KYOTO UNIVERSITY HOSPITAL

Report of the Medical
Exchange Activities
in Bhutan 2017 ‑ 2018

Signing Ceremony (October, 2017)■ CONTACTKYOTO UNIVERSITY HOSPITAL
E-mail：bhutanku@kuhp.kyoto-u.ac.jp

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KYOTO UNIVERSITY HOSPITAL

Project overview
In October 2013, Kyoto University Hospital concluded a medical exchange agreement with the Bhutan Ministry of
Health and the Universit y of M edical Science of Bhutan to develop young doc tors in Bhutan. Based on thisagreement, we dispatched about 70 medical staﬀ members including doctors, nurses, technicians and nutritionists
to Jigme Dorji Wangchuck National Referral Hospital（hereinaf ter referred to as

JDW Hospital ）, which is theﬂagship hospital of Bhutan, for 3 years following the agreement to provide medical support and participate ininternational exchanges.
The agreement expired af ter 3 years, but there was a lot of positive feedback in Bhutan that the dispatch of
medical staﬀ from our hospital has been very beneﬁcial to improve the medical situation in Bhutan. To continue
with this project, the agreement involving the four parties of Kyoto University Hospital, the University of Medical
Science of Bhutan, the Bhutan Ministry of Health, and JDW Hospital was renewed. The signing ceremony was heldat the University of Medical Science of Bhutan in October 2017, and we resumed the dispatch of our medical staﬀ to
JDW Hospital. Based on the agreement, we are mainly performing the following three activities:
1

Dispatch of medical staff including doctors as requested by Bhutan

2 Assistance with the development of a specialized residency program through clinical practice
3 Instruction on public health and how to use medical equipment to improve the medical environment in Bhutan

Medical staﬀ members dispatched from Kyoto University Hospital to conduct medical activities in Bhutan, with its
national philosophy ofGross National Happiness（GNH）, have obtained valuable oppor tunities not only tocontribute to the improvement of healthcare in Bhutan, but also to review the practices in Japan through medicalcare with limited medical equipment and to think about what is happiness.

Signing ceremony

Activity Report

Activity Report2

●Department of Hematology and Oncology

Activities performed from 2017 to 2018
As mentioned above, we sent medical staﬀ to JDW Hospital from October 2017 to December 2018, including
specialists in diabetes, endocrinology, nutrition, hematology, gynecology and pediatrics, which have been highly
needed and requested in Bhutan, based on the renewed agreement. JDW Hospital, where our hospital staﬀ team is
performing medical assistance activities, is located in the capital city Thimphu. This hospital is the largest general
hospital in Bhutan and has 381 beds, 20 departments and approximately 80 doctors. It is adjacent to the Universityof Medical Science of Bhutan and also functions as an educational research institution where residents, interns, andnurses are receiving training.
The following members were dispatched to JDW Hospital for medical assistance from October 2017 to December
2018. For details of the activities, please see the reports by the dispatched staﬀ on the following pages:

In March 2017, Professor Takaori, the director of this department visited JDW Hospital for a preliminary inspectionof the medical treatment of blood diseases. There are no hematology specialists in Bhutan. Many patients withh e m a t o l o g i c a l d i s o rd e r s h a v e b e e n h o s p i t a l i z e d a t J DW H o s p i t a l , b u t t h ey d o n o t u n d e rg o a p p ro p r i a t e
examinations and do not receive adequate treatment. In February 2018, Drs. Kanda and Miyoshi gave lectures andtrained residents as well as hematology test technicians while providing medical care in the ward and outpatient
clinic of the Department of Hematology. The specialized guidance to residents and technicians enhanced the levelof cli ni c al p ra c ti ce fo r h e mato log i c al d is o rd e rs a n d i m p rove d t h e p roto co l of t h e d e pa r t m e nt p e r fo rm i n ghematology tests. On the other hand, it was found to be diﬃcult to make a diagnosis of hematopoietic disorders inmany cases at JDW Hospital. At JDW Hospital with its serious shortage of doctors, it is necessary to improve thetechniques of the technicians to ensure accurate diagnoses. We therefore decided to invite two technicians of JDW
Hospital to our hospital and provide training on ﬂow cy tometry and microscopic visualization of bone marrow

Team 8PeriodName

Title and department

October 7 to 18, 2017

Tsukasa Baba

Associate professor, Dpt. of Obstetrics and Gynecology

Daisuke Taura

Program-Speciﬁc Assistant Professor, Dpt. of Diabetes, Endocrinology and Nutrition

Kanae Asai

Registered dietician, Dpt. of Metabolism and Clinical Nutrition

Junji Fujikura

Assistant professor, Dpt. of Diabetes, Endocrinology and Nutrition

Hanako Yamauchi

Nurse, Nursing Department

February 5 to 22, 2018

Junya Kanda

Assistant professor, Dpt. of Hematology and Oncology

February 17 to March 3, 2018

Takashi Miyoshi

Program-speciﬁc assistant professor, Dpt. of Hematology and Oncology

February 5 to March 3, 2018

Yurie Omae

Nurse, Nursing Department

Tsukasa Baba

Associate professor, Dpt. of Obstetrics and Gynecology

possible using the medical resources of JDW Hospital. They also gave lectures on techniques and anatomy speciﬁc

Masumi Sunada

Chief physician, Obstetrics and Gynecology, Mitsubishi Kyoto Hospitalto laparoscopic surgery to deepen participants understanding. In response to a request from Bhutan to dispatch

Hirofumi Shibata

Clinical fellow, Dpt. of Pediatrics

Shoko Matsuyama

Chief nurse（Surgery）,Nursing Department

Hisako Harada

Deputy chief nurse（CCU）,Nursing Department

October 7 to November 4, 2017

October 28 to November 25, 2017

Team 9March 18 to 25, 2018

Team 10

November 25 to December 15, 2018

●Department of Diabetes, Endocrinology and Nutrition

images to the technicians. If it becomes possible to make an accurate diagnosis in Bhutan, it will not be necessary
to needlessly send patients to India, which will reduce the patients burden and medical expenses.
Also, Dr. Kanda and Dr. Miyoshi continue to support the local doctors, for example by providing consultations on
medical care in the ﬁeld of hematolog y to the residents by email , to improve the medical treatment of blood
diseases at JDW Hospital.

●Department of Obstetrics and Gynecology
Dr. Baba took part in ward rounds and surgical tours to learn the actual conditions and needs in the clinicalpractice of obstetrics and gynecology in the hospital in October 2017. In March 2018, Dr. Baba and Dr. Sunada weredispatched to JDW Hospital. They provided demonstration and guidance on laparoscopic surgical procedures tothe local g ynecologists, including residents, and demonstrated that laparoscopic simple total hysterectomy isgynecologists to provide guidance because the surgical instructions provided by our gynecologists had been very
useful, we are sending gynecologists there again to provide guidance on laparoscopic surgery in February 2019.

●Department of Pediatrics
Dr. Shibata（specialty: immunology and allergy）provided guidance on the management of atopic dermatitis andthe response to food allergies at the outpatient department as well as ultrasonography to the local doctors andNon-Communicable Diseases（ NCD）prevention measures are listed as one of the main issues in the healthcare

residents, while providing on-site medical treatment in the pediatric ward and PICU of JDW Hospital and attending

ﬁeld of the 11th Five-Year Plan（2013 to 2018）. According to the Annual Health Bulletin 2017 issued by the Bhutan

ward rounds. He also gave specialized lectures in response to a request by the residents and discussed points to be

Ministry of Health, however, the increase in lifestyle-related diseases is remarkable, and the number of patients withimproved with local doctors, in reference to the contents of the residency program.

diabetes increased from 4,097 patients in 2012 to 12,120 patients in 2016, while the number of patients withhypertension also increased from 27,023 patients in 2012 to 30,260 patients in 2016.
At JDW Hospital, outpatient medical care for lifestyle-related diseases is provided twice a week on Tuesdays andThursdays, but there are no specialists in this ﬁeld. Dr. Taura and Dr. Fujikura improved the care of patients withdiabetes at JDW Hospital by teaching and advising local doctors concerning hospitalization for glycemic control
and enforcement of diabetes screening, and by giving lectures to local nurses on diabetes care while providing
diabetes care at the outpatient department to learn about local practices.

●Department of Nursing
Ms. Yamauchi and Ms. Omae were dispatched in October 2017 and February 2018 respectively to provide training
on easy-to-master nursing procedures to nurses and nursing students at JDW Hospital while working in the wardsof their own specialties.
In December 2018, two instructor-level nurses were dispatched, and they practiced nursing management and carewith the local nurses in the operating room and ICU. In view of the points to be improved they noticed while getting●Department of Metabolism and Clinical Nutrition
Ms. Asai, a nutritionist of Kyoto Universit y Hospital worked with nutritionists at JDW Hospital to improve the3

to know the actual situation, they gave t wo lectures（ measures against infections in the operating room

andimportance of early interventional rehabilitation in the ICU ）to the local nurses and doctors. After the lecture on
measures against infections in the operating room, the issues of enlightenment on hand hygiene,

introduction of

hospital food service, implement nutrition management with the aim of introducing an NST（Nutritional Support

a one-footwear system, and development of a day leader supervising operation management were addressedTeam）, and enhance nutritional guidance materials for patients with lifestyle-related diseases.

using the PDCA cycle.

Activity Report

Activity Report4Period

October 7 to November 4, 2017

Program-Specific AssistantProfessor, Dpt. of Diabetes,
Endocrinology and Nutrition

Daisuke Taura
Activities●Providing actual medical care in the lifestylerelated diseases outpatient clinic and the
medical ward of JDW Hospital●Providing guidance, advice and lectures to local
physicians and nurses●Understanding the food service system at JDW
Hospital and improving related issues（assistingwith activities of the nutritionist Asai）
Issues noticed during the activities●Lifestyle-related disease outpatient care

Asai improved this pamphlet so that those who do notwanted to see the Bhutanese food culture and diet.

to find answers themselves as necessary, and sometimes

understand English would also understand it. For more

Typical Bhutanese cuisine generally consists of rice,ask the senior doctors for advice.

details, please refer to Ms. Asai’s report. Regarding oral

cheese and red pepper. The amount of rice consumed

Patients have to come to JDW Hospital the day

hypoglycemic drugs for patients with diabetes, metformin

per meal is very high, although there are individual

before their consultation to undergo such blood tests as

was used for almost all patients, and when the diseasedifferences. According to the data of the Bhutan Ministry

fasting glucose and blood glucose 2 hours after a meal,

could not be controlled with metformin alone, gliclazide

of Health, the mean amount of salt consumed perother serum chemistry exams and HbA1c if the doctor

was selected as the second-line drug, and pioglitazone

day is 9 g. I actually thought that Bhutanese people

prescribed it at the previous visit. Therefore, patientswas selected as the third-line drug. The frequency of

consume more salt because there are many patients

who come from rural areas need to overnight in Thimphu

insulin use appeared to be lower than at diabetes

with hypertension, hypertension-associated cerebral

City. The doctors could spend only an extremely short

outpatient clinics in Japan. In my opinion, the pancreatic

hemorrhage and renal failure among both hospitalized

time with each patient, and their main tasks were to

insulin secretory ability of Bhutanese patients withpatients and outpatients. However, a nutritionist working

confirm the results of blood tests and the details of

diabetes may remain better compared with Japaneseat the Bhutan Ministry of Health with whom I discussed

the prescription. Two dedicated diabetes nurses andpatients with diabetes.

the matter told me that the data of 9 g/day is reliable

a nutritionist shared the booth. To all patients newly

The reports by Dr. Fujikura, who was appointed as

because the data was not only collected from people indiagnosed with diabetes, the Bhutan Diabetic Patient

my successor, provide details on the analysis of drugs

Thimphu but also from people randomly extracted from

Handbook（which also serves as a patients’own medical

selected for outpatients with diabetes. For example,

the whole country. To ascertain this matter, I planned

record）
was first handed out. A nutritionist gave themsince DPP4 inhibitors are not adopted at the hospital,

to estimate salt intake by measuring the urinary Na

nutritional guidance, a nurse measured their blood

patients who needed to use them had to buy theand creatinine excreted by patients immediately after

Outpatient treatment at the department calledpressure and provided instructions on self-injection ofdrugs themselves. DPP4 inhibitors are known to behospitalization, explained my plan to Dr. Fujikura and the“Lifestyle-related disease outpatient care”has been

insulin as necessary. Although I thought that this was a

expensive, but well-informed patients who wished toresident, and then returned to Japan. Unfortunately, thisprovided since 2007, and this department manages

wonderful form of team care provided at the outpatientuse it, purchased it from India and used it as prescribedstudy could not be done after all. I also saw that people

patients with diabetes every Tuesday and Thursday.

booth for diabetic patients, I unfortunately could not see

by their doctor. No cases who used SGLT2 inhibitors,

often sprinkled salt on dishes such as soup, so I strongly

Indeed, patients diagnosed with diabetes comeany information sharing between doctors and nurses or

which are even more expensive than DPP4 inhibitors,

felt the need for activities to raise public awareness offrom various parts of Bhutan to visit this outpatient

nutritionists while busy performing outpatient care. Only

could be confirmed. This seems to be closely related tosalt intake.

department at JDW Hospital. About 50 to 120 patientsfirst-time patients were referred to receive nutritional

the fact that medical costs in Bhutan, including drugs, areper day form long lines in front of the outpatient booth.

consulting, and doctors did not seem to inquirebasically all free.

A total of two doctors, namely, a senior doctor and aabout diet or referred patients for follow-up with the

In addition, while actually conducting outpatient care, I

working for JICA. Ms. Asai was dispatched to join thisresident provide care to these patients side by side. In

nutritionist. The dedicated outpatient nurses were highlysoon noticed the low reliability of the HbA1c test values

team and also assisted with the Japanese volunteer

effect, each resident provides medical care separately

informed, aware and enthusiastic, and they prepared a

at JDW Hospital. I was surprised to see a patient with anactivities. The nutritionists made enteral foods themselvesfrom the senior doctor. There were almost no strange or

pamphlet on dietary guidance which was provided at

HbA1c value of 40 units on the first day of my outpatientand also determined the ingredients of enteral nutrition

wrong points in the medical treatment provided by thethe outpatient booth（see Photos 1 and 2）. Nutritionist

work, and was told by a local doctor that he had seen

and total calories themselves. Unfortunately, the doctors

a value of 80 units, which means that the specimen

at the hospital have a lower awareness of nutrition.

examination system needs to be improved.

Although there are many nutritionists, we did not see

Photo 1 Photo of specialist outpatient nurses and thenutritionist Asai
5

residents. They said that they were making daily efforts

Activity Report

Photo 2 Poster displayed in the outpatient department
with diet guidance for patientsJDW Hospital has a total of 6 nutritionists, including 5
local nutritionists and one Japanese volunteer nutritionist

Many patients with hypertension as well as thoseany NST or related activities. The hospital prepareswith both diabetes and hypertension also presented

only one type of meal and the patients or a family

at the Hospital, but losartan and amlodipine weremember come to a place close to the kitchen to pick

predominantly used among the antihypertensive agents.

up the prepared meals at specified times（Photo 3）. It

In some cases, hypertension might be poorly controlled

is said that the hospital meals are made in accordance

even with a combination of multiple drugs, and mostwith the recommendation of the Bhutan Ministry of

hypertension patients with concomitant or non-

Health, but only curry rice is actually provided every

concomitant diabetes already showed signs or symptoms

day and the proportion of carbohydrates is extremelyof decreased renal function.

high. The volume of food dished out is determined by●Nutritionist activities and feeding service system
at JDW Hospital, and food culture in Bhutan

the size of the plate, therefore, it is almost impossible

Lifestyle-related diseases such as diabetes andfamily of a patient who was hospitalized for hypertension

hypertension are closely related to diet. Therefore, I

complained that,“The hospital’s meals are too salty,”

to calculate the total calories. Quite impressively, theActivity Report6and I saw how that family actually prepared and brought

diabetes treatment at the outpatient diabetes clinic, alloutpatient care, which were recorded by nurses, actually

hypertension are detected only by chance. Ideally, it is

low-salt meals to the patient every day. Both the calories

Bhutanese doctors suddenly disappeared and I then had

existed. These included the patient’s name, blood sugar

better to organize and consolidate outpatient medical

and the amount of salt included in enteral nutrition

to face smiling patients who only spoke Dzongkha andvalue, birthplace, and the presence/absence of renal

records at the current JDW Hospital and to establish

and hospital meals per gram are ambiguous. It was

did not understand English. I experienced such cases

dysfunction. Body weight was not recorded, but after thean appropriate health examination system using theconcluded through discussion with Ms. Asai that it was

several times. The ideal way of improving the current

content was discussed, it was improved.

collected data at the national level to lead to the earlynecessary to accurately calculate these values, and she

situation is to develop diabetes-specialized doctors with

Several clinical research projects have also alreadyworked with other nutritionists to calculate them. These

an interest in clinical diabetes. Currently, all specialized

started. Statisticians and nutritionists have beencardiovascular events that occurs as a result of lifestyle-appear to be important data to subsequently improvemedicine in Bhutan is centralized at JDW Hospital, whichcollaborating to create digitalized diabetes outpatient

related diseases, eventually leading to a reduction of

the hospital food service and enteral nutrition feedingmeans that if Bhutanese doctors want to acquire somecare data since several years ago. However, data are

public health and medical expenses. At the same time, I

programs.

form of specialization, they need to undergo training at

input when nutritionists skilled in data entry into thethink it is essential to promote educational activities to

JDW Hospital. However, this also means that if JDWcomputer happen to be there, but are left out when they

improve the entire population’s awareness of lifestyle-

Hospital has only one diabetes and endocrinology-

don’t, and it is doubtful whether there are continuous

related diseases.

specialized doctor, diabetes and endocrine care will

data for all visiting patients. I explained to them theimprove, which will promote the education and guidance

importance of continuing to collect continuous data.
ward medical records. The content on the first page may

is necessary to consider spreading medical practice at

In the 1-month period, there was only one patientfor example be test values, a summary of current medical

JDW Hospital to local hospitals in the future. On theadmitted suffering mainly from my specialty, endocrine

history, or the doctor’s notes of first visit depending onother hand, conducting an investigation on diabetes anddiseases, and the patient was only suspected to havethe patient. As preparation for emergencies, we urged

hypertension at JDW Hospital, even at one site, is enoughan endocrine disease. If the diagnostic level regarding

both the doctors and nurses to standardize at least theto grasp the current status of these diseases covering

endocrine diseases in the countryside does not improve,

first page of the medical record and provided data for a

all areas in Bhutan, which is a very special situation. It

there is concern that patients will not make their way

standard first page form we had prepared as an example.

is necessary to confirm this point, and then to continue

to JDW Hospital. However, there are fortunately two

Patients admitted to the medical ward are also

recording patients’medical information at the outpatient

residents in the medical ward of JDW Hospital who arerecorded in the computer when they are discharged.

section for diabetes while refining this valuable clinical●Guidance, advice, and lectures to local doctors
and nurses●Providing nutritional guidance, understanding
the current state of hospital food service, andimproving related issues●Inspecting and improving medical record anddata systems

interested in endocrinology and who want to become an

However, only the name of the main disease is input,

database. Especially, lifestyle-related diseases such as

endocrinologist. Furthermore, in response to a request

and I thus felt that more improvements are necessary todiabetes and hypertension are greatly related to eachof the local nurses, a lecture regarding the nature ofprovide viable information for clinical research. However,country's own history, customs and environment, anddiabetes and the state of clinical diabetes in Japan wascompared to the information gathered before ourthe Golden Standard for medical treatment of diabetes

given, and a large number of nurses attended it（Photo 4）.

dispatch to Bhutan, it is evident that advancement has

in Bhutan may be different from that in Europe, theBefore the dispatch to Bhutan, I knew that patientscurrently been made in terms of the digitalization andUnited States or even Japan.
（I explained to the resident

In view of the opportunity to give daily advice

would carry their medical records themselves and noorganization of medical information.

that it is necessary to obtain Bhutan’s own clinical data,

regarding diabetes care and endocrine care to local

data remained at the hospital. Accordingly, the objective

even if the sample size is small. In addition, we also

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Healthdiscussed the clinical research topic of one local resident

patients with diabetes in Bhutan, where it is predicted

When I asked many outpatients with diabetes whomsome extent.）
It is essential to gather clinical data not onlythat the disease will grow in incidence, local internal

I met, “How were you diagnosed with diabetes?”for daily medical practice in the clinical setting, such as

medicine doctors want to learn more and acquire

most of them answered that they were found to havediabetes and hypertension, but also for epidemiologicalknowledge about the reality of clinical diabetes in Japanelevated blood glucose when they visited a local clinic

research and therapy evaluation. It is also necessary to

and often asked our opinions. On the other hand, sinceand underwent blood tests because they had a cold,

further discuss with the local doctors and the Bhutan

no doctors are currently specialized in diabetes, daily

gastroenteritis or some other health problem. It is a

Ministry of Health concerning how to prepare and store

outpatient diabetes care is conducted by busy internal

good thing to also evaluate the blood sugar and blood

clinical data at JDW Hospital in the future.

medicine doctors and residents taking turns performing

pressure at the time of a visit, but many patients tend

It is considered necessary to introduce DPP4 inhibitors

outpatient diabetes care, which internal medicine

to be diagnosed with diabetes or hypertension only

for the treatment of diabetes. In fact, there are many

after the disease has progressed to a certain extent

patients with diabetes who are poorly controlled with

under the current circumstances that diabetes andtwo drugs of metformin and gliclazide. However, sincedoctors including residents, nurses, nutritionists, andwas to inspect and improve the current JDW Hospital

students, I gave as much advice and guidance as I

medical record and data systems. As of October 2017,

could. Having understood the importance of caring foroutpatient visit records of all patients who had received

doctors unfortunately consider as something they would
rather not engage in. For example, when I started actual
7

Bhutan have been diagnosed with diabetes for the firsttime at the outpatient department of JDW Hospital. It

professionals working at JDW Hospital.

Accomplishments and results of this dispatch

Currently, all outpatients with diabetes from all over

It is difficult to understand what is written where in theof all doctors, residents, interns, and allied healthcare

Photo 3 Providing hospital fooddetection of lifestyle-related diseases and a decrease in

Activity Report

Photo 4 Lecture

and prepared study designs for such research as theidentification of risk factors for renal failure in Bhutan to

Activity Report8Periodcurrently blood IRI and CPR can only be measured with

doctors frequently asked questions about how certain

support from India, and Bhutanese patients actually show

cases would be handled in Japan, giving us the feelingan instinctively negative reaction to insulin self-injection,that continued future support from Kyoto University is

it has been difficult to move to the next step in many

desired.

cases. Indeed, many patients import DPP4 inhibitors

Regarding the dispatch period of 1 month, I felt that

individually, so in order for the clinical care of diabetes

it was too long simply for inspection, but too short toin Bhutan to improve and expand, it is necessary tomeaningfully get involved in local activities. Just as itprescribe DPP4 inhibitors, which have a low risk ofbecame easier to put our plans into action as we have

hypoglycemia and much clinical evidence of their efficacy

gained close relationships with the local medical staff,

in Asians.

we already had to return home, although reluctantly.
Personally, I would gladly visit JDW Hospital andgastrointestinal diseases（liver failure）, renal diseases

Assistant professor, Dpt. of
Diabetes, Endocrinology andNutrition

Junji Fujikura
Activities●Diabetes care and education in the ward andoutpatient clinic of JDW Hospital（nephrosis and renal failure）, autoimmune diseases
and pneumonia.
Many hospitalized patients with diabetes had endstage renal failure. It seemed that JDW Hospital has
no room for the educational admission of patientswith diabetes. During this dispatch period, several
outpatients were hospitalized to control theirblood glucose. For patients who might be following
inadequate diet therapy or be practicing a poor insulin
injection technique, improvement in the blood glucose

Overall impression of the present medical
assistance activities

rekindle my friendship with the local medical staff with

Issues noticed during the activities

whom I became close, but also to help JDW Hospital

According to the Annual Health Bulletin, whilesome patients’disease remained poorly controlled

I am very grateful that I could partake in the medical

and the newly founded Bhutan Medical College if thepatients with malnutrition decreased from 331 in 2011

despite hospitalization. It seemed to be better for themassistance activities in Bhutan this time. As someone

opportunity arises. The local nurses are tenacious andto 311 in 2015, patients with diabetes increased fromto continuously maintain awareness of the significance

who is used to the convenience of life in Japan, I was

asked me to bring many SKII and anime DVDs when

3,740 in 2011 to 12,384 in 2015, and patients withof diabetes examinations/educational admission. Ifvery worried about how I would work over there and if

I return to Bhutan. While 1 month was short, I assess

hypertension increased from 23,051 in 2011 to 34,646

the hospital has doctors specialized in diabetes andI could live normally before the dispatch, but Thimphu

that I was able to interact much with local doctors andin 2015, suggesting an improvement in nutritional

lifestyle-related diseases, there is no doubt that theturned out to be a very nice city. The country has theallied medical professionals and that I could support mystatus and an increase in patients with lifestyle-related

care of patients with these diseases will improve.

goal of becoming a tourism-rich nation and there weresuccessor, Dr. Fujikura, to begin his activities.

diseases.

level was promptly observed after hospitalization, but

Although 18% of patients hospitalized in the medical

no issues regarding food or other amenities, and the diet

Finally, I would like to express my gratitude to the（1）Exclusive physicians specializing in diabetes

ward had blood glucose and HbA1c values at a

I had planned before going there failed. Not being able

hospital director Inagaki, Dr. Okajima, and Mr. Yasumoto/ endocrinology / lifestyle-related diseases are

diabetes level, 45% of them did not undergo tests

to eat much fish, also raw fish, was something that I, as afor having granted me this precious opportunity, as wellrequired.

for blood glucose and HbA1c after discharge. Blood

Japanese, found tough.

as the obstetrician Dr. Baba and the nutritionist Ms.

The Diabetes Section of the Lifestyle-related Diseasecell and liver/kidney function tests were adequately

Asai for having accompanied me. With those who wereUnit opens twice a week on Tuesdays and Thursdays,

performed, but I advised them to also perform

dispatched with me, it truly was a blessed Team 8.

and about 100 to 150 patients visit the office per day.

metabolism-related examinations because they were

Both inside and outside JDW Hospital, the local
Bhutanese were kind and overflowing with hospitality.

9

October 28 to November 25, 2017

Due to the efforts of Dasho Nishioka as well as the

JDW Hospital currently does not have any（exclusive）

activities of JICA, the sentiment towards Japanese

doctors specializing in lifestyle-related diseases andpeople is very friendly. In recent years, Japanese anime

has only one or two residents in training and medical

In Bhutan, the Department of Medical Supplies and（comics）
has also swept over Bhutan. Almost all young

staff not specialized in the diseases, who take turns

Health Infrastructure（DMSHI）
of the Ministry of Healthnurses know the Japanese manga Naruto, and some of

to see patients. The outpatient department has two

restricts the available drugs for prescription to thosethem have seen the film“Kimi no Na wa”（“Your Name”

nurses, who measure the blood pressure and weight ofon the National Essential Medicine Formulary（ seein English）. In addition, due to the efforts of people

outpatients, and give guidance on insulin administration

below）.

who have been dispatched from various departments

procedures. There are several nutritionists in theuntil now, the name Kyoto University has become aoutpatient department, mainly providing nutritionalcommonly understood word at JDW Hospital. Thanks

guidance to new patients.

to the dispatch activities up to the present, we wereDuring the dispatch period, we provided medical

able to achieve some form of significance to ourcare at outpatients, were consulted by local staff, andactivities this time. I express my gratitude to everyone

conducted various studies on outpatients with diabetes

who has taken part in the dispatch activities until now.

to grasp the current status of diabetes treatment.

All members of the medical staff that I met at JDW（2）Find significance in diabetic care.

not in the habit of conducting such examinations.
（3）Increase or update available drugs.

Hospital were eager to learn about the newest Japanese

Investigation of hospitalized patients in the medical

and Western medical knowledge and technology. The

ward by disease area showed that it is a top priority

nurses repeatedly requested that Kyoto University will

to hospitalize and treat symptomatic patientsdispatch field-specific nurses such as diabetes carewith neurological diseases（ stroke and epilepsy）,

Anti-diabetes agents are limited to three types of oral

instructors instead of general nurses in the future. The

cardiovascular diseases（ angina and heart failure）,

drugs, namely, metformin, glipizide and pioglitazone,

Activity Report

Activity Report10and three types of insulin, namely, Isophane（NPH）,

sometimes show considerably high K values, and theof patients with diabetes also had renal dysfunction.

a week, and to recruit a dedicated doctor.

Mixtard（Neutral + Isophane）30:70, and Soluble

local physicians seemed to think that the abnormal（7）Lipid is well controlled, but there is some room（ 2 ）T h o r o u g h q u a l i t y c o n t r o l o f b l o o d t e s t s i s（Neutral, Regular）, which are provided in 10 ml vials

values suggest issues with leaving the collected

for improving BP management.

required.

for home injection with a syringe. There are no single-

blood for some time before measuring them or theuse insulin injection pen or cartridge formulations, ormeasurement method.

continuous subcutaneous insulin infusion therapy or（3）Expand patient data management at the hospital.

and blood pressure in outpatients with diabetes,

We investigated the actual situation in Bhutan

Patients’autoantibodies（ anti-GAD antibody, anti-

and diabetic patients with LDL〈 120 accounted forwhile seeing patients at the outpatient unit and ininsulin antibody）cannot be measured in Bhutan,

80%, indicating that lipid is well controlled. However,

the medical ward. Patients in Bhutan bring their own

The frequency of use of anti-diabetes agents in

not even that of inpatients. Thyroid hormone can

50% of diabetic patients showed systolic blood

medical charts as shown below when visiting theoutpatients was 34% for metformin monotherapy,

be measured in Bhutan, but samples should bepressure ≥130, indicating that there is some room forclinic for management of the examination results,

22% for combination of metformin and glipizide, 15%sent to India to measure C peptide, insulin, GH and

improvement of blood pressure control. We also foundcharts and medications. These medical records arefor triple-drug combination of metformin, glipizide

urinary albumin. Currently, it is difficult to select thethat many diabetic patients with poorly controlleduseful for raising public awareness of their own

and pioglitazone, and 10% for insulin monotherapy.

optimum therapy based on the diagnosis of diabetes

blood pressure had renal dysfunction. We heard that

health management. If patients bring their notebooks,

Glipizide is probably added when the disease cannot

type or test results of insulin secretion ability, or tothere are many patients with renal dysfunction caused

including medical records when visiting any hospital,

be controlled with metformin, and pioglitazone isdiagnose endocrine diseases or assess therapeutic

by renal sclerosis in the Kidney Outpatient Unit, andall medical staff there can grasp the medical treatment

added if it is still poorly controlled, and finally theeffects. Since the local doctors cannot perform theit was suggested that blood pressure control is also

they received, but they are useless for epidemiologicaltreatment method is shifted to insulin monotherapy if

examinations, even if they know about them, I felt thatimportant as one of the measures against renal failure

studies. The data including those at the first visit

all of those drugs together cannot control the disease.

their motivation to gain clinical experience to perform

in diabetic patients.

are partly managed at JDW Hospital, but there

Some patients purchased DPP4 inhibitors at theirexpert medical treatment for diabetes and other

Available antihypertensive agents include losartan,

is a demand for further improvement of the data

own expense. I asked the pharmaceutical company

endocrine diseases was negatively influenced in thisenalapril, amlodipine, nifedipine, atenolol, propranolol,

management system and the adoption of electronic

about the circumstances under which pioglitazone issituation of a lack of examinations.

hydrochlorothiazide, furosemide, spironolactone,

medical records.

frequently used. The company answered that generic（5）There is some room for improvement of glucose

methyldopa, hydralazine and clonidine.

drugs made in India are imported at low prices

control.

blood glucose self-monitoring systems.

because the drug patent has already expired.

The frequency of use of hypotensive agents in

Although blood glucose levels of all outpatients withhypertensive patients with diabetes was 47% for

There are many patients with diabetes leading

diabetes were measured, HbA1c was not measured

losartan monotherapy, and 27% for amlodipine

to end-stage renal failure, but due to a lack of oral

in 48% of patients. Among the patients whose HbA1cmonotherapy. Among angiotensin II receptor

drugs such as DPP4 inhibitors, rapid-acting insulin

was measured, the percentage of patients with anantagonists（ARBs）, only losartan is commonly used, butsecretagogues andα -glucosidase inhibitors with a

HbA1c〈7% was 69%, that of HbA1c 〉7% to〈8% wasit seemed that improvement of blood pressure control

low risk, even in renal failure patients, local doctors

6%, and that of HbA1c 〉8% was 25%. When estimatedcan be expected if more powerful ARBs are adopted.

administered metformin, glipizide and pioglitazone atin conjunction with the blood glucose level, 60% to（8）Increase public awareness of weight control.

lower doses. Since insulin injections are both difficult

70% of patients were achieving good control andPatients hospitalized in the medical ward and theirin terms of management and treatment, they are not

20% to 30% of patients were poorly controlled, whichfamilies said that 96% of the households do not have afrequently used in patients with poorly controlledsuggests that there is some room for improvement ofbody weight scale at home and they usually have theirglycemia or renal failure.

blood sugar control.

weight measured at school or BHU. It may be difficult（4）Increase available tests and focus on accuracy
control.

11

We examined the control status of LDL cholesterol

Regarding diabetes management, there seems to beenough room for improvement if exclusive doctors/

For outpatient examinations, blood samples areallied healthcare professionals are recruited, thecollected on the day before the outpatient consultation

accuracy of examinations is increased, and other anti-

day to evaluate FBS, PPBS, HbA1c, BUN, Cre, Na, K, Cl,diabetes agents are also newly introduced.

TCho, TG, HDL, LDL, AST, ALT and CBC. Urinalysis is（ 6 ）M a n y h y p e r t e n s i v e d i a b e t i c p a t i e n t s h a v erarely implemented. Sometimes the HbA1c test showsadvanced renal dysfunction.

for obese patients to manage their weight at home.

Accomplishments and results of this dispatch●I was able to grasp the state of diabetes care at
JDW Hospital.

Overall impression of the present medical
assistance activities
Nurses who came as JICA volunteers were assigned
to various departments within the hospital, making
JICA’s presence ubiquitous. Many retired doctors andfixed-term volunteers from the US and Australia were

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Healthalso present and conducted education and medicalcare with great passion. On the other hand, as a

unexpected outliers（3% or 40%）
, and the doctors do

Investigation of the prevalence of hypertension,

not seem to consider the results of these examinations

hyperlipemia, renal dysfunction（serum creatinine 〉1.5）（ 1 ）E n h a n c e t h e L i f e s t y l e - r e l a t e d D i s e a s e C a r every different from my usual activities and I felt that I

to be accurate or reliable. Sekisui Medical’s NORUDIA

in diabetic outpatients showed that the proportion

Outpatient Unit.

lacked both advance preparation and knowledge.

N has been used with DIRLICS6008 to measure HbA1c,of diabetic patients with hypertension was as highAs the number of patients is increasing, it is

so I asked Sekisui Medical about abnormal values, but

as 41%, and the proportion of hypertensive diabetic

necessary to increase the number of outpatient

I could not identify a clear cause. However, blood tests

patients with hyperlipemia was 29%. In addition, 17%

consultations, which are currently provided only twice

Activity Reportdoctor from Kyoto University Hospital, everything was

Activity Report12Period

October 7 to November 4, 2017

Registered dietician, Dpt. of
Metabolism and Clinical Nutrition

Kanae Asaiin line with the eating habits of Bhutan. Since there area nutrition guidance system. To this end, with efficiency

amount. Therefore, with the objective of improving

many patients with hypertension and renal diseases inin mind, pamphlets regarding hypertension and renal

the meal quality as well as staff awareness, a meal

Bhutan, it is considered necessary to further establish

diseases were prepared（Material 2）.

inspection system was introduced where a nutritionist
evaluates and records the daily hospital meals andMaterial 2）
Nutrition guidance pamphlet
For patients with diabetes

provides feedback to the chef
（Material 1）. In the future,

DIETARY MODIFICATION FOR DIABETES

a system will be required where the chef is able to cook

Activities

dishes consisting of appropriate amounts of nutrients.

I conducted activities at the nutrition section of

While there is an issue with hygiene management in the

JDW Hospital for a 1-month period. The JDW Hospital

kitchen, measures were taken as far as possible, such as

nutrition section has existed for 10 years and currently

ensuring that those preparing food wear hats and masks

employs five nutritionists. During my period of activity,and establishing a supervisor who manages cleaning of

one nutritionist was dispatched from JICA to thethe kitchen.

Vitamins&
Minerals

Next is nutrition management. The most frequent

objectives of the activities were to improve the foodrequests nutritionists receive from the ward concern

service, to implement nutrition management with theenteral nutrition prescriptions. Upon request, theaim of introducing an NST（Nutritional Support Team）,

nutritionist prepared a thick liquid diet by calculating

and to enhance nutritional guidance materials. Firstly,

the required amount for each individual patient andregarding the food service, food was made and provided

adjusting the ingredients and supplements for thein the hospital to 200 out of the 400 beds. A nutritionist

patient. In addition, nutritionists went on ward rounds

prepared balanced meals weekly, but the amountfour times a week, recording body weight and nutritionof nutrients was not calculated, making it difficult toparameters on a nutrition management sheet and re-evaluate whether the patients were provided withevaluating the nutritional condition of the patients.

proper nutritional composition. Therefore, the amount

However, the currently provided amount of nutrients, asof nutrients was calculated based on the amount ofwell as the matter of whether the required amount of

Before improvements

ingredients in the hospital food. The results showed anutrients is met or not is not recorded, and in view of the

For patients with chronic renal diseases

very high carbohydrate energy ratio of over 70% andfuture introduction of NST, information sharing between

a low protein energy ratio of approximately 10%. The

doctors, nurses, and other medical professionals

same trend was visible in Bhutan’s general eating habits,

would be difficult. As such, to facilitate understanding

making a transition to meals with a proper nutritionalof nutrition management for other professional staff,

composition difficult from both cultural and ingredient

the nutrition management sheet was improved. Tools

cost perspectives, but improvements were suggested towere also created to enable local nutritionists to easily

come even just a little closer to realizing it. Furthermore,measure the amount of nutrients for thick liquid diets.

although a chef was cooking the food, since the amounts

Next is nutrition guidance. Nutrition guidance wasof seasoning and ingredients were not measured, themainly conducted for outpatients with diabetes. For

Small frequent meals →5−6 meals per day

Chew eachmouthful wellOver 30 times

Date;

/

/

EnergyProtein
Fat
Carbohydrates
Salt equivalent

How does the meal look?

1

2

3

4

5

How does the meal taste?

1

2

3

4

5

How does the meal smell?

1

2

3

4

5

How is the texture?
1
How would you rate the meal
overall?
1

2

3

4

5

2

3

4

5

Signature

kcal
g
g
g
g

Any comments

Do physical activity
for about 30-45
minutes / day

Change eating habits①③②

After improvements

Chronic Kidney Disease１

Cut down on salt

２

Prevent excessive
intake of protein

matchibox size３and the approach to balanced meals was explained,

Maintain IBW

amongst others. The pamphlets were printed only

Directions: Circle the number that best answers each question.
1 is the worst and 5 is the best.

in English and although explanations were given in４
Hyperpotassemia

Cut down potassium

Dzongkha for patients who cannot speak English,
it seemed as if the pamphlets were not properly
understood. The pamphlet was improved to focus

K

more on illustrations, making it possible for non-English
speakers to also understand the contents so that they
Daietitian ;Cook;Material 1）
Introduced meal inspection register

Activity Report

Carbohydrates

diabetes guidance, shared pamphlets were used

*
*
*

1111

Proteins

nutrition section to participate in the activities. The main

How was today’s meal

13

patients experienced variations in terms of taste andK

K

Over 15 minutes

can improve their eating habits at home. Opinions were
exchanged with local nutritionists to create something

Before improvements

After improvements

Activity Report14PeriodIf future improvements in each individual patient’s dietgut syndrome. When doctors asked for their opinions, it

could be suggested in addition to conveying the general

seemed that nutritionists’motivation was increased. It

thought behind diet therapy, patient performance may

would be good to further increase opportunities for teamincrease further.

involvement in nutrition management in the future.

October 28 to November 25, 2017high risk of needle sticks. While they do recognize

Nurse,
Nursing Department

Hanako Yamauchi

In addition, since local nutritionists wanted to know
about the current state of Japanese hospital foodbeen established, so I reinforced the importance ofthe pincushion and a method to use it for continued
use. I also explained the method of washing hair in

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Health

Activities

there are few opportunities to obtain new information,

I have heard that patients with lifestyle-related diseases

I was given the opportunity to engage in nursing

cannot really perform large-scale care such as bedsidethey showed great interest. On request by the ICU

such as obesity, hypertension and diabetes haveprocedures for 1 month in the surgical ward of JDW

hair washing, the family also greatly appreciated thenurses, we had the opportunity to talk about the nutrition

increased due to a lack of exercise caused by the recent

Hospital. In the beginning, since I was unfamiliar

method.

management of renal diseases while supported by Dr.

widespread use of automobiles in Bhutan. For patientswith my surroundings, I started performing daily

As mentioned previously, daily life assistance such

Taura of the Department of Diabetes, Endocrinology, andvisiting the hospital, it seems that information andprocedures with the Bhutanese nurses to learn whatas hygiene maintenance and toilet assistance is

Nutrition.

guidance systems including dietary guidance have beenkind of nursing is being conducted.

mainly performed by the accompanying family. Theirservices, we introduced the hospital food service system
and meal content of our hospital. Since it seemed as if

bed using a Kelly pad and implemented it together
with nurses and students. Daily patient life assistanceis mainly performed by the family, but since they

established, but it is necessary to take measures focused

The 5S activities that the previous team performed

passionate daily care impressed me. If necessary, theyon primary preventive care in Bhutan in the future. Since

seem to have been established in the entire hospital,

would also help patients in adjacent beds. The way

JDW Hospital currently provides a hospital foodnutritionists are considered to play an important roleand items in the surgical ward were organized inthey looked after each other was very memorable.

service, but only half of the inpatients actually use thein such a situation, it would be necessary to develop

an easily understandable way. When I had time,

Activities outside the hospital included participation

service, and the others prepare meals themselves or

nutritionists and improve their status.

I replenished items and keep things tidy with thein international conferences and visiting the National

nursing assistant. When seeing the staff putting

Institute of Traditional Medicine. It provided me with

Overall impression of the present medical
assistance activities

away items not used, cleaning up things spreada valuable opportunity to gain new knowledge aboutaround the patient’s room, or instructing families, I

the medical situation and issues in Bhutan and about

service also only prepares one type of regular meal,

I was worried about the kind of assistance I could

strongly felt that 5S had become ingrained in them.

Bhutanese traditional medicine.

there is an issue that patients who need consideration

give in Bhutan, but thanks to the warmness of theI was concerned how interested the staff was infor the consistency of their food and those who need

Bhutanese people and the heartfelt support of the staff,

hand washing and hand hygiene; however, during

a therapeutic diet may not consume an appropriate

the activities were concluded without any issues. Despite

interviews, most staff and nursing students answered

diet. Local nutritionists also want to increase the kinds

having only limited access to tests and information,that they wash their hands with every procedure.

of hospital food that is served and provide therapeutic

when local nutritionists conduct nutrition management,This made me understand that the awareness of“1foods, but it may be difficult to handle the problems withthey perform nutritional evaluation by touching the bodyprocedure, 1 wash”was thoroughly ingrained.

the current kitchen facilities and the number of kitchenof the patient themselves. I learned the importance ofstaff. It is necessary to enhance the kitchen facilities andphysical assessment from them. Through the activities incooking equipment and increase the number of kitchen

Bhutan, I was also given the opportunity to consider dietstaff.

therapy in light of a different food culture and values from

Issues noticed during the activities

have family members prepare meals for them. Therefore,
it was difficult to grasp the content of meals and manage
the nutrition status of many patients. Since the hospitalIn addition, doctors and nurses sometimes consult

those in Japan. I was able to once more experience how

nutritionists about patients who have problems

important support by a nutritionist who understands andto manage their nutrition, but only nutritionists

respects the lifestyle and thoughts of the patient is, but

can determine and change the dietary amounts. It

also how difficult it is. It is something I want to remember

Issues noticed during the activities

seemed that opportunities for discussions with otherduring my future work as a nutritionist.

In the surgical ward, surgery is performed 3 toPortable pincushion

professionals were lacking. Although it is good that

I am deeply grateful towards Kyoto University and

4 days a week. An average of about 10 or up to

nutritionists’opinions are respected, I think that patients’

the people at JDW Hospital for having granted me this20 operations per day is performed. I think it isnutrition can be better managed by sharing information

precious opportunity.

with other professionals including doctors and nurses.

15

that“needle sticks are dangerous,”no measures had

5S fully implemented

necessary to observe the general condition ofpatients postoperatively using a biological information

In cooperation with Dr. Taura of the Department of

As a contribution to the procedures in the ward, I

monitor, but there are an absolute insufficient number

Diabetes, Endocrinology and Nutrition, we provided

made a portable pincushion. Needles used for bloodof monitors. In addition, some personnel notice it

opportunities for local doctors and nutritionists tosampling and securing peripheral routes had been put

when the alarm of the monitor goes off, but otherdiscuss the nutrition management of patients with short

directly on a tray and brought along, creating a very

personnel do not seem to care about the alarm.

Activity Report

Activity Report16Period

The lack of monitors may be unavoidable, but I felt

any issues. As I was washing the hair and bed-bathing

it necessary to improve physical assessment using

the patients together with the staff and watched how

the five senses including auscultation and palpation

they carefully washed the patients, I realized how I in

regardless of whether monitors are used or not. I

Japan performed care constantly pressed for time. It

think it is essential that personnel who can practicegave me the opportunity to re-evaluate whether myphysical assessment educate younger staff.

care actually was patient-oriented or not.

internal medicine. However, because there are no

Assistant professor, Dpt. of
Hematology and Oncology

Junya Kanda

hematologists, approaches to hospitalized patients with
idiopathic thrombocytopenic purpura or pancytopenia
were inadequate.
Multiple patients with alcohol-related diseases suchas alcoholic cirrhosis, alcoholic myocardiopathy andIn terms of the nursing records, there are various

I was not able to contribute anything towards thekinds of documents for recording including a table

Bhutanese nurses or nursing students. However,to record the patient’s postural changes and athrough working as a nurse in a foreign country, I was

postoperative checklist, but it turned out that someable to learn many things including the Bhutanese

staff members were aware of these documents, while

way of thinking about life-and-death and nursing, theothers were not. Even once the documents were

importance of mutual support and cooperation, howused, they were left unrecorded for several days inthe thoughtfulness and kindness of the Bhutanesesome cases. Therefore, it is necessary to ensure thatis reflected in their nursing and medical care, andIssues noticed during the activities

all staff members use these documents on an ongoing

how slowing down would improve my patient care.

Every morning at the medical ward, a team composed

patients with thrombocytopenia of unknown cause,

basis.

It became a valuable chance to reconsider my ownof three doctors, namely, an intern（1st to 2nd year

two patients with neutropenia of unknown cause andEstablishment of educational systems among staff

humanity and nursing values. Being called“kind sisterof career）, a medical resident（3 years of career）
andone patient with pancytopenia were hospitalized, andand the development of leadership have been listed（nurse）” by the nursing students and the families

a consultant（senior doctor）, takes a couple of hours

bone marrow aspiration was scheduled as necessary.

as challenges since before, but I felt these shouldof the patients made me happy and it felt like myto go on a round of hospitalized patients. During thisHowever, there were only two bone marrow puncture

remain matters to be addressed in the future.

nursing had been acknowledged.

round, education was given to interns and residents

kits, and the number of bone marrow examinations per

Activities①Performing hematological care in the ward andoutpatient clinic and providing training andlectures to residents at JDW Hospital②Providing training to technicians at the hematology
test department of JDW Hospitalberiberi, and patients with tuberculosis-related diseases
such as tuberculous pericarditis were hospitalized
in the medical ward.（The hospital has a separate
tuberculosis ward.）
Regarding blood disorders, threepatients with idiopathic thrombocytopenic purpura,
one patient with acute leukemia, one patient withsuspected recurrence of acute lymphocytic leukemia,
one patient with chronic myelocytic leukemia, two

Accomplishments and results of this dispatch

Thanks to the chief nurse and other staff members（presentation of newly admitted patients is usually

day was limited. Bone marrow biopsy also includedof the ward who kindly sent me off on this dispatch

made at the morning conference）. Although thetechnical and equipment issues（ there was only one

Since it was a period of only 1 month, my goals

round, and the nursing department and the public

contents of education and guidance vary greatly

biopsy needle set）
, and the threshold appeared to beduring the dispatch were to learn and experience

relations officers who supported me, my month went

depending on the consultant, a certain educationalvery high. A patient with pancytopenia underwent bone

the current situation of medicine and nursing inby without any issues. I am very grateful.

system seemed to have been established and somemarrow aspiration but a bone marrow smear could

Bhutan. I learned that the activities implemented

physicians provided courteous instruction not only on

not be prepared due to a dry tap. Biopsy was thenby the previous team are continuing, and although

the differential diagnosis and therapeutic strategies but

performed, but the in-house pathologist could not reach

there is less equipment than in Japan, nursing care isalso on presentation methods for interns and residents.

a diagnosis, so a hospital in India was requested toperformed through clever ingenuity.

The system according to which imaging tests such as CT

provide a second opinion. The hemogram was normal.

I was also able to instruct the families of patientsand MRI and examinations that are conducted in India

However, since the condition of the patient deteriorated

in the importance and methods of postoperative

cannot be done without the consultant’s permission

during follow-up, I re-conducted a bone marrow

postural changing. In the beginning, I asked themseems to contribute somewhat to examination withaspiration to prepare a bone marrow smear by spraying

to assist me every time I made a 2-hourly patient

limited resources and reduced medical costs.

a very small specimen of bone marrow aspirate, andcheckup. However, the family gradually started asking

Thanks to the above-mentioned educational system,me for assistance, turning postural changing into a

residents are excellent, but it may be impossible tohabit. This time I gave individual instructions, but it

conduct adequate medical treatment because there

might have been more effective if it could have been

are too many inpatients and outpatients.
（One resident

conducted as group instructions.

often has about 70 outpatients to take care of.）

Overall impression of the present medical
assistance activities

17

February 5 to 22, 2018

Photo with JDW Hospital nurses

However, the residents in Bhutan must handle a wide
range of diseases from cirrhosis to stroke, and also havesufficient knowledge about differential diseases. They

Since the dispatch only lasted a short period of 1

seem to have superior skills to Japanese residents ofmonth, I was worried and felt pressure about what

the same generation as far as both medical care andI could achieve. However, the staff, patients, andpractical procedures are concerned. Consultants whofamilies were all amiable, accepted me as a nurse,

are also known as senior doctors were not only familiar

and with their support, my time there went by withoutwith their own area of expertise but also with general

Activity Report

the patient was diagnosed with acute leukemia on theBone marrow examination

Activity Report18Periodsame day. As described above, diagnostic bone marrow

Helicobacter pylori（the rate of infection is higher in

examinations using sprayed bone marrow aspirate had

Bhutan than Japan）, which is not included in Western

not been performed before.

guidelines, was very beneficial, allowing them to

One of the technicians in the blood test unit who

actually experience the rapid increase in platelet countwrites comments on peripheral blood smears wasin response to eradication therapy. In Bhutan, researchtrained in the UK and has very in-depth knowledge

on the efficacy of Helicobacter pylori eradicationof the examination of peripheral blood smears andtreatment can be expected in the future. Other issues intheir clinical interpretation, so he played a very

the hematology test department were also highlighted

important role in the education of other younger staff.

and improvements were suggested.

However, examination of bone marrow images andflow cytometry examination seemed to be inadequate.
Flow cytometry examination using peripheral blood
specimens is performed when abnormal cells increase

Program-specific assistantprofessor, Dpt. of Hematology
and Oncology

Takashi Miyoshi
Activities①Performing hematological care in the ward andoutpatient clinic and providing training andlectures to residents at JDW Hospital②Providing training to technicians at the hematology
test department of JDW Hospitalin the hemogram, but bone marrow specimens could

Issues noticed during the activities

not be prepared because there were no filters for① The inpatients’medical records are maintained inprocessing of bone marrow specimens. I encountered

the hospital, but outpatients bring their own medicala patient who could not be diagnosed with acuterecords themselves, and the doctors check them within

lymphocytic leukemia or acute myelogenous leukemia
in the hospital since flow cytometric examination ofbone marrow specimens could not be performed

Meeting with the chief hematology technician

a limited time and write down the estimated diagnosis
and the results of examinations in the notebook.

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of HealthThis system seems to have certain benefits（ patientsnot be performed（because there was not a stablein patients presenting with acute leukemia and aMark needles used for bone marrow puncture

activities that Dr. Kanda, who supervised initially, had
created. The contents of the activities are as follows.

①Receiving consultations by residents（discussing
the diagnosis and treatment policies）②Discussing bone marrow examination results inthe blood laboratory, and reflecting the results inthe medical practice③Giving lectures to residents

bring all information to any hospital）, but from an① Bone marrow examinations of patients withepidemiologic point of view, there are various problems

pancytopenia were performed before the holiday（theBhutan seems to have a shortage of doctors andsuch as restrictions on assessment of the total number

current King’s birthday）. Analyzing them by myself on

supply of the stain solution, and the examination was

specialist physicians. I would like Bhutan to remainof diseases and the duration of treatment by different

the morning of the holiday showed increased blast

discontinued）. For the diagnosis of hematopoietic

focused on the development of specialists in thehealthcare professionals. I felt it essential to takecells and AML was detected. With smears in the foreign

disorder, examination of the bone marrow smear andcountry. It seems necessary to dispatch regular doctors

measures to keep records in the hospital in some way,

country that are different from those in Japan andflow cytometry examination by a technician of theto rural areas, but it is also important to make personnel

such as copying the medical records brought by theuncertainty about which patient it was, I had planned

hematology department are essential. If an accuratechanges to an extent that does not obstruct the training

patients.

to proceed on the day after the holiday; however,diagnosis is obtained in the hospital, it will not beof specialists. Instructions by volunteer doctors through② The hospital windows were opened, and theI reported it by email to Dr. Kanda only. The reply

necessary to send the patient to India, which will reduce

Health Volunteers Overseas may also have to becorridors were flooded with water after cleaning.

advised me to immediately inform the resident doctor

the medical expenses. In addition, since JDW Hospitalconsidered more actively.

Although patients with severe neutropenia wereof my suspicion of AML, which I did by email. The

normal hemogram and peroxidase staining could

is the largest hospital in Bhutan, numerous patients withhematological disorders have been hospitalized and I
realized that a hematologist is required.

19

February 17 to March 3, 2018

hospitalized in private rooms, it seemed difficult toresident acted immediately, and blood transfusion, etc.

Overall impression of the present medical
assistance activities

prevent infectious diseases such as Aspergillus infection

were conducted in preparation for the patient’s transfer

that must have been carried by dust that entered

to India. The patient was transferred without delay.

As expected, the hygienic environment andthrough the open window.

Two CML patients were diagnosed with the chronic

Accomplishments and results of this dispatch

infrastructure in Bhutan are still insufficient. Regarding③ I found that a gauze covering the access puncturephase on a myelogram and treatment began with

Appropriate medical care and guidance were

medicine in Bhutan, while access to the most recent

site to a central vein for dialysis had peeled off, and aimatinib 400 mg/day（ other first-line drugs were not

performed for outpatients and inpatients with bloodinformation from around the world is possible due to

Bhutanese doctor considered it a problem during thelisted）.

diseases. Five bone marrow examinations were

the spread of the internet, and there are many highly

round. When he asked me whether the same thing

Patient with ITP: I informed the doctor that it isconducted and also applied to make a diagnosis.

knowledgeable doctors, medical care is limited by amight be observed in Japan, I replied“Occasionally”

necessary to administer a large amount of IVIG for 5

Blood disease medical care was improved throughlack of doctors and testing is limited by insufficient（e.g. when a patient tries to remove the tube）. I felt it

days starting 7 days before the splenectomy, and toresident lectures（2 lectures, namely on myelodysplastic

medical equipment. As such, knowledge about thenecessary to change the perception of that point.

prepare PC in case the preoperative platelet count is

syndrome and idiopathic thrombocytopenic purpura）.

current situation was updated. However, we strongly

During this period, since several patients withfelt that by improving the standard of doctors and test

idiopathic thrombocytopenic purpura were admitted,
the explanation about the eradication treatment for
Activity Report④ Shortage of doctors（detailed below）

insufficient.
Patient with severe neutropenia: The patient had

technicians, we would be able to contribute to improve

Accomplishments and results of this dispatch

received CyA during previous incidences of bone

the level of medical practice.

We continued within the framework of the threemarrow failure（?）. However, due to such adverse
Activity Report20

reactions as edema, the patient discontinued the drugthat infection treatment would continue while closely

independently and was admitted to the hospital with afollowing the peripheral blood smear.

② While I stayed in Bhutan, there were only three

When I was observing outpatient examinations, aphysicians at the Department of Medicine in JDWyoung man visited with the complaint of tremors of his

Hospital due to traveling abroad and sick leave. It

fingers. A resident doctor checked for focal symptoms,

seemed that the residents studied by themselves andlistened to the patient’s heart and said“the pitch of theTaking the environment into consideration, it wasprovided medical care according to the diagnostic

second heart sound…”（ the rest was inaudible）,

considered the best to resume CyA, and I requested

policy. It seems necessary to establish a system ofsuspected pulmonary hypertension, and put in an orderto persuade the patient. The trough value was 150 toconsultation with specialist doctors, including overseas

for an ECG. At the time, I was completely unaware but,

200 and a CPFX
（until the neutrophil value exceeded

doctors. In particular, it seems that discussions using

a neurologic symptom of hypercarbia（in severe cases,

500）+ ST combination was administered for infection

Skype and e-mail exchanges are becoming increasingly

was tremors. While I do
CO2 narcosis can induce coma）

prevention.

important, as previously mentioned.

not know the result, I take off my hat to the attitude toneutrophil count of below 500. Bone marrow showedmarrow hypoplasia, and AA and ICUS were suspected.

③ Blood disease treatment was improved through a
resident lecture（1 lecture on multiple myeloma）.

deduce that much within minutes and strive towards a②Particularly meaningful discussions were achieved in

Overall impression of the present medical
assistance activities

diagnosis using limited resources.

From pouring water on the floors during the day anddoctors who barely speak English was their first, mycleaning it with mops, to using dirty vinyl bags to coverstay was one of receiving help from the medical student

one’s shoes when entering the NICU, awareness of the

Ishibashi who accompanied me all the way on the

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Healthhygienic environment and infrastructural maintenancevoyage. I am deeply grateful toward all the staff at JDW

were insufficient.

Hospital who, despite my inept English, persevered andAppropriate usable drugs also seemed to be very

accompanied me in our communications in writing.

common infection in Bhutan is called“leishmaniasis”

Bhutan seems to generally have a shortage of doctors

limited. Treatments for multiple myeloma were limited

I would also like to express my sincere thanks toand is caused by an insect. It was documented that it isand specialist physicians. I think that it is necessary

to melpharan, thalidomide, steroids, and drugs that had

Professor Takaori, the outpatient department directortransmitted through small flies（sandflies）
and is treatedto establish a mechanism whereby doctors who havebeen used a decade or two ago.

Kondo, the ward manager Hishizawa, and the doctors

with a drug called“miltefosine.”learned expertise in other countries return or want to

the following two cases.
The first case occurred on the morning of the lastworking day. I was asked by the resident to look at amyelogram showing pancytopenia（ ?）in a 7-year-old
child. Looking together with the test technician in the
blood laboratory, we detected numerous small objects
inside the macrophages. At the instant the technician
saw this, he commented“Leishmania!”This relatively

The other case occurred the day after the holiday

21

Lecture for residents

return to Bhutan to work in their home country.

On the other hand, the presentation ability ofand nurses in the ward for granting me this opportunity.

residents during rounds and the discussion andwhen the technician showed me a peripheral blood

At the same time, I felt the necessity for healthcare

diagnosing skills of staff doctors are very high. The test

smear of a baby
（approximately 19-day old）
in the NICU

professionals other than doctors to take charge of work

technician, who analyzes microscopic tests, is diligently

with suspected ALL. The staining was poor, but the core

within their own fields of expertise.

reading the WHO Book, and the attitude of a group ofof some slightly large lymphocytes seemed delicate① At the outpatient unit, many patients visited thehighly skilled individuals exerting themselves despite theand nucleoli were noted as suspected. When arriving

hospital every day. In the Department of Medicine,poor infrastructure is astounding. I felt that improving

the NICU to report this, Dr. Nishizawa happened to be

one resident examined more than 50 outpatientsthe level of other professionals can contribute tothere and I was able to discuss it with him. As a result,while checking the patients’medical records that they

improving the level of medical practice as well.

it was revealed that the baby had been intubated inbrought with them. Despite the chaotic state whereby

the NICU and was receiving treatment for an infection.

the next patient entered the examination room without

The perinatal platelet count was 166,000, decreased

permission even during the examination of anotherto 35,000 and then normalized at 196,000. Afterwards,

patient, the resident finished the physical examination,

it decreased again and the recent count was 11,000.

made a presumptive diagnosis, and ordered theConcluding that this was test result fluctuation as parttargeted examinations. A few such excellent doctorsof an infection, and not leukemia, we decided to waittake turns consulting many outpatients. I think thatfor the results of the peripheral blood FCM submitted

administrative staff should at least be responsible forto the blood laboratory of JDW Hospital. The following

management of the ID and the name the outpatients

day, I was able to discuss it with the FCM technician

using a PC. In addition, if a system can be introduced

and Dr. Tashi from the pathology department. Due

whereby administrative staff can ask patients about

to the lymphocyte grouping of approximately 10%

their symptoms and diseases, classify them to somecomprising mainly of T-cells（ approximately 90%）,extent before the medical consultation, and tell theand that the occurrence of CD45 had not decreased,

doctor, it can be expected to decrease the burden on

everyone agreed that the T-cell group was normal andthe doctors and protect patient safety.

Activity Report

While I imagine that the Bhutan assignment for

I would like to talk about what influenced me
personally during this voyage.

Photo with the blood bank supervisor, Dr. Mahrukh
GetshenPhoto with the local staff in the medical ward

Activity Report22Period

February 5 to March 3, 2018

Nurse,
Nursing Department

period, I did not think that I could contribute anything inof being able to experience non-Japanese medicine

parents who learned just with that; however, because

terms of assistance. However, it was all a very valuable

and nursing. However, I will never forget the thrillingof this, I often witnessed breastfeeding and milking

experience for me personally.

sensation I felt when I arrived in Bhutan.

assistance methods that were ineffective, and parents

As I mentioned previously, the family takes care of

I was in a loop of constant nervousness as a result ofsometimes asked me for assistance. Moreover, while

the patient’s every need 24 hours a day. Moreover,working in an unfamiliar environment, but the local staff

there is a page in the maternal handbook introducing

they would also cradle other crying babies, assist

would talk to me in kind voices and allowed me to work

breastfeeding methods, I felt that parents did not havewith examinations, and interpret between the parents

while feeling at ease. Being able to work for the firstmany opportunities to see it since it was kept with thewho do not speak English and me who cannot

time at a specialized place called the KMC unit allowed

I worked for 1 month in the kangaroo mother care unit

patient’s medical record. Therefore, for future guidance,

speak Dzongkha. The sight of them naturally andme to not only experience medicine but also Bhutan（hereinafter, KMC unit）
in the Neonatal Ward of JDWI prepared something parents can keep with them andspontaneously helping each other was wonderful andchildcare. Childcare involving direct physical contact

Hospital.

something with pictures that can be easily understood.

heartwarming. I was able to experience the thoughts

makes both the child and the parents feel at ease, andand culture of the Bhutanese people, something thatthey probably do not feel the insecurity of mother-you cannot do in Japan.

child separation we experience in Japan. When I return

Yurie Omae
Activities

Although everything was completely unfamiliar at the
beginning of the dispatch, I accompanied the nurses on

Issues noticed during the activities

their daily routines to grasp the flow of a day in the unit.

There were posters in the ward to promote 5S

The attitude of the staff towards childcare guidance

The KMC unit was very interesting and something

activities, provide hand hygiene enlightenment, andwas to observe as far as possible. Even when necessary,of which I had no experience in Japan. In this unit, 24-

to show how to wash one’s hands. Also, when seeing

they provided guidance via a hands-off approach.

During our dispatch, there were many holidays suchhour constant KMC is possible. Parents who hesitate to

the chief nurse instructed the patient’s family on how

The stance of realizing the parents’potential and notas the New Year and the King’s Birthday, giving us an

perform KMC are actively encouraged to do so by theto disinfect their hands and fingers, I realized that the

instructing more than necessary provided me with aexcellent chance to get to know the Bhutanese culture.

doctors and nurses. There is also frequent guidance on

activities our predecessors had carried out were taking

good opportunity to review my own way of nursing with

I cannot forget the lovely faces of the children greeting

KMC by the chief nurse.

root. Some staff does not practice the concept ofa hands-on approach, with which I could feel a sense of

us in the city. The experience of working and living for

While the KMC unit is located across the hallway inhygiene, even if they know about it, and it seems that it

accomplishment of having performed care.

1 month in Bhutan where I visited for the first time, has

the same ward as the Phototherapy unit, most nurses

will take some time to change the behavior of all staff

are stationed in the Phototherapy unit with a highmembers.

When performing breastfeeding or milking assistance,

home, I would like to introduce the warm nursing of
Bhutan to Japan and integrate it as far as possible.

become a priceless asset to me.

seeing the parents earnestly listening and striving toLastly, to all those who politely listened and tried

patient turnover, leaving one nurse to care for seven to

Assistants clean the floor and other staff members

implement what I had taught them despite my poor

to understand my poor English, including the hospitalnine patients in the KMC unit. However, as the previous

work to prepare their working environment every

English made me happy and gave me confidence. I also

staff, the families of the patients, and the local people, I

team has reported, patients are basically taken caremorning. However, I often found that only those areas

experienced blood sampling from babies, which you

would like to say thank you.

of by their family. The same is also true for babies;that can be seen by the staff are properly cleaned,cannot really experience in Japan, and I feel that mysince the parents are essentially constantly with their

while personnel and patients’family members throwskills have also improved.

babies to care of them, it felt that the duties could be

garbage on the floor and dust accumulated on theperformed even if there would be just one nurse.

blood sampling cart. I felt it necessary for staff members

I was also able to experience blood sampling frombabies almost every day, which is something very

Through this dispatch, I was able to discover new
personal challenges.

and patients’family members to raise their awarenessof keeping the environment clean.

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Health

It is also important to maintain the environment

too few doctors, so the nurses have to do everything,”

and items that can disinfect the goods necessary

but I thought their assessment skills that do not only

for breastfeeding and teach the correct method andIt would be good if their awareness is enhanced andrely on the monitor, as well as their technical skills areknowledge in the future. Staff and patients’family

disinfectant can be available so that items required forhigh.

members seemed to understand that disinfectionbreastfeeding can be disinfected properly.

English translations of methods for latch-on
breastfeeding and methods for simultaneous

those concerned at Kyoto University, JDW Hospital, andUniversity of Medical Sciences of Bhutan for granting
me this valuable opportunity, and also to the hospitalfor kindly sending me off despite their busy working
schedule.

is important to babies, but the environment andknowledge including finances were not adequate.

Overall impression of the present medical
assistance activities

breastfeeding of twins. Parents learned about

Accomplishments and results of this dispatch

I always hoped to be a part of this endeavor. My

breastfeeding and milking assistance very quickly

I engaged in the work constantly thinking of whatwish came true and I was granted the opportunity toand the assistance of staff was not needed, even

I can contribute during the 1-month period. I started

with preterm babies. As for breastfeeding guidance,with learning about the current status of medicine

Before the dispatch, I was partly worried and anxious

there was only a pre-childbirth parents’class showing

and nursing in Bhutan as well as childcare there. As aabout language and working and living abroad for aa video and one to two post-childbirth guidance

result, with many holidays and only a short working

month, and partly excited for the valuable experience

Activity Report

I would also like to offer my deepest gratitude towhere I am currently assigned, Ayabe City Hospital,

unusual in Japan. The nurses were saying,“There are

Concerning involvement in the ward, I prepared23

sessions. I was surprised by the high skills of theparticipate in the dispatch.

Photo with local patients

Activity Report24Period

October 7 to 18, 2017
March 18 to 25, 2018

PeriodMarch 18 to 25, 2018a great harvest for me to see that all the participants

Associate professor, Dpt. of
Obstetrics and Gynecology

Chief physician, Obstetrics
and Gynecology, Mitsubishi
Kyoto Hospitalenthusiastically worked during training and sometimes

Tsukasa Baba

Masumi Sunada

to continue practicing, as accurate suturing during

Issues noticed during the activities

other. I strongly emphasized that it is most importantactual surgery is more difficult than during practice.
Whether training can be continued depends on theirfor trainee doctors, and the primary objective was

motivation.

All patients who need specialized gynecologic care in

to introduce, especially, laparoscopic simple total

I joined three laparoscopic surgical procedures

Bhutan have been centralized at JDW Hospital. Therehysterectomy, which is not conducted in Bhutan. Since

on Day 3. The first patient underwent the first everare over 4,300 deliveries per year at JDW Hospital,

the actual working period was as short as 5 days, I

laparoscopic simple total hysterectomy conductedLecturewhereas the number of major gynecologic operations

created the educational materials in advance in Japan,

at JDW Hospital, and the second and third

port placement and unfamiliar surgical procedures, I

reaches 400 cases per year, indicating that clinicaland scheduled the lectures and training exercises onpatients underwent laparoscopic ovarian operations

also took a turn and performed surgery. In order forpractice is excessively focused on perinatal care.

laparoscopic surgery after the morning conferences（ o o p h o r o c y s t e c t o m y a n d a d n e x e c t o m y ）. W ethem to actually learn the procedures, they need ourand the main consultation hours, as far as possible,

prioritized safely completing the surgery with surgicalongoing support for a while.

after consultation with the local doctors.

instruments that are available in the hospital andSince there was no surgery scheduled on Day 4, I

Team 8 visited mainly for inspections, and we were
impressed with the passionate education whereby

25

pointed out certain points to be improved to eachsix senior doctors and four trainees took turns to

Since I had an opportunity to help with a laparotomy

brought a minimum of necessary equipment thatgave a lecture on laparoscopic surgery as a review

hold theme-specific presentations every morning

procedure in the morning on Day 2, I participatedare not available in Bhutan, from Japan. Especially,of the surgery performed the previous day. I gavefrom Monday through Saturday（twice and four times,

in the surgery with the purpose of getting to know

the first patient was obese, weighing more than 90

a lecture on oophorocystectomy at the morning

respectively）, and at the time of the director’s wardthe actual condition of the operating room. First, thekg, and the surgeons struggled with the unfamiliar

conference, and a lecture with a video focusing onround on Tuesday, a bed-side oral examination on

concept on hygiene in the surgical field was different

instruments, so we completed the operation with few

simple total hysterectomy at the afternoon conference.

one patient of interest per week was held for morefrom Japan. No uniform standard has been establishedexplanations. There were many unexpected problems

A doctor working for JDW Hospital stated that thethan 1 hour with trainee doctors, interns and medical

among the staff members regarding securing of clean

in the situation where we did not have enoughtechnique used for simple hysterectomy operation

students. On the other hand, most of the education

areas and handling of clean items. Therefore, I felt

equipment for all three patients. However, we could

they had learned during laparoscopic surgery training

was devoted to perinatal and preventive medicine. The

uneasy about whether hygiene was ensured in theshare various countermeasures with the local staff

in India was simpler than the one we taught. Although

director is familiar with perinatal guidelines and key

operating room. I found a relatively large number ofincluding improvement strategies. There were some

it is easy to introduce the technique used in India, I

texts and always conducts tough oral tests based on

wound infections associated with cesarean sections atinadequacies; they did not fully understand the basic

explained the procedures so that they can select either

encyclopedic knowledge in daily practice, so I foundthe time of the ward rounds, which might have been

surgical position, the placement and preparation ofof the procedures considering the future developmentthat all doctors including senior physicians focused

due partly to poor hygienic control of the surgicalequipment, and how to use the equipment. However,of malignant tumor surgery and avoiding the risk ofon perinatal care while they were concerned about

field. Staff education on hygiene management is

if the team members in the operating room obtained

damaging other organs in atypical cases.

gynecologic tumors and surgery. Since there are more

obviously necessary, but the expanded applicationa deeper understanding of laparoscopic surgery and

I conducted laparoscopic simple total hysterectomyobese people in Bhutan than in Japan, it is difficultof laparoscopic surgery may also contribute to ashared more knowledge, then it can be expected thatagain in the morning on Day 5. As with surgery on Day

to ensure the visual field with laparotomy surgery.

reduction in the number of wound infections after

they will improve. A local doctor initially conducted

3, I was impressed with the local doctor’s technique

Although many of the local doctors recognize thesurgery.

the operation on the third patient, but due to the riskof cleanly inserting the first trocar. This seems to be aof damage to other organs associated with unusualtechnique that was developed to handle the lack ofnecessity of laparoscopic surgery and 185 laparoscopic

In the afternoon on Day 2, six gynecologists

operations per year are conducted, mainly for oviductcompleted training for laparoscopic surgery using aequipment and the many cases of extreme obesity. I

ligation as a method of sterilization surgery, oviductal

training box. Training is very important to introduce

demonstrated surgery while explaining the key points

pregnancy surgery and ovarian benign tumor surgery,laparoscopic surgery and shorten the learning curve. I

one by one based on the lecture of the previous day.

they cannot expand application of the procedure due

heard from the staff that the hospital has no equipment

The patient who underwent surgery was obese andto a lack of experience. Systematic surgical education

for practice, and suture training is done only when

had severe adhesions. The local staff understoodhas not been provided in the field of gynecology where

it is actually needed, but they probably have somehow our technique contributes to securing vision andempirical rules have been emphasized. A request foropportunities. Using training equipment brought

avoiding ureteral injury. Since the local staff could notgynecological surgery education including laparoscopy

from Japan, I explained and demonstrated needle

afford to conduct surgery this time, I would like toprocedures was received from the trainee doctors.

holding and ligature assuming actual intracorporeal

support them in completing surgery if there would be

After Team 8 returned, Team 9 was dispatchedsuturing. Participants actively practiced and soon

to provide guidance on laparoscopic surgery mainly

understood the basics of suturing procedures. It was

Activity Report

another opportunity. In the afternoon on Day 5, Dr.
Laparoscopic surgery

Baba demonstrated surgery for the treatment of the
Activity Report26Periodvulva cancer at the request of the local doctors, andlaparoscopic surgery at JDW Hospital, a full-time

Dr. Sunada provided guidance using a training box

doctor of obstetrics and gynecology should acquire

again. Since two trainee doctors participated from theproficiency in laparoscopic surgery and instruct the

beginning, we could give intensive guidance to them.

younger physicians on the surgical technique. I felt it

Their forceps technique obviously improved comparednecessary to continue training at the central hospitalwith that observed during training on Day 2. It wasfor a while so that the trainee doctors can become

impressive that the trainee doctors who participatedmore familiar with laparoscopic surgery.

remained focused on the exercise.

Team medical care is particularly important forlaparoscopic surgery. Not only the skill of the surgeon,
but also the cooperation of the assistants, nurses,
and clinical engineering technicians are all making
it possible to provide high quality medical care.
Although it is a fact that technical guidance to doctors

Surgery with local doctors

Box training: last day

November 25 to December 15, 2018

Clinical fellow,
Dpt. of Pediatrics

Hirofumi Shibata
Activities●Supervision of the pediatrician program●On-site medical care and participation in rounds
in the Pediatric Ward and PICU of JDW Hospital●Guidance, advice, and lectures to local doctors
and residents

PICU roundIn addition to the rounds in the pediatric department,
I also joined a round in the surgical department once.

is required, giving technical instruction and hygiene

Issues noticed during the activities

management guidance to surgical nurses and clinical

I was dispatched to JDW Hospital for 3 weeks from

confirmed the understanding of the residents andengineering technicians will lead to improvement of

the end of November 2018. The theme of the presentinterns, not only by discussing a patient’s disease andthe surgical environment and the overall medical care.

dispatch was“supervision of the pediatrician program,”current problems in the presence of the actual patient,

It will be helpful to provide off-site programsand I informed my local counterpart, Dr. Mimi Lhamu

but also by repeatedly asking diagnostic criteria,such as periodic web conferences as well as on-

Mynak, of our intention by email before leaving

treatment strategy, patient management, etc. in detailsite training such as practical training and surgicalJapan. After arriving there, I cooperated with theirand teaching points to note on the spot to them in a

instruction as one way of training doctors. Since there

medical services, while inspecting the entire pediatricthoughtful manner. I felt that this bed-side training is

are no obstetrics and gynecology societies in Bhutan,

department, in consultation with Dr. H. P. Chhetri, who

implemented thoroughly because the residents andestablishing an academic society and becoming

mainly supervises the pediatric inpatients ward andinterns will have to see various patients by themselvesa member of the Asian Oceania Obstetrics and

PICU. More specifically, I joined the daily round forafter they are transferred to a local hospital/clinic in

Gynecology Association will open a way of receiving

all patients in the Pediatric Intensive Care Unit(PICU)

the future.

global support.

and pediatric inpatients ward with residents to inspect

I think that the pediatrician development program

the current situation of pediatric care and resident

allows the residents to have very meaningfultraining in Bhutan through bed-side medical care andexperiences as a general pediatrician with a variety

discussions. During the rounds, I asked about theof patients in terms of bed-side training. However, intreatment strategy for each patient in Bhutan and thenthe discussions with the local supervisory doctors,

explained the strategy in Japan, proposed tests thatthe following points were raised as issues: Systemic

should be added, and provided guidance. After the

training in each specialized field is insufficient because

end of a round, I assessed newly hospitalized patients

there are only general pediatricians, and residents

with the residents and visited related departments tocannot experience the entire process of diagnosis andunderstand the actual situation.

treatment for patients with intractable conditions, who

I was impressed with the way the local physicians

are transferred to India.

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Healthatopic dermatitis and the response to food allergies in

The primary purpose of this activity wason responses that can even be taken in Bhutan. Since

demonstration of and guidance on laparoscopic

the residents and interns were not positive towards

surgery to trainee doctors, focusing on educating

performing ultrasonographic examination themselves,them. However, since they will work at hospitals in

I provided guidance on general screening tests byrural areas for a while after leaving JDW Hospital, theyultrasonography and explained the importance of

I was also consulted about the management of
outpatients, and then explained and provided guidance

will have few opportunities to perform laparoscopic
surgery. In order for them to continuously perform
27

Activity Reportseeing things themselves.
Photo with Chief nurse of Department of Pediatrics

Most of the patients in the pediatric ward and PICU
Activity Report28

were suspected to have infections, and patients in

PICU or pediatric ward with beriberi heart diseasevarious conditions（e.g., cardiac disease, renal disease,caused by vitamin B1 deficiency or Wernicke’s

When a child with chickenpox（routine vaccinations

the archive and the charts were piled in high stacks bynutritional and metabolic disease, neurologicalencephalopathy-like symptoms during the dispatch

are not available in Bhutan）was admitted to themonth of hospital admission on the floor of the archive.

disease）
were referred to JDW Hospital. On the otherperiod. There were also quite a number of school-

hospital during the dispatch period, there was noTo efficiently perform statistical processing forhand, the blood test parameters that can be measured

aged children who were found to have poor weightavailable room for immediate quarantine, and we hadthesis preparation and epidemiological research, it isin the hospital are limited, and measurement of othergain possibly due to malnutrition（without any apparent

no choice but to isolate the child in a large generalconsidered necessary to improve this system.

test parameters has to be entrusted to a testing

endocrine abnormalities）.

ward room after transferring the other patients in theamount of medical charts exceeded the capacity ofcompany. Therefore, I often had difficulty assessing

Based on an interview at the nutritional department,

room. However, since large ward rooms do not have

Accomplishments and results of this dispatch

the clinical condition of patients soon after hospital

meals consist mainly of polished rice with a highdoors that can be closed, there was concern about

Despite the short period of time, I could grasp theadmission. During this dispatch period, the MRI system,

carbohydrate energy ratio of 70% and a protein energy

airborne transmission to patients and their families

actual situation of the pediatric care and resident

the only unit available in Bhutan, was out of order andratio of approximately 10%, which is unbalanced, andsharing the passage ways and bathroom.

training at JDW Hospital by inspecting various

fixing it would take about 1 month; it was also difficult

there are many beriberi patients, even in the capital

I saw patients’families cooperating with eachdepartments. I was given the opportunity to giveto examine patients with suspected neurologicalcity Timphu. Since the situation of vitamin B1 deficiency

other to take care of the patients, which was athree lectures, in which I could learn about problems

disease.

in infants is serious, awareness-raising activities,

heartwarming scene. However, there were no curtains

they frequently encounter in daily medical practiceespecially among pregnant women and lactatingor partitions between the beds, and I occasionally saw

and situations on which they need advice throughparticularly noticed are listed below.

mothers are considered essential. According to theirsuch incidences as a child with severe heart disease

discussions.

①Development of doctors with sub-specialties

explanation, the nutritional department provides

lying across from a child with cough due to infection

Since there were no pediatricians with sub-nutritional guidance via workshops, but it has only adeveloped upper respiratory tract symptoms several

specialties, except for the NICU, a system was adopted

temporary effect, and their efforts are not sufficient indays later and the child’s condition worsened. I had

whereby the partner hospital in India is consulted

rural areas, where foodstuff is limited compared with

the impression that the situation is not sufficient in

about children with intractable or complicate

urban areas where plenty of foodstuff and supplements

terms of the prevention of infection.

conditions, and such patients are transferred to thatare available. I think that awareness-raising activities④Improvement of the medical chart system and thehospital as necessary. During the dispatch period,and efforts at a country-wide level are necessary toneed for statistics

I occasionally saw cases whose results of cardiac

improve the situation.

Medical care-related issues and problems I

Residents of the pediatric department were given

Lecture for local doctors

ultrasonography were inaccurate, who were transferred

Inpatient children not only received vitamin B1

various research themes and collected data to write

Since the period of the present dispatch was as shortfor a renal biopsy although the symptoms were mild,

supplementation, but also underwent daily assessment

theses on renal disease, vitamin B1 deficiency, etc.

as 3 weeks, I emphasized the importance of keeping

or whose condition worsened while debating whetherof body weight gain, and dietary supplements

However, when I asked them about the statistics ofin touch. I exchanged email addresses with the local

to have a consultation or not, and I felt that improving

such as F100 were supplied as necessary, and thethese diseases, they only answered“mainly infections,”

doctors and residents, and asked them to email me if

the consultation system and developing doctors with

doctors spent a considerable amount of time towhich implies that annual statistics are not taken in thethey have any problems. I would like to maintain thissub-specialties are future issues. Some of the residents

provide nutritional guidance to the parents and otherpediatric department.

communication system.

in the pediatric department were interested in renal

family members. It seemed that the doctors do not

Medical care was mainly recorded on paper medical

diseases or NICU, and it seemed that the need forcollaborate with the nutritional department. I felt thatcharts, except for some hematology/imaging data.

sub-specialization is recognized there. Considering theby establishing a collaborative relationship with the

For outpatients, since the information is written inrate of transfer to India or Thailand, I think that it is an

nutritional department, so that nutritional assessment

a notebook that is kept by the patient, who takes it

urgent task to develop pediatric cardiologists who can

is possible even during hospitalization, it would be

home, the outpatient unit for pediatric chronic diseases● There is an absolute shortage not only of doctors

make accurate decisions based on ultrasonography

possible to provide medical care more efficiently.

had a dedicated ledger-type notebook to ensure that

but also nurses and allied healthcare professionals,

and the indications for surgery.

③ Prevention of infection and response to

information is recorded both in the notebooks of thewhich creates harsh working conditions. This system,② Importance of nutritional guidance on a country-

nosocomial infection

patient as well as the outpatient unit ledger.

which heavily depends on individuals’efforts, may

wide level29

only when nurses performed certain procedures.

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of HealthThe previous report has stated that highly resistant

As for medical charts for inpatients, information

collapse at some stage, and I therefore think that

According to the website of the Tourism Council

strains of Escherichia coli, Pseudomonas aeruginosa,

was written on standardized hospital forms that were

further recruitment of personnel, improvement ofof Bhutan, it is reported that 31% of the population

etc. are prevalent in Bhutan; the situation is also true inbound in a ring file, which was retained in the medical

their treatment, as well as improvement of thein Bhutan are poor in terms of income. It seems thatthe pediatric and neonatal fields. I was surprised thatchart archive after the patient was discharged. In thework environment should be considered to ensure

the people are living without worrying much about

gentamicin and ciprofloxacin, which are not commonly

medial chart archive, data were processed so that

continuous and stable provision of medical care.

clothing, food, and housing, thanks to the government

used for children in Japan, were frequently used there.

simple statistics based on the International Statistical● A number of infants and young children suspected

measures. Since I had such an impression, I was

The doctors always took care to disinfect their hands

Classification of Diseases and Related Health Problems

to have serious vitamin B1 deficiency were transferredsurprised that many children were admitted in the

before a medical consultation, but gloves were used

（ICD）
could be taken using Microsoft Access, but the

to JDW Hospital, and I had the impression that

Activity Report

Activity Report30Period

November 25 to December 15, 2018

they accounted for about half of those admitted toduring the break time. Although material resources are

the PICU. The eating habits based on imbalanced

Chief nurse（Surgery）,
Nursing Department

carbohydrate-heavy meals consisting mainly of polished
white rice, use of thiaminase-containing flavorings such

Shoko Matsuyama

as Doma, and alcohol intake by pregnant women andlactating mothers are considered to contribute to thesituation, and I therefore think it is necessary to raise

limited, including protective gear, it seemed that there
were many things that we could work on. I gave a lecture
on infection control in the operating room and talked
about in-hospital infection control for patients and healthmanagement of healthcare professionals working in theoperation rooms, where they are frequently exposed tothe awareness of the entire country concerning their

Activities

nutritional intake.

We performed medical exchange activities in theof infections. After I gave the lecture until the end ofoperating rooms and ICU of JDW Hospital. Two

the dispatch period, we took the approach of using the

dispatched nurses paired up with each other and

PDCA cycle to disseminate information on hand hygiene,● Epidemiological data are important for the countryof Bhutan to grasp and consider improving the
medical circumstances and to reinforce the primary

Pediatric playgroundbody fluids, according to our manual on the prevention

practiced nursing management and care with therecommend the introduction of a one-footwear system,

prevention of diseases. I felt that improvement of thelocal nurses. JDW Hospital has eight operating rooms,

and recommend the assignment of a leading nurse who

medical chart system（including computerization, etc.）

about 30 nurses, and 15 nurse anesthetists. Four to six

manages daily surgical operations and education tois an important issue concerning the training andoperations are performed in one operating room per day.

develop leaders.

development of highly specialized residents in the

The staff work on a three-shift system consisting of 8:00

In the ICU, there are 8 beds and 26 nurses, one nurse

future.

to 14:00, 14:00 to 20:00, and 20:00 to 8:00, and manyfor each patient. The chief nurse has worked at the● I also felt it necessary to further improve both the

emergency operations are carried out, even at night. We

ICU for 10 years and has recorded the history andtest parameters and facilities（hematology and imaging）

discussed what we could do based on what we had

detailed statistics of the ICU from the beginning overin response to the on-site needs as a base hospital ofnoticed after arriving there, and addressed the issues

the years. She showed me the record and I found it to

the country.

using the PDCA cycle. We also made recommendations

be a great record. Nurses to be assigned to the ICU

about what we can do to improve works needed at theare subjected to 6-month training in the specialized

clinical site with the local nurses using the PDCA cycle. In

course after receiving the nurse license. Although suchthe operating rooms, we observed the general situation

nurses traditionally received training in a neighboring

Overall impression of the present medical
assistance activities
Bhutanese people both in and outside the hospitalin terms of infection control as I was asked by the chiefcountry, the specialized course in Bhutan started thiswere all friendly and kind. Bhutanese children, as I saw

surgical nurse of JDW Hospital to give a lecture on thatyear and produced six graduates. It seemed that thethem in the city, seemed more active than Japanesein the operating rooms. Doctors and nurses working innurses worked confidently with their acquired expertisechildren of the same age and I was impressed by thethe operating rooms are all kind and friendly. We worked

and skills. Hand hygiene was properly maintained.

fact that they were running around with twinkling eyes

together taking into account the importance of building

They actively exchange their opinions on treatment

and loud voices.

up a good relationship with the local staff. Regarding

and nursing care at joint conferences for doctors and

The doctors at JDW Hospital were generally very

perioperative assistance, we worked with the local

nurses that start at 10 am every day. Regarding the

education-minded, curious, gentle, and friendly, and I

nurses during three surgical operations as scrub andweekly schedule, they provide guidance to patients’

therefore had no particular problems communicating

circulating nurses. As doctors, technicians, and nurses

family members every Monday and cooperate with thewith them, which I had worried about. As for medical

have a break together and we could have a good time offamily in caring for the patients. A physical therapist

practice, in which volunteer doctors from all over theconversation with them to get to know them, I focused

visits the ICU every day, but nurses do not participate

world including the US and France were also actively

on collecting information by asking them questionsin the rehabilitation. We also reviewed things that caninvolved, I felt that the level of medical care is not very

be introduced during nursing care in the ICU, which are

different from that in Japan. On the other hand, theactually implemented in our hospital, by practicing daily

situation of limited tests for difficult-to-diagnose cases,

tasks including preparation of the work environment andetc. and the absence of specialists to consult with was

nursing care as well as shadowing. Since a nurse had

more frustrating than I had expected, which reminded

been dispatched by JICA and had worked in the ICU

me of how very comfortable the Japanese medical

for two years, Japanese nursing care has already beenenvironment is.

introduced and put into practice. It seemed that local
nurses were eager to improve their nursing care. There
are three designated hospitals in Bhutan. JDW Hospital
Lecture on infection control

31

Activity Report

is located in the capital city and plays a central role in
Activity Report32medical care. However, since it seemed to be necessary

anesthetists, and anesthesiologists. I explained thefor them to shorten the length of stay in beds in the ICU,

importance of standard precautions because all patients

which has only eight beds, we demonstrated our efforts

do not undergo preoperative tests. I also explainedin rehabilitation. Local nurses including the chief nurse ofsome points to note in the operating room concerning

the ICU became interested and agreed with the principleof early ambulation based on rehabilitation starting on
the bed, to shorten the period of use of the bed. More

Proposals that can be made to JDW Hospital, theUniversity of Medical Science of Bhutan and the
Bhutan Ministry of Healthcommitment. However, we would like to keep in touch

infection control in case of patients with suspected

I thought it would be necessary to improve thethe different healthcare professionals. I found they had aacquired immunodeficiency syndrome, tuberculosis,

handling of surgical drapes in the management of thefriendly relationship regardless of age or experience in theor Creutzfeldt-Jakob disease. After the lecture, I could

operations. The Kingdom of Bhutan, located in theoperating room and ICU. Teamwork is important in medical

preparation and time may be needed to decide on how

exchange opinions with local nurses who took an

Himalayan range, has very beautiful nature consisting ofcare, and communication is essential for teamwork to

we can achieve these objectives.

interest and shared knowledge that can be readily

the sky, mountains, woods and forest, rivers, and lakes.

work effectively. Daily smooth communication among theincorporated in their practice. Our activities during the

However, infrastructure facilities have not been installed,

healthcare professionals seemed to work effectively in the

dispatch period produced some achievements, such as:

and drained water and scattered garbage are seen allclinical practice. For example, safety should be confirmed

Issues noticed during the activities

with them via email.
One thing that I found is the good relationship among

They had disinfectant for hand hygiene but seemed

nurses implemented hand hygiene based on awarenessover the town. Environmental preservation helps tobased on the safety checklist in the operating room, andnot to use it as one of the measures for infection control

of its importance; they newly realized the importance ofprotect the people’s health and preserve the beautiful

the number of surgical instruments should be counted atin the operating rooms. It may be necessary to improve

protectors and started to wear them; they also started

nature. Surgical drapes are always stained with blood

the end of an operation, to prevent foreign materials fromthe staff members’awareness, devise the location of theto take actions concerning patients’footwear, as thereor other bodily fluids. Used drapes are collected into

remaining inside a patient’s body. When doing this, alldisinfectant, and accumulate and share historical data. In

is no solution only by arguing about it. The director ofcollection box, washed and sun-dried in the hospital andmedical staff members in the room talked to one anotheraddition, patients walked barefoot in the operating rooms

the Anesthesiology Department asked me a question

sterilized by autoclave. Surgical fabric gowns supplied

to ensure that such incidents were prevented. In ourwhile healthcare professionals changed their footwear

during the lecture. According to the director, on theto the operating rooms often become wet. More thanoperating rooms, usually a scrub nurse and a circulating

because a one-footwear system was not implemented

day of an operation, many nurses move back and forth

ten surgical drapes are needed for each operation.

nurse are allocated in each room. All staff members countyet. The operating rooms were cleaned, but some sharp

between adjacent operating rooms because there had

There are concerns about the amount of water that is

the instruments in their allocated areas, isolating the

instruments that had been dropped and residual bodynot been a person who is responsible for the overallrequired for washing and the water to be discharged,

members in their roles. The communication style used in

fluid were found on the floor. We suggested to add

schedule of the day to take a lead role depending on theand the securing of human resources because about 40

daily life and English as one of their official languages may

an instruction to patients to bring their own footwear

progress of the operations. One or two surgeons work

operations are performed on one day. An incineration

help to facilitate communication because the grammar

because it would be practically difficult for the hospitalon each operation, and they sometimes should perform

facility should be built when disposable products are

has subjective, objective, explanatory, and passive

to provide shoes or slippers for all. It appeared to be

several patients’operations at the same time. Therefore,

used. It shall be necessary to discuss this based on theexpressions, so it is easier to clearly say what has to benecessary for the hospital as a whole to introduce a one-some operations started after a waiting time, and otherestimation of the cost.

communicated in clinical practice. I really want to acquire

footwear system based on the evidence data. There may

operations took much longer than the scheduled time.

be difficulties to procure material resources, but someBased on this situation at JDW Hospital, the director

challenges were found with the washing and sterilization

wanted to know how our hospital manages operations.

of surgical instruments. Small steel instruments sterilized

communication skills derived from usual conversation andOverall impression of the present medical
assistance activities

use those skills in my nursing care, administrative tasks,JDW Hospital has eight operating rooms but only one

We left Japan and arrived in the Kingdom of Bhutan

Healthcare professionals working at JDW Hospital,by autoclave were wrapped in cloth when sterilized but

room is available after 14:00. I recommended thatlocated in the Himalayan range on November 25. I am

the families tending to the patients, and the people I

moisture sometimes remained on them. Endoscopic

they appoint a day leader among the surgical nurses

deeply grateful to the staff members of the Nursing

encountered in the town were all kind and gentle. Family

instruments and energy devices were disinfected withto coordinate the progress of the daily operations. I

Department and Operation Department who supported

bonds are very strong, and family members also engage

chemicals or formalin after they were washed in water,

also made recommendations to the chief surgical nurse

the dispatch, and Dr. Okajima, a team leader of thein the patients’care. I wish that more appropriate

and then placed in the operating rooms. It appeared toand the deputy chief nurse concerning the workflow ofdispatch taught us how to coordinate the operations

medical treatment and nursing care will continue tobe necessary to improve the washing and sterilization

three measures using the PDCA cycle after the session,and how to live on-site, which supported our activities.

reach patients with medical needs in the Kingdom ofof the instruments, since there were concerns aboutbecause I could not print out the material at the site.

I greatly benefitted by hearing the reports of Team 10

Bhutan through these medical exchange activities.

sterilization assurance that may affect the human body.

I also had an opportunity to give a lecture on care formembers about the important matters concerning eachserious patients as I considered it necessary to let themfield of expertise. I think it is important to respect otherknow about the importance of rehabilitation with nurses’

cultures and customs during international exchanges.

It is essential to provide a safe operation environment

involvement. Nurses including the chief nurse and the

We could have interactions with local staff members

for patients and to manage the staff members’healthdeputy chief nurse of the ICU listened attentively to myby observing how they provided nursing care, working

for proper surgical operations. On December 1, I gave

lecture and agreed to further discuss these matters.

with them, and having discussions to exchange opinions.

Accomplishments and results of this dispatch

33

items to be improved and could not evaluate theira one-hour lecture on in-hospital infection control in the

During the 3-week dispatch period, the local nurses

operating rooms based on the measures that our hospital

listened attentively to what we two nurses mentioned in

has taken, and it was attended by surgical nurses, nurse

the operating rooms and ICU. We could only recommend

Activity Reporteducation, and training.

Activity Report34Period

November 25 to December 15, 2018

Deputy chief nurse（CCU）,
Nursing Department

Hisako Harada
Activities

appropriate temperature by the time of administration. To

rehabilitation in Bhutan, and I therefore made proposals

deeply about the offer, because I only felt anxious andmy surprise, most of the patients’family members who

by giving a lecture on early interventional rehabilitation.

confused. Finally, I decided to accept the offer with theprovided such care were male, and they were mostly

The proposals included a recommendation to provide

encouragement of others.

biological siblings but also included many siblings-in-law.

guidance on rehabilitation methods to patients’family

According to the explanation, guidance on how to makemembers because they have strong family ties. Although

preparations and take care of patients is provided on a

it may be difficult to achieve it straight away, the chief

In the operating room, the communication was smooth

specific day of the week. I was impressed by the tight

ICU nurse said,“Let’s continue such exchanges.”I hopeand the atmosphere was also positive, and the local

family ties as patients’family members appropriatelythat my proposals will help them in the future.

staff welcomed us very favorably. By watching them

I worked with chief nurse Matsuyama for about 3transferred the tasks from one member to another whenweeks in the operating rooms and ICU of JDW Hospital,

they switched the role of attendant from one to another.

following the advice of Dr. Okajima.

Issues noticed during the activities

Matsuyama. I appreciate the proposal by Dr. Okajima.

performing operations one after another with excellent
communication and teamwork in front of me, I felt theIn the ICU, both doctors and nurses almost completely

I felt that, basically, things are lacking in the ICU. Air

importance of communication anew. They concentrated

In the first week, I worked in the operating rooms. The 5Scomplied with hand hygiene. The environment was verymats had been introduced because there were many

very hard on their work during the 6-hour on-duty period,

activities, which had previously been initiated, were steadilyclean, as it was cleaned by all nurses once a day in thepatients requiring postural changes, but only one pillow

possibly due to the absence of overtime pay.

implemented in the operating rooms and ICU, and thingsmorning. The nurses in the ICU also included many young

per patient was available. Since pillows could not be

In the ICU, the atmosphere was initially somewhat

were neat and organized, showing clear management.

nurses with only a few years of experience, but theyused for the lower limbs, it was difficult to explain about

tense compared to the operating room, but the local

There were eight operating rooms in total, and an average

were all very observant and responsive and it was hard

positioning. I also received a request for new clipboards

staff were friendly toward Japanese, because a JICA staff

of four to five operations were performed every day into imagine that they had only 1 to 2 years’experience.

（boards used to hold the flow charts）
because the boards

member had worked there for the previous 2 years, until

each room. There are a few anesthetists, and anesthesia

When I asked them, these nurses said that they hadthat had probably been supplied by Japan were old.

immediately before we arrived there. Since this was theis performed by a pair of nurses assigned exclusively forbeen trained in Thailand, as I expected.

In addition, no towels, paper towels, etc. werefirst time that staff of Kyoto University Hospital provided

that purpose. They are nurses who underwent training inIn the ICU, all patients are placed on a ventilator, andavailable for use after hand-washing in the operating

medical assistance in the ICU for the short period of 3

Thailand. In many cases, only one surgeon was assigned

many patients undergo tracheostomy, unless extubation

room or ICU. The ICU was equipped with a hand dryer,

weeks, the local staff might have been confused about

to an operation, and the operation was performed withis possible. However, unlike the situation in Japan, there

but it was sometimes not functioning, and I did not know

our presence in the beginning. As they invited us to havethe assistance of nurses. Wound closure is performed

are no systems or hospitals where patients can receive

what to do then.

lunch together, we could talk to them, and after that, someby nurses, and according to their explanation, they learn

local staff members frequently talked to us. Thus, it was

the techniques by watching the procedures as OJT in the

Accomplishments and results of this dispatch

operating room. It turned out that the issue of shortage ofSince the present dispatch period was as short as 3

clearly show what we are thinking from an early stage, anddoctors is addressed by assigning various roles to nurses

weeks, it was meaningful that I worked while learning

to fit in with them by performing bed-side care together.

with specialist skills. The nurses with high specialist skills

about the actual situation and discussing proposals in

The care was basically the same as ours. The chief nurse

were working enthusiastically.

partnership with chief nurse Matsuyama. Even in the samein the ICU had retained various kinds of information in the

In the operating room, the communication among

situation, we do not always have exactly the same views.

form of data. The chief nurse there would like to absorb

members working together is very smooth and the

I strongly felt that discussing what we feel would allow us

new information coming from outside, and therefore gave

atmosphere is also positive. However, hand hygiene is not

to learn more. I also realized that things are very simple

me opportunities to lecture. I really appreciate that.
（I

completely practiced, patients enter the room with bareand go efficiently both in the operating room and the ICU.

would also like to thank chief nurse Matsuyama and Dr.

feet, and there were no personnel who took control of the

Although I could not confirm that our proposals had soon

Kashiwagi who covered my bad English in the lectures.）entire operating room, which are points that should be

Care at the ICU

discussed for improvement. Chief nurse Matsuyama gave

been put into practice, I hope that they will provide good
opportunities for improvement in the future.

possible to obtain their understanding by giving lectures toBoth in the operating room and the ICU, nurses had highspecialist skills and were working with confidence. Theya lecture on these points. About 50 medical staff members

Our activities will become more meaningful if a

explained that they had been trained in Thailand. I was

including anesthetists attended this lecture and theysystem for cooperation with JICA staff members, whovery interested in what kind of training they had received.

presented many affirmative opinions.

are dispatched for a longer period of time to provide

I have not seen senior nurses imposing tough guidance on

medical assistance, is organized.

junior nurses in the operating room or the ICU, which may

The next week, I worked in the ICU. There were 4 beds

have a lot to do with the training they had received. Thisin the ICU and HCU, respectively, and almost all patientswere on ventilators. There are no restrictions on the visiting
hours, and oral care, aspiration, assistance to maintain bodycleanliness, sheet exchanges, and postural changes are all
performed by patients’family members in collaboration
with the hospital staff. They brought enteral foods at an
35

My anxiety was gone as I could work with chief nurse

Activity Report

Overall impression of the present medical
assistance activities

may be a national characteristic of Bhutan, but I wouldThis was the first time for me to visit Bhutan. Since I

future educational plan for young nurses so that they will

had never thought I would have such an opportunity
Conference with ICU doctors and nurses

for medical assistance activities, I really thought

like to emulate them. I would also like to formulate abe able to work enthusiastically and with confidence.
Regarding the present dispatch, I would like to thankActivity Report36the staff of the Nursing Department, including director
Igawa and deputy director Matsuno who chose me, andthe staff of JDW Hospital who welcomed us. I would
also like to thank chief nurse Uno who approved thedispatch from the CCU and who coordinated the work
shifts, deputy chief nurse Takekado, who took charge ofall duties of the deputy chief nurse during my absence,
and all CCU members who cooperated to performthe bed-side care duties. I also had to be absent fromwork in the LVAD outpatient unit. During this period,
chief nurse Mitomi and the staff of the 4th floor of the

Lectureoutpatient unit also cooperated taking extra effort. I
would like to thank them all. In closing, I would also liketo thank all other individuals who encouraged me when
I was anxious about the dispatch.

Photo with anesthetists and nurses

37

Activity Report

Activity Report