour reserved for tourists only.

Lots of chronic infections have been in the hospital since we arrived a month ago. No
discharge plan as of yet.

All in all. Pretty much business as usual.

Life in Thimpu

Life has been fairly hectic lately. Surgery, teaching, and clinics have been steady. Cases continue to be challenging in a way that is quite difficult to explain. There are no textbooks that describe the difficulties of working on extremely complex orthopedic challenges without all the tools. We do the best we can and so far our outcomes have been good. Today I operated on a guy who has been in bed in traction for eight months. He will be quite happy when we get him out of bed tomorrow to walk. The bear-mauling guy was discharged. The queen’s mother did not return for follow-up.
Our social calendar has been quite busy. It seems that everyone knows everyone in Thimpu. When we came we could not understand the fact that everyone referred to everyone else as a cousin-brother or cousin-sister. We now realize that it simply means that there is some distant relationship that might bind people together. It is not unusual to spontaneously meet someone and they take the weekend off and take you on a local tour or to their family home. This has happened each weekend that we have been in Thimpu. Access to VIP’s is also unbelievably easy. We had dinner with the assistant Minister of home affairs one night. He wears a lot of hats. He was in charge of the recent census in Bhutan and described the difficulties that were encountered counting nomadic yak herders and their kids. He also is in charge of disaster planning for the country and immigration/naturalization. There is only one road that crosses the country and an earthquake would isolate everyone in an instant. We also talked to the assistant Minister of health who is also our neighbor. He is very excited about a rural clubfoot project I proposed. Might be grounds for a return trip.
Last evening we had dinner with Dorji Wangchuck, one of the people who introduced the infrastructure for television and internet to Bhutan. Strangely enough, the pressure caused by the desire of many people to watch the 1998 Soccer World Cup prompted the introduction of TV. Small satellite dishes were purchased on the black market from India and the rest is history. In retrospect, he has definite reservations about the decision. Bhutan has a rich oral tradition, which has been passed on for centuries. It has very little written history. It is now slowly disintegrating as people spend their time watching some pretty strange stuff. Imagine skipping an archery tournament to watch the PGA playoffs in a country that has one golf course. Mr. Wangchuck has now turned his efforts into documenting the rich traditions of Bhutan on documentary films as he sees some of these traditions disappear.

Getting out of Town

It is rice harvest time in the valley. We visited a friend’s ancestral farmhouse and I did a house call on her dad’s shoulder. I will return back before we leave to inject his shoulder in exchange for some of their freshly harvested red rice. It was really a treat to see their farmhouse, which had implements from century ago. Pigs and cows still occupied the ground floor. Second floor is the granary filled with dried peppers, rice, corn, potatoes, apples, persimmons, etc. The third floor is living space and their personal family shrine. The wooden ladder above led up to the open-air attic. No heat. Running water and electricity added a few years ago. The two seventy year olds seemed very happy as they served up some delicious sweet milk tea.
Last weekend we took a road trip to eastern Bhutan. We hired a driver and drove 300 km to Bumthang for a festival. Hiring a driver was interesting. We had to actually talk him into how much money we were going to pay him. He seemed embarrassed when we paid him more than he had asked. Interesting place! During our trip we saw another distinct representation of the country. I now know why 75% of this place is still virgin forest. It is simply impossible to log. The road is famous for motion sickness. We estimated that there were about 10 hairpin turns per kilometer (no exaggeration). There were three high mountain passes each with its own decorations of prayer flags. The road is one lane, rare guardrails or impediments to a surely fatal 500 meter drop-off, impenetrable forest everywhere. There were waterfalls, small repaired landslides, shrines, and it was raining much of the time. Every once in a while we would come upon a beautiful valley with rice terraces or small farms. Monasteries seem to be built out in the middle of nowhere. In the road we encountered two species of monkeys, cows, goats, horses, the ubiquitous dogs, people milking cows, monks, Nepali and Indian road workers, and one person lying in the middle of the road who had consumed too much arak. This road equals the nail biting we did in northern Pakistan, Nepal, and Tibet. I asked one of the docs I work with about how long it takes him to get to his parents house in eastern Bhutan. It is a three day 10 hour car ride followed by a six-hour hike to get to his village. Narrows bridge traffic will now have a relative perspective for me.
We stayed one night of our trip in the Probjikha Valley in an ice-cold traditional farmhouse. Natalie was not impressed. IT WAS COLD! The valley floor (at 11,000 feet) is filled with small farms and fields of dwarf bamboo. The rare black-necked cranes migrate across the Himalayas from Tibet in December when the valley is snowbound. They know how to get away from it all. All electricity was solar and the kids were fetching water from the communal well in the morning. Thimpu seemed like Manhattan. This is where the bear-mauling guy came from before he was transported by rickety ambulance seven hours over the hairpin turns to the referral center of Thimpu.
In Bumthang, we hoped to go to a festival. Unfortunately, time is relative in the monastery calendar and we only caught the tail end of the dancing and festivities after our ten-hour death defying drive in the rain. Our dates did not correspond with their dates. (This year a couple of months doubled) However, in true Bhutan fashion, the monks at the monastery realized out disappointment and took out their ornate costumes and masks and put on a private show for us. They were laughing and having a great time. Nobody asks for money, which is amazing since the monk allowance is $5.00 per month. We visited a bunch of famous monasteries and dzongs. Natalie is actually getting used to gutteral chanting, incense, thousands of Buddha statues, butter lamps, and monks blowing horns made of human femurs. It is amazing how she acclimated to all this stuff. For me, every monastery is still quite special. They are peaceful and dramatic at the same time. Each one is different. We got the opportunity to visit a 500-year-old monastery that was getting a facelift. The amount of labor and the artistic and architectural talent of the laborers are amazing. All the buildings are built with massive hand hewn timbers without nails. Ornate carvings cover all the wood. It is done the same way now as it was 500 years ago. No machinery or shortcuts. Pretty amazing.

Dark Side of Shangri La

There is one dark side that we have seen in Bhutan. All are not Happy in Shangri La. The king and his ministers seem to have made the decision that you are either Bhutanese or nothing (a refugee). There seems to be an arbitrary reasoning regarding who is granted citizenship. If you are not a citizen you are not afforded all the perks in education and jobs. It is unfortunate if you are ethnic Nepali or Tibetan and you are not a citizen. The Minister of Home Affairs was very excited to explain the concept of Gross National Happiness and the overall future goals of the king, which are quite impressive for all the Bhutanese citizens. For those that are not Bhutanese the outlook is more guarded. There is a definite pecking order here. Most of the laborers are imported from India and Nepal. ManyTibetans are still refugees despite the fact that they have lived here their entire lives.

Chilies How many kilos?

Tenzin, Unidentified Monk, Nat in kira

BA in our Kitchen

The Operating Theatre and the OPD

We have been doing a number of interesting cases here. I will not gross people out with photos of the gory details. You are welcome to see them when we return. This is definitely a different brand of orthopedic surgery here. There are two types of cases here- both difficult. The first type is unusual things. These would include a Himalayan bear mauling, paraplegia due to tuberculosis of the spine, two machete injuries to the knee and pediatric hand burns from cooking fires. The other cases include usual things with unusual presentations. This is particularly evident in the pediatric population. We have operated on three children who had severe elbow fractures that did not show up to the clinic until they healed in a malunited position of their growth plate. These cases are extremely difficult. We do not have CT or MRI. Last week we reconstructed a child’s hand that was burned in a fire. All his fingers fused together into a ball and we separated them and skin grafted him from his abdomen. I also operated on a young lady who walked on her hands. She had contractures from CP and showed up in the outpatient department. There are also a lot of chronic bone infections that are difficult to treat. All these cases present late. It takes three days to cross the country by public bus and there are no domestic flights. The surgeons here are a delight and very skilled but are somewhat overwhelmed with business.
The outpatient department is great. The variety of patients is fascinating. Farmers come to clinic in their rice farming clothes with chronic injuries. Their red smiles of betel nut juice crack me up. Buddhist monks, nuns, and lamas show up in their crimson and saffron robes. Kids walk in with plaster casts that were placed two months ago. There are army guys in fatigues, Indian women in saris, and imported Indian laborers from the nearby hospital project. A highlight of my OPD experience was when I was asked to see the mother of the queen who had developed knee pain. She was in a VIP exam room. This consisted of a concrete sink, two stools, a wooden exam table with a pad, and an entourage of people. Lots of history, lots of gold jewelry, very little skin to examine, and very tentative treatment with NSAID’s. If I caused the queen mother to get gastritis I would be in trouble! A number of people have seen traditional healers as well. It is quite a menagerie on a daily basis. The hospital and the OPD are old but spotlessly clean. They make the best of their limited resources. Families are always attentively at the bedside even if the patient is there for weeks. Nurses wear traditional nursing caps and are called “Sister”. The operating room is clean but the concept of operating room sterile technique is taken to the limit. We are working hard on training the OR techs. This will be the role of any OR personnel that come during the next visit here. All in all, the medical experience here is quite amusing and rewarding at the same time.

Gross National Happiness and the Environment

These are a few of the interesting features of this country based on a benevolent monarchy who truly seems to care about the future of this country. It is almost like they waited to see what other mistakes developing counties in the region before they made them as well.
For instance: (Only in a kingdom)

1) Smoking is against the law here.
2) Bhutan is still 75 % covered in forest. They closed the plywood factory because it used too much wood.
3) The zoo was abandoned because the king and the Bhutanese believed that it was not in the Buddhist tradition to incarcerate animals. They freed all the animals and the low IQ takins (half goat-half cow, more later) hung out in town. Now they have their own sanctuary. Maybe they were not so dumb but they sure look it.
4) There are lots of National Parks and Wildlife Sanctuaries.
5) Some of the big peaks here have not been climbed because the king heard that the expeditions bothered the nomadic yak herders.
6) Plastic bags are not used. There is very little litter.
7) Schoolchildren are recruited to clean up the local streets.
8) Most of their animals are protected by law.
9) There have been only 60 cases of HIV, mostly on the truck route from India.
10) Health care reaches about 80% of the population. In the rural area this is in the form of rural health units. There is a thriving traditional medicine scene here with a very organized program of teaching and pharmaceuticals. Health care here is free. There is no private practice scene as of yet. Immunization of children is 100%.
11) Education is free. Unfortunately, you have to test to get more than a 10th grade education and competition is fierce. As more kids need jobs things might get sticky.
12) Men are required to wear the national dress “gho” for anything formal and most people wear them every day. This has kept a national tradition alive and made the place a lot more colorful and less contrived.
13) The architecture here is required to be built in a traditional manner. Mostly post and beam with recyclable materials (Bamboo, mud, etc)
14) They have hydroelectric power they SELL to India. They have no oil or gas and do not use much on their limited roads.
15) Cable TV is available since 1999 and is corrupting some minds. It is bizarre to see very simple farmers in the waiting room watching ESPN The internet has one government provider. It is not a monitored fake internet like Myanmar.
16) Per capita income is $1300.00 year. Despite this fact there is no famine in this place where most people are subsistence farmers. 98% of the farmers own the land they farm. They seem to be cautious in their acceptance of international development. Some of the big new expensive hotels scare me a bit.
17) With the exception of what I see and hear about Thimpu the government seems to have a plan to prevent urban sprawl and the stagnation and poverty that is produced by this problem.
18) I have not met a foreign aid worker yet that has not loved it here. The people are unbelievably honest and not pushy. BettiAnn left some of her stuff at a café for three days and it was there when she returned (including the bag of potato chips). I have asked some of the doctors about whether they believe that privatization of medicine will occur as it has in India. They look at me quizzically and respond “Why should it… we are all pretty happy”)
In general, the concept of Gross National Happiness appears to be alive and well. Although I have met a few people that do not seem entirely satisfied with their situation (especially refugees) the satisfaction of people with their simple uncomplicated lives seems almost embarrassing.

Traditional Bhutanese dress at the Paro Sunday Market. We got out of Thimpu this weekend and hiked up 900m from the Paro Valley to the Tiger's Nest. According to the resident monks the lama who built the monastery flew up there on the wings of a winged Tigress. I think that 400 years ago it would have been extremely difficult to haul concrete and huge beams up this cliff so I tend to agree with the monks. It was a fabulous hike to a spectacular monastery. Natalie was accompanied by a Bhutanese friend and they were not effected by the altitude. I wish I could say the same for BA and I.

The Jigme Dorji Wangchuck National Referral Hospital hospital and the Thimpu Valley.
I will try to walk you through a day in our lives. The sunshine has broken through the clouds and the rain has stopped. We are still waking up a lot at night. This is either due to the altitude or the barking dogs. A dog’s life is not so bad in Bhutan. The Bhutanese believe that dogs have the best opportunity to be reborn or reincarnated as humans. They are also thought to be helpful in the afterlife by leading people with their tails to a better life. Hence, there are lots and lots of dogs around here. They are not fetching type dogs like our lab Lizzie. Instead, they like to curl up a lot in the middle of the street for naps. At any rate they compete for the magnitude of their barking every night when it is not raining. Earplugs are essential.

I walk down a path to the hospital about 500 meters. They are building a new hospital with Indian labor and the laborers live in corrugated metal lean-tos covered with blue plastic tarps. They collect rain water in big black bins for showers. They work long days. I do not assume they make more than a couple of dollars a day. A lot of them show up in the clinic with injuries. No OSHA requirements. Bamboo scaffolding four stories high bound together with cheap Indian manila twine is somewhat unstable. They build each story of the structure supported by a multitude of 4 inch poles and sticks and it looks like a giant jail. Some of them fall off the scaffolding and the hospital ER is quite convenient.

My walk to the hospital is quite pleasant. Bhutan is quite verdant and there are field of cosmos, dahlias, and sunflowers in bloom right in the middle of the city. There are fruit trees in our front yard. Thimpu is in a valley and I look up to some snow dusted mountains. Every building here has the ornate traditional architecture. They have gone through great lengths to maintain these traditions. The hospital is dilapidated but quite pretty. There is a gold spire in the center. Yesterday morning I walked past Buddhist nuns and monks with their prayer wheels rolling, men in their ghos, and women in their traditional kiras. There were a few people in Indian saris and a few in Nepali dress. Most people here wear traditional Bhutanese dress and it is quite colorful. I will send some pictures because it is hard to explain these outfits. The most fabulous outfits are the bizarre accessories. Yesterday I saw a patient with a traditional gho, a cowboy hat, sunlasses, knee length argyle socks and purple Converse high-tops. Yesterday I also came across thr Rinpoche (holy lama) in his crimson and gold monk outfit.

I usually walk through the filled emergency room and down to the outpatient department.
The halls are filled with patients in the early morn. It is an amazing menagerie of people. Small children are slung on the backs of their mothers. About a third of the adults are chewing doma which is actually betel nut. It is a nut mixed with lime powder and wrapped in a leaf. It turns your mouth bright red and stains your teeth black. It is their answer to a morning Starbucks. There are signs all over the hospital asking people to please not spit their doma in the hospital and people usually follow the rules if they can read. There are always interesting juxtapositions between old and new. The main orthopedic waiting room filled with about 60 people were all watching ESPN cable TV with Tiger Woods playing golf.

We have a great clinc. Some problems are the same as I see in Gig Harbor. For instance, instead of tennis elbow I see archery elbow. There are lots of people with back pain from carrying heavy loads. There are a multitude of old fractures and dislocations that never got to a health care facility for months that show up. Theses are the most difficult cases since we never see them in our country and the references that are written about management are historical at best. Other problems include falling from bamboo scaffolds, struck by arrows during archery tournaments, and a peculiar injury that I am not sure of yet that occurs when a person slips and falls into an Indian toilet and ruptures their Achilles. A fair number of people have tried some traditional medicine before they ventured to the referral hospital.

Archery Tournament and men wearing gho's. They stand right next to the target and the opposing team shoots from 140 meters away with bamboo bows. No wonder we see arrow injuries in clinic