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Trauma Care in the Himalayas

David Lhowe Trauma Surgeon at Mass General Hospital David Lhowe, MD is an Orthopedic Trauma and Hip & Knee Replacement surgeon in the Department of Orthopaedic Surgery, Massachusetts General Hospital, and Assistant Clinical Professor of Orthopedic Surgery at Harvard Medical School.

Sandwiched between its gigantic neighbors, China and India, the tiny nation of Bhutan is making a rapid transition from an isolated kingdom to a modern Asian democracy. Its 600,000 residents are almost exclusively Buddhist, and are dispersed over a landscape that remains largely forested with relatively little arable terrain. The population clusters in valleys, separated by Himalayan mountain barriers which have only recently become connected by two-lane roads. Through most of its history the country has been isolated from even its closest neighbors, and has only opened to Western tourists in the last 20 years. While visiting Bhutan from the United States is now possible it doesn’t come cheaply. The Bhutanese government charges US citizens a substantial daily tax for the duration of their visits.

A longstanding program through Health Volunteers Overseas places volunteer orthopedic surgeons from the US and other countries at the Jigme Dorji Wangchuk National Referral Hospital in Thimphu where they assist in the training of orthopedic technicians and participate in the clinics and operating rooms. Volunteers and their families are provided with basic housing, and the Bhutanese waives the daily tourist fees for all. The volunteer’s schedule allows ample time to explore the country with knowledgeable guides and drivers who negotiate the narrow mountain roads (which are largely devoid of guardrails). Although technical mountain climbing is forbidden, day hikes are readily available and – for the more adventurous – multi-day treks with horses.

With a median life expectancy of 68 years, the population is relatively young. The Bhutanese diet is largely plant-based, with little consumption of sugar or processed food. People walk extensively, which invariably involves a lot of hill climbing. Obesity and diabetes are rarely seen, and smoking is uncommon. Medical care – including basic medications – is provided to all Bhutanese at no charge. Though rudimentary by US standards, the per capita cost is a fraction of that in any developed country.

Figure 1. Tiger’s Nest Monastery, perched high up in the mountains.
Bird's Nest Monastery in Bhutan

Orthopedic care for the entire country is provided by five surgeons, four of whom work at the Jigme Dorji Wangchuk National Referral Hospital in the capital city of Thimphu. A single orthopedic surgeon is stationed in Mongar, a small city in the eastern part of the country. There is a network of clinics throughout the country, where nonsurgical orthopedic care is provided by orthopedic technicians who function much as orthopedic physician assistants in the US. These individuals perform reductions, apply casts, and follow patients to healing in outlying areas without direct orthopedic supervision, referring those patients in need of surgery to either Thimphu or Mongar. Treatment is largely devoted to trauma, infections, and pediatric problems. There is no joint replacement program. Patients in need of arthroplasty are referred to hospitals in India at the government’s expense.

Figure 2. National Referral Hospital in Thimphu, Bhutan.
National Referral Hospital in Thimphu, Bhutan

Within the hospital items such as gloves, dressings and hand sanitizers are in short supply. Every sponge that is used during surgery is washed and re-sterilized for use in a subsequent procedure. Implants for fracture fixation are limited to SIGN nails and basic plates, which are capably applied by the experienced orthopedic staff. Although image intensifiers are available, they are rarely utilized, and femoral intramedullary nailings are performed as open procedures. Surgeons perform tibial nailings without imaging, using SIGN techniques.

The pattern of orthopedic trauma differs from that seen in an American hospital. There are, for example, very few osteoporotic fractures. In an entire month, I saw no hip fractures and only one distal radius fracture in an elderly woman. Most trauma was the result of road accidents often from vehicles going off the narrow roads and down into ravines – versus those we see in the US that are primarily associated with collisions. Work-related injuries were also prevalent, as road maintenance and building construction are done with extensive manual labor and little safety equipment or regulation. There were some injuries we do not see in New England – i.e. a laborer who lost his finger as the result of a cobra bite and a road worker who sustained a femur fracture when a domesticated working elephant stepped on his thigh.

Serving as an orthopedic volunteer in Bhutan offers the surgeon and his/her family an opportunity to see and participate in a unique culture – more deeply than would be possible as a tourist. The Bhutanese are a friendly, graceful, and welcoming people, and they remain the most memorable part of the experience. I encourage any orthopedic surgeon to consider serving them in this kind of volunteer capacity.

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