Kyoto University Hospital

Report of the Activities in Bhutan
October, 2013 ‑ March, 2016

MoU Signing Ceremony, October 29, 2013

Kyoto University Hospital

54 Kawaharacho, Shogoin, Sakyo-ku Kyoto,606-8507, JAPANTEL : +81-(0)75-751-3111 (Reception)

京都大学医学部附属病院

Kyoto University Hospital
KYOTO UNIVERSITY FOUNDED 1897

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Kyoto University Hospital

Report of the Activities in Bhutan

CONTENTS

1. Message from the Director - Prof. Nobuya Inagaki - ……………………………………………………… P1
2. Message from the ex-Director - Prof. Michiaki Mishima - ……………………………………………… P1
3. Clinical Practice and Field Medicine in Bhutan - Prof. Kozo Matsubayashi - ………………………… P2
4. Contribution
Dr. Kinzang P. Tshering President, Khesar Gyalpo University of Medical Sciences of Bhutan - … P2
5. Message from Chairperson, KUH-Bhutan Medical Exchange Working Group- Prof. Shuichi Matsuda - ……………………………………………………………………………………… P3
6. Message from Chairperson, KUH-Bhutan Medical Exchange Subcommittee- Associate Prof. Hideaki Okajima - ………………………………………………………………………… P3
7. Outline and the Condition of Medical Service in the Kingdom of Bhutan - …………………………… P4
8. Kyoto University Hospital Delegation ………………………………………………………………………… P5
9. Reports of Activities in Bhutan - ……………………………………………………………………………… P7
1st team - Department of Hepatobiliary Pancreatic Surgery and Transplantation - ……………………………… P8
1st and 2nd teams - Sae Maeda, Nursing Department - ……………………………………………………………………………………………… P9
1st and 3rd teams - Kanami Muramoto, Nursing Department - …………………………………………………………………………… P10
2nd team - Department of Surgery - ……………………………………………………………………………………………………………………………………… P11
2nd and 3rd teams - Department of Gastroenterology and Hepatology - ……………………………………………………… P12
2nd team - Yoko Takahashi, Nursing Department - …………………………………………………………………………………………………… P13
3rd team - Department of Urology - ……………………………………………………………………………………………………………………………………… P14
3rd and 5th teams - Ayuko Ishii, Nursing Department - …………………………………………………………………………………………… P15
4th team - Department of Nephrology - ……………………………………………………………………………………………………………………………… P16
4th team - Department of Pediatrics - …………………………………………………………………………………………………………………………………… P17
4th and 5th teams - Yoko Nishi, Nursing Department - ……………………………………………………………………………………………… P18
5th team - Department of Orthopedic Surgery - ……………………………………………………………………………………………………………… P19
5th team - Department of Cardiovascular Medicine - ………………………………………………………………………………………………… P20
6th team - Department of Primary Care and Emergency Medicine - ………………………………………………………………… P21
6th team - Clinical Radiology Service Unit - ……………………………………………………………………………………………………………………… P22
6th and 7th teams - Department of Respiratory Medicine - …………………………………………………………………………………… P23
6th team - Shizuoka Childrenʼs Hospital - …………………………………………………………………………………………………………………………… P24
6th team - Ai Matsuyama, Nursing Department - …………………………………………………………………………………………………………… P25
6th team - Ikumi Ueda, Nursing Department - ………………………………………………………………………………………………………………… P26
7th team - Department of Diagnostic Pathology - ………………………………………………………………………………………………………… P27
7th team - Department of Otolaryngology - ……………………………………………………………………………………………………………………… P28
7th team - Microbiology Laboratory, Department of Clinical Laboratory - ………………………………………………… P29
7th team - Department of Infection Control and Prevention - ……………………………………………………………………………… P30
10. Our Exchanges- Prof. Shinji Uemoto, Dean of the Graduate School of Medicine and the Faculty of Medicine - … P31

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Kyoto University Hospital

Report of the Activities in Bhutan
October, 2013 ‑ March, 2016

Published in March, 2016
Oﬃce of Secretarial Work and Information Service
Kyoto University Hospital
54 Kawaharacho, Shogoin, Sakyo-ku, 606-8507, Japan
TEL : +81-(0)75-751-4334

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Kyoto University Hospital

Report of the Activities in Bhutan
1. Message from the Director

Prof., Director of
Kyoto University Hospital

Nobuya Inagaki
Before my speech regarding the activity report on Kyoto University
Hospital in the Kingdom of Bhutan, I first would like tocongratulate the birth of the prince between His Majesty King
Jigme Khesar Namgyel Wangchuck and Her Majesty Queen Jetsun
Pema.
In October 2013, our hospital, Kyoto University Hospital, signed an
MOU with the Ministr y of Health in Bhutan and University of
Medical Sciences of Bhutan and dispatched our 1st team of medical
staf f, including doctors, nurses, and clinical examination
technicians based on the MOU. Since then, we have continuously
provided medical support to the Kingdom of Bhutan by dispatching
our medical staff. Recently, we dispatched the 7th team, and thenumber of our medical staff who has been dispatched has reachedapproximately 70 people.
In this project, the medical staff from our hospital perform clinicalactivities at hospitals and medical camps in the Kingdom of Bhutan
and and at the same time support the establishment of a program totrain medical specialists at Jigme Dorji Wangchuck National
Referral Hospital (JDW Hospital) to solve the shortage of doctors in
the Kingdom of Bhutan. Presently, training programs for internal
medicine, surgery, and pediatrics have been established, resulting

in achievement such as establishing two medical specialist interns
at each surgical department. Furthermore, we have actively strived
to provide education, such as a lecture course on basic life support(BLS) and promotion of "5S activities" to keep things tidy and inorder, which we plan to continue. Additionally, from 2016, we plan
to dispatch our nutritionist from our hospital to JDW Hospital inorder to support the nutrition guidance at the hospital as well as toinvite the medical staf f from the Kingdom of Bhutan so as toprovide them training.
On the other hand, working with the doctors and nurses andser ving patients in the medical environment of the Kingdom of
Bhutan is a precious experience which cannot be provided throughmerely working in our hospital, and I expect that our medical staff's"learning", "thinking", "handling issues", and "acting" in a different
environment from Japan will enrich their medical activities also at
Kyoto University Hospital.
This book reports the activities of our medical staff who haveworked in the Kingdom of Bhutan. The reports are mainly made by
doctors, nurses, and clinical examination technicians who were sent
to Bhutan. However, their dispatch has been supported by many ofthe medical staf f from various depar tments, such as thedepar tments of pharmacy, infection control and prevention,
surgery, and administrative office. Therefore, one can say that thisbook reports the united activities of the Kyoto University Hospital
medical staff in Bhutan.
At Kyoto University Hospital, we would like to continue this project
and we hope that the activities by the dispatched medical staff will
improve the relationship between Kingdom of Bhutan and our
hospital, and eventually Japan.

2. Message from the ex-Director

Prof., ex-Director of
Kyoto University HospitalMichiaki Mishima
In October 2013, Kyoto University signed an MOU on equal
partnership with the Ministry of Health of the Kingdom of Bhutan(hereinafter called “Bhutan”) and the University of Medical
Sciences of Bhutan. The MOU was signed with the aim to dispatch
medical care staff, such as doctors and nurses, to Bhutan, in orderto help nur turing young doctors in Bhutan, along with anopportunity for the Kyoto University Hospital’s medical staff tothink about “happiness” in the country which values Gross National
Happiness (GNH) under limited conditions, thus to establish areciprocal and mutually advantageous relationship.
Since the dispatch of the 1st team of doctors and nurses to Bhutanin October 27, 2013, Kyoto University has dispatched 7 teams toprovide medical care as of March 2016. The details will be reported
in the next and succeeding pages by the team members who visited
Bhutan. I believe that each member, through the exchange with thedoctors and nurses in Bhutan along with trials and er rors,

deepened the knowledge of each other as a precious experience.
Furthermore, research by the team members also led to a new
objective to utilize our exchange to help the people in Bhutan
establish medical schools and create specialized training programsfor each medical department. In Bhutan, doctors have been trainedin overseas medical schools. Furthermore, even after graduations,the doctors receive specialized trainings for each medical
department for 5 to 10 years. This has led to substantial lack of
doctors; the number of doctors in Bhutan is approximately 25
doctors per 100 thousand people, compared to approximately 230
doctors per 100 thousand people in Japan. In Bhutan, thegovernment hopes to solve this problem by opening medical
schools and creating specialized training programs for each
medical department. The medical staff dispatched from Kyoto
University Hospital will also help this plan.
As stated in the following report by Prof. Matsubayashi, Bhutan andKyoto University have maintained friendly relationship for morethan half a century through exchanges. This report on the medicalcare activities by the Kyoto University Hospital staff can be one ofsuch reports on our exchanges.
As Kyoto University Hospital, we hope to continue our cooperation
with Bhutan, through activities such as inviting medical staff from
Bhutan so as to expand our activities.
I sincerely hope to maintain this relationship.

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Kyoto University Hospital

Report of the Activities in Bhutan
3. Clinical Practice and Field Medicine in Bhutan

Prof., Center for Southeast Asian Studies,
Kyoto University

Kozo Matsubayashi
Two and half years have passed since Kyoto University Hospitalstar ted dispatching its regular medical staf f to JDW National
Referral Hospital. The idea of this project was initially formed when
Prof. Michiaki Mishima, then director of the Kyoto University
Hospital, visited Bhutan as the representative of the Kyoto
University president to sign an MOU with the Royal University of
Bhutan. His talk with the director of JDW National Referral
Hospital led to an agreement and Prof. Mishima, after returning toJapan, began working on the project upon receiving the approval of
the Kyoto University Hospital executive committee. We admire thisbold decision by Prof. Mishima along with the Kyoto University
Hospital.
The exchange between the Kyoto University Hospital and Bhutan
was preceded by the activity of the Center for Southeast AsianStudies 3 years before that in 2010 whereby Dr. Ryota Sakamoto,
Program-Specific Assistant Professor at The Hakubi Center for
Advanced Research, was dispatched to Khaling in east Bhutan andstayed there for a long period to build a healthcare design for the
local elderly people. Its purpose is as follows.
Clinical practice involves serving patients at their bedside. On theother hand, unlike the care for acute diseases, the medical care forthe elderly with often chronic diseases requires more than the care
at hospitals. Patients at the hospital are merely in their “temporary
state”. Their true state lies in their homes and communities, where

they live. Therefore, to understand the medical problems of theelderly people, the medical staff is required to visit the area where
the elderly people live to assess the states of these patients living invarious environments and cultural backgrounds.
Hospital-based medical care have greatly contributed to thelifesaving of patients with acute diseases and prolonging of life.
However, as a result of medical care at hospitals becoming highly
specialized, doctors tend to focus on their specialized lesions
without affording attention to other problems. How are elderly
people living their life? What kind of friends and families do they
have? What do they eat? What kind of medical problems do they
have in their daily life? What kind of wisdom do they have to makelife wor thwhile? These issues are mostly unobser vable in thehospital-based medical care. Our “field medicine” to visit
communities and homes from hospitals is based on such
understanding.
At the Center for Southeast Asian Studies, the Field Medicine teamled by Dr. Sakamoto have developed a healthcare design for the
local elderly people in Bhutan and it was adopted in the 11th fiveyear plan of Bhutan's Ministry of Health. In the future, it is planned
to be applied throughout the Kingdom of Bhutan. However, thelevel of medical care at hospitals in rural districts and that of basic
health units (BHU) in Bhutan is limited in both the the number of
medical care providers and medical facilities. Presently, people such
as Dr. Sakamoto and Dr. Fujisawa of the Center for Southeast AsianStudies are providing the program “Training of Trainer (TOT)” inorder to foster local medical care providers.
I hope that this will eventually lead to the cooperation between the
medical staf f with highly advanced medical treatment skills,
dispatched from Kyoto University Hospital to JDW National
Refer ral Hospital, and the grass-roots Field Medicine teammembers from Center for Southeast Asian Studies.

4. Contribution

President, Khesar Gyalpo University of
Medical Sciences of Bhutan

Dr. Kinzang P. Tshering
The University Of Medical Science Of Bhutan is the first Medical
University ever established in the country. It was established on the
2nd May 2013 by the Act of the Parliament with the aim to address
the shor tage of health human resources in the countr y.
Furthermore, on 28th of February 2015, Her Majesty Jetsuen Pema
Wangchuck, the Queen of Bhutan formally launched the Khesar
Gyalpo University of Medical Sciences Of Bhutan.
The University established its first institutional collaboration with
the Kyoto University Hospital, Japan by formally signing a
Memorandum of Understanding (MoU) on 29th October 2013. This
linkage with the Kyoto Hospital helped in further promoting thecooperation and the friendship between the two countries whichdates back to early 1950s, where there were numerous exchanges
in the field of researches and students.

As a result of the collaboration, numbers of Doctors and nurses
from Kyoto University Hospital have come to Bhutan and worked ina various departments at Jigme Dorji Wangchuck National Referral
Hospital helping the Bhutanese doctors to gain skills andknowledge. This visit by the health professionals from KUH has
had great positive influence to the hospital and the people at large.
Lately 23 Japanese health of ficials have come into dif ferent
departments in Jigme Dorji Wangchuck National Referral Hospitalin different batches from last September till now. With diverse
skills and specialties of the Kyoto Doctors, the exchange program
has immensely helped in curbing the shor tage of doctors andtransfer of knowledge and skills besides cultural exchange to the
Bhutanese Doctors.
Different ideology and work ethics of the KUH officials has left ahuge impression on the staf fs of JDWNRH. All the staf fs at
JDWNRH are fully inspired and charged up with energy from the
hardworking officials of KUH to work tirelessly and evermore
effectively to take medical care to a greater height and provide thebest health care possible to our people.
We would like to express our deep gratitude to Kyoto University
Hospital for generous help extended to us and we look forward tofurther consolidate and strengthen this collaboration for mutual
benefits.

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Kyoto University Hospital

Report of the Activities in Bhutan
5. Message from Chairperson, KUH-Bhutan Medical Exchange Working Group

Chairperson, KUH-Bhutan Medical
Exchange Working Group
Prof., Department of Orthopaedic Surgery

Shuichi Matsuda
At Kyoto University Hospital, from Januar y 2013 we havedispatched 7 teams of doctors and nurses to Bhutan. Each member,through the exchange with doctors and nurses in Bhutan, has had aprecious experience. I would like to thank the people who havestrived to start and continue this project. Dispatching the staff ofmany hospital depar tments may have caused shor tage ofmanpower and difficulties. I thank the people who permitted thedispatch and ask for their continuing support of this project.
This project aims to help train young doctors in Bhutan, but I
believe that it has also provided for the dispatched staff a precious
experience to live and provide medical care in a different culture.
Our staff has also learned and was given opportunities to think
about issues. Such a rare experience will contribute to their careers
as medical care providers. We hope that people will continue
actively participating in this project.
In addition to our staff going to Bhutan, we have started inviting thestaf f from Bhutan to Kyoto University. We have managed tocontinue this project to dispatch the staf f thanks to the warm
support by the people of Bhutan. We hope to provide our best
support when Kyoto University receives the people from Bhutan.
I hope that this wonderful exchange with Bhutan will continue anddevelop, with us learning from each other and growing. I ask foryour continuous support.

6. Message from Chairperson, KUH-Bhutan Medical Exchange Subcommittee
Chairperson, KUH-Bhutan Medical
Exchange Subcommittee
Associate Professor,
Department of Hepatobiliary Pancreatic
Surgery and Transplantation

Hideaki Okajima
My association with the Kingdom of Bhutan began when we visitedthe Kingdom of Bhutan in October 2013 as the 1st team andprovided surgical services for 3 months in JDWNR Hospital within
the capital of the Kingdom of Bhutan Thimphu. Throughcollaboration with local surgery staff, we mostly treated inpatients;
our main areas were general, gastrointestinal, and pediatricsurgeries, as well as surgery for emergency. We participated in a
total of 180 procedures.
Bhutan faced a shortage of doctors. For example, the number ofsurgeons engaged in medical ser vices on a nationwide basis,including those specializing in neurology, urology, and pediatrics,
was limited to 6; therefore, we also assisted in open surgery and alarge number of urological procedures. Furthermore, we provided
advice on preoperative assessment and treatment policies so as topromote the clear classification of patients into those requiring and
not requiring transfer to India or other countries for treatment thatis difficult to perform in Bhutan, in order to reduce unnecessary
patient transfers. When treating domestically unmanageable
patients requiring hepato-biliary-pancreatic surgery, we performed
surgery while providing technical guidance so as to avoid transferof patients to other countries.
In Bhutan, due to the presence of surgeons mainly at hospitals in
Thimphu, patients throughout the countr y are transferred toThimphu, sometime taking several days. Unfortunately, some ofthem lose their lives before arrival. To resolve such a situation,
surgical camps to provide surgical services for several weeks in
hospitals located in rural areas are established, and we participatedin some of them. The surgeons, nurses, and anesthesiologists
participating in surgical camps held in diverse areas to performsurgery are volunteers. We chose relatively mild cases to perform
same-day or overnight surgery. We also made efforts to assess the
cur rent status of medical education systems in Bhutan andconsidered what kind of education system would be required to
improve the quality of medical services in Bhutan.
The unavailability of sufficient doctors was also prevalent in rural
areas, suggesting the need for doctor support from other countries.
We encountered also a serious shor tage of medical resource.
Referral meetings to identify patients requiring transfer to othercountries (mainly India) were held weekly, and approximately 15 to
20 patients were transferred abroad. The costs of such transfers,
including treatment, were fully covered by the government,
revealing a heavy burden.
Consequently, the quantities of surgical and suture instruments
were limited; many expired or reused products were being used.
We may have been able to provide more advanced services if only
there had been sufficient instruments and supplies, so ensuring theavailability of suf ficient medical resources may be anotherchallenge.
We were dispatched as a surgical team, but we felt the need toregularly dispatch medical teams, covering as diverse fields as
possible, and comprehensively clarify the current status, in order todevelop future perspectives on medical ser vices in Bhutan byidentifying problems and points of improvement in each medical
department.
I was anxious about the provision of medical ser vices in an
unfamiliar place without preparation before being dispatched, but
Bhutanese people received us very warmly. The current status of
medical services in Bhutan was similar to that in Japan when I wasa resident or even earlier. We encountered diseases that areuncommon in present Japan. Although I was occasionally confused,
I was able to receive support from other members of the first
medical team and kind Bhutanese people. This was one of the mostvaluable experiences in my life.
Furthermore, in 2015, as the leader of our sixth team, I had an
opportunity to talk with Bhutanese people and support the teammembers as their advisor. I hope to continue participating in thisproject in various forms.

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Kyoto University Hospital

Report of the Activities in Bhutan
7. Outline and the Condition of Medical Service in the Kingdom of Bhutan[Outline]
The Kingdom of Bhutan is located east of Nepal and sandwiched between
two large countries, China and India. Its land covers approximately 380,000
km2. The land stretching to east and west is mostly comprised of forests andmountainous regions, accounting for 70%, and few plains. Its northern
region has Himalaya Mountains reaching 7,000 m above sea level, while its
southern region is only 300 m above sea level, having the substantial
difference of elevation. Its capital city, Thimphu, in the eastern region is also
at a highland of approximately 2,500 m above sea level.
The Kingdom of Bhutan is known internationally for valuing gross national
happiness (GNH), and the educational and medical fees are all free in
Bhutan. Medical institutions in the Kingdom of Bhutan are comprised ofreferral hospitals to provide specialized medical treatment, regional anddistrict hospitals at the prefectural level, and basic health units in each areaadministering out-reach clinics. (See the table “Medical Institutions in theKingdom of Bhutan”.) The 3 referral hospitals are comprised of the one
located in the capital city Thimphu, the one located in Gelephu in southern
Sarpang prefecture, and the one located in Mongar in the eastern Mongar
prefecture. Jigme Dorji Wangchuck National Referral Hospital (JDW
National Referral Hospital) in the capital city is the countr y’s top-level
hospital.
Medical Institutions in the Kingdom of Bhutan
Medical Institution Referral Hospitals Regional Hospitals
Number3
22

Clinics192[Issues Concerning Medical Care]Thus, while there are hospitals and clinics to some degree, the number ofdoctors in the Kingdom of Bhutan is insufficient. As of 2014, there are only
approximately 200 doctors in the entire country, and the number of doctors
in Bhutan is approximately 25 doctors per 100 thousand people (compared toapproximately 230 doctors per 100 thousand people in Japan). Doctors are
stationed only to the level of district hospitals, and there are not enoughmedical specialists.
Due to such shortage of doctors in rural areas, many of the residents in theeastern region are required to visit JDW National Referral Hospital, locatedin Thimphu in the western region to receive full-fledged treatment. However,to travel from the eastern region to the JDW National Referral Hospital, one
needs to travel through steep mountain paths for a few days, and it is very
difficult to transport patients that way.
[Absence of Education System for Doctors]
The above-mentioned shor tage of doctors is fur ther worsened by theabsence of education system for doctors in the Kingdom of Bhutan. There isno university in Bhutan with a medical school, so people who aspire to
become doctors are required to receive medical education overseas.
Furthermore, they return to Bhutan as medical interns after graduating anoverseas medical school, but after their initial training in Bhutan (byworking at departments in referral hospitals, regional hospitals, or regional
clinics as interns), they need to receive trainings overseas to become
medical specialists. This training to become medical specialists normallytakes 5 or more years. This has led to a decline in the number of doctors
working in the Kingdom of Bhutan as well as the decline in the number ofyoung people who aspire to become doctors. In the Kingdom of Bhutan,
people tend to value spending time with their families, but becoming adoctor forces one to spend a long period overseas. Thus, many young people
hesitate to become doctors.
[Shortage of Mid-Career Doctors and Medical Specialists]
The doctors who receive the training to become medical specialists aremainly in their thirties with some clinical experience, the age which is thebest time for working. However, they cannot provide medical care in theKingdom of Bhutan while receiving the training overseas. Since such midcareer doctors are away to foreign countries, the doctors remaining in theKingdom of Bhutan are only young medical interns in their twenties anddoctors in their forties and above, who are in positions such as the head ofthe medical depar tment and professors. Thus, medical care is being
provided through such an abnormal distributed structure of doctors without
the mid-career.
In the Kingdom of Bhutan, the number of medical specialists is especiallylow, not to mention the overall lack of doctors. For example, there are only 6
surgeons in the entire country, even if we also count urological surgeons. Allof these 6 surgeons are working at JDW National Referral Hospital in thecapital city Thimphu in order to deal with diversified surgeries and increase

number of cases, and they can only afford to work in rotation there. (See thelist “Number of doctors at JDW National Referral Hospital [and their
specialized fields]”.) Under these circumstances, it is difficult for patients toreceive specialized surger y or medical treatment at referral hospitals inother regions or at regional hospitals.
Number of doctors at JDW National Referral Hospital (and their specialized fields)
Specialized Field
Surgery (general surgery, urology, etc.)
Internal medicine (cardiovascular medicine,
gastrointestinal medicine, nephrology, neurology, etc.)
Anesthesiology
Obstetrics and Gynecology
Orthopedics
Otorhinolaryngology
Ophthalmology
Pediatrics
Dermatology
Dentistry
PsychiatryRadiology
Pathology
Emergency
Total

Number
4
6
5
4
4
3
4
4
3
6
3
3
5
2
56

[Strain on the National Finances]
The current state of doctors receiving trainings overseas to become medical
specialists is also imposing a strain on the national finances of the Kingdomof Bhutan. The government of the Kingdom of Bhutan is covering all the
expenses for the overseas medical education and medical specialist training.
The cost covered includes not only the school and training fees but also theliving expenses during one’s stay and travel expenses. The government of
the Kingdom of Bhutan also covers the expenses for public health andmedical ser vices for its citizens. However, due to the lack of medical
specialists as stated above, patients requiring advanced surgeries must be
sent overseas to receive medical treatment in India or other countries. To dothat, the expenses such as those for sending the patients overseas arecovered by the government of the Kingdom of Bhutan. In Japanese yen, it
would be as high as several hundred millions of yen.
[Policy]
In light of the present situation, to help solve the shortage of medical staff in
the rural areas in the Kingdom of Bhutan, we are striving to establish asystem whereby doctors can receive medical training in the Kingdom of
Bhutan so as to prevent mid-career doctors from being in foreign countries
and solve the shor tage of doctors in the Kingdom of Bhutan. This is
expected to help stationing sufficient number of doctors at referral hospitals
in rural areas, where there are only sufficient medical equipment at present.
Furthermore, establishing a medical training system in the Kingdom of
Bhutan would lead to reducing the strains on the national finances and thebudget for overseas medical training and overseas patient transfer could bespent on other policies for the welfare of citizens and residents.
The government of the Kingdom of Bhutan is also aware of the importanceof establishing a training system for doctors and medical specialists in the
countr y. In 2013, the government founded the University of Medical
Sciences of Bhutan (UMSB) and established Postgraduate Medical
Education Centre (PGMEC) in the JDW National Referral Hospital.
However, so far, they have only started faculties, namely the Faculty of
Nursing and Public Health and Faculty of Traditional Medicine, along with
the Midwifery course. An essential medical school is lacking. It is partly due
to the shortage of doctors who can become medical instructors. Therefore,
in the Kingdom of Bhutan, prior to the opening of the medical school, JDW
National Referral Hospital and Kyoto University Hospital are working
together to start a “medical specialist training program”. We also plan todevelop this medical specialist training program through this project. If it
becomes possible to train medical specialists of all fields so as to solve theshortage of doctors and sufficient number of doctors can afford the time toprovide training as medical instructors, we believe that it helps them focus
on the training of medical students in the Kingdom of Bhutan and eventuallylead to the establishment of a medical school.

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8. Kyoto University Hospital Delegation 1st team~7th team -4th team

3rd team

2nd team

1st team

Term

Name

Department

Occupation2013.10.27−2013.10.31

Shinji Uemoto

Department of Hepatobiliary
Pancreatic Surgery andTransplantation

Deputy Director,Professor

2013.10.27−2013.11.2

Megumi Iida

Nursing Department

Head Nurse

2013.10.27−2013.11.2

Mayumi Tsujioka

Nursing Department

Head Nurse

2013.10.27−2013.11.2

Tetsuya Ino

Administrative Office

Head of General Affairs
Section2013.10.27−2014.1.25

Hideaki Okajima

2013.10.27−2014.1.25

Tadahiro Uemura

2013.10.27−2014.1.3

Sae Maeda

Nursing Department

Nurse

2013.10.27−2014.1.25

Kanami Muramoto

Nursing Department

Nurse

2014.1.19−2014.1.24

Kazuo Matsubara

Department of ClinicalPharmacology and Therapeutics

Assistant Director,Professor

2014.1.19−2014.3.28

Shigeru Tsunoda

Surgery

Assistant Professor

2014.1.19−2014.3.28

Mitsuhiro Nikaido

Gastroenterology and Hepatology

Clinical Fellow

2014.1.19−2014.4.14

Yoko Takahashi

Nursing Department

Nurse

2014.1.19−2014.4.14

Sae Maeda

Nursing Department

Nurse

2014.1.19−2014.2.28

Yusuke Sakai

Administrative OfficeStaff2014.6.29−2014.7.3

Satoshi Ichiyama

Clinical Laboratory

Deputy Director,Professor

2014.6.30−2014.7.5

Tsutomu Chiba

Gastroenterology andHepatology,Cancer Center

HoD,Professor

2014.6.29−2014.7.3

Kiyomasa Machida

Clinical Laboratory

Clinical Laboratory
Technician

2014.6.29−2014.7.3

Hiroaki Yamaki

Administrative Office

Head of Administrative Office

2014.6.29−2014.7.5

Masaharu Oda

Administrative Office

Chief2014.6.30−2014.7.3

Yusuke Sakai

Administrative OfficeStaff2014.6.30−2014.9.20

Yoshiyuki Matsui

Urology

Senior Lecturer

2014.6.30−2014.7.28

Yuzo Kodama

Gastroenterology and Hepatology

Assistant Professor

2014.7.26−2014.8.26

Yoshihisa Tsuji

Gastroenterology and Hepatology

Assistant Professor

2014.8.22−2014.9.20

Norimitsu Uza

Gastroenterology and Hepatology

Assistant Professor

2014.6.30−2014.9.20

Ayuko Ishii

Nursing Department

Nurse

2014.6.30−2014.10.2

Kanami Muramoto

Nursing Department

Nurse

Department of Hepatobiliary
Pancreatic Surgery andTransplantation
Department of Hepatobiliary
Pancreatic Surgery andTransplantation

Associate Professor
Assistant Professor

2014.9.16−2014.9.22

Tomoya Akiyama

Nursing Department

Assistant Director, Head of
Nursing Department

2014.9.16−2014.9.23

Tatsuo Tsukamoto

Nephrology

Associate Professor

2014.9.30−2014.10.10

Yumi Matsuno

Nursing Department

Deputy Head of Nursing
Department

2014.9.30−2014.10.10

Yuki Adachi

Nursing Department

Head Nurse

2014.10.27−2014.10.30

Hiromu Ito

Orthopaedic Surgery

Associate Professor

2014.10.27−2014.10.30

Bungo Otsuki

Orthopaedic Surgery

Assistant Professor

2014.10.14−2014.10.27

Hiroyuki Yamada

Nephrology

Clinical Fellow

2014.11.16−2014.12.15

Hirotaka Imamaki

Nephrology

Assistant Professor

2014.9.16−2014.11.5

Yuri Dowa

Pediatrics

Clinical Fellow

2014.11.10−2014.12.15

Tomoyoshi Matsui

Pediatrics

Clinical Fellow

2014.9.30−2014.12.30

Yoko Nishi

Nursing Department

Nurse

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8. Kyoto University Hospital Delegation 1st team~7th team -7th team

6th team

5th team

Term

Name

Department

Occupation

2014.12.26−H27.1.2

Tetsuo Shioi

Cardiovascular Medicine

Senior Lecturer

2015.1.12−2015.2.9

Junichi Tazaki

Cardiovascular Medicine

Assistant Professor

2015.2.8−2015.3.7

Masao Imai

Cardiovascular Medicine

Assistant Professor

2014.12.15−2015.3.13

Bungo Otsuki

Orthopaedic Surgery

Assistant Professor

2014.12.26−2015.3.13

Ayuko Ishii

Nursing Department

Nurse

2015.1.7−2015.3.13

Yoko Nishi

Nursing Department

Nurse

2015.9.6−2015.9.10

Hideaki Okajima

Department of Hepatobiliary
Pancreatic Surgery andTransplantation

Associate Professor

2015.10.12−2015.10.14

Toshiya Shibata

Clinical Radiology Service Unit

Associate Professor

2015.9.16−2015.9.23

Shigeo Muro

Respiratory Medicine

Senior Lecturer

2015.9.6−2015.10.7

Tomoharu Mori

Clinical Fellow

2015.10.5−2015.11.6

Manabu Shimoto2015.10.28−2015.12.1

Shigeru Ohtsuru

Primary Care and Emergency
Medicine
Primary Care and Emergency
Medicine
Primary Care and Emergency
Medicine

2015.9.6−2015.12.1

Ai Matsuyama

Nursing Department

Nurse

2015.9.6−2015.12.1

Ikumi Ueda

Nursing Department

Nurse

2015.10.5−2015.10.17

Yasuhiko Tanaka

Shizuoka Children’s Hospital
Department of Neonatology

Head2015.10.12−2015.11.6

Rinpei Imamine

Clinical Radiology Service Unit

Assistant Professor

2015.10.28−2015.11.20

Akihiro Furuta

Clinical Radiology Service Unit

Assistant Professor

2016.1.8−2016.1.15

Bungo Otsuki

Orthopaedic Surgery

Assistant Professor

2016.1.8−2016.1.15

Ayano Kimura

Administrative Office

Assistant Staff

Assistant Professor
Senior Lecturer

2016.2.24−2016.3.1

Ami Matsubara

Metabolism and Clinical Nutrition

Dietician2016.2.24−2016.3.1

Shigeru Tsunoda

Surgery

Assistant Professor

2016.2.24−2016.3.1

Mitsuhiro Nikaido

Gastroenterology and Hepatology

Graduate Fellow/Doctor

2016.2.24−2016.3.1

Ai Matsuyama

Nursing Department

Nurse

2016.1.8−2016.1.29

Akihiko Yoshizawa

Diagnostic Pathology

Senior Lecturer

2016.1.8−2016.1.29

Masahiro Hirata

Diagnostic Pathology

2016.1.8−2016.2.5

Yoko Tanaka

Clinical Laboratory

Clinical Laboratory
Technician
Clinical Laboratory
Technician

2016.1.11−2016.2.5

Chiaki Suzuki

Clinical Fellow

2016.2.2−2016.2.29

Morimasa Kitamura

2016.2.24−2016.3.19

Tatsunori Sakamoto

Otolaryngology, Head and Neck
Surgery
Otolaryngology, Head and Neck
Surgery
Otolaryngology, Head and Neck
Surgery

2016.2.2−2016.2.29

Yasuhiro Tsuchido

Infection Control and Prevention

Graduate Fellow/Doctor

2016.2.19−2016.2.29

Tadao Nagasaki

Respiratory Medicine

Clinical Fellow

2016.3.1−2016.3.11

Shinsaku Tokuda

Respiratory Medicine

Clinical Fellow

Assistant Professor
Assistant Professor

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9. Report of the Activities in Bhutan

1st team ~ 7th team of Kyoto University Hospital,

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Kyoto University Hospital
Department of Hepatobiliary Pancreatic Surgery and Transplantation

Report of the activities of the first team
Term: October 27, 2013 ‑ January 25, 2014

Associate Professor,
Department of Hepatobiliary Pancreatic
Surgery and Transplantation

Assistant Professor,
Department of Hepatobiliary Pancreatic
Surgery and Transplantation

Hideaki Okajima

Tadahiro Uemura

Content of Activity

Challenges and problems

We provided surgical services for 3 months in JDWNR Hospital within the

In Bhutan, there seemed to be 3 potential base hospitals, including that

capital of the Kingdom of Bhutan Thimphu. Through collaboration with local

located in the capital Thimphu. However, as surgeons were available only insurgery staff, we mostly treated inpatients; our main areas were general,the hospital of Thimphu, all patients requiring surger y throughout thegastrointestinal, and pediatric surgeries, as well as surger y for trauma

countr y are transfer red to it, taking several days. In other medical(emergency). We participated in a total of 180 procedures in consideration of

departments, the unavailability of sufficient doctors was also even more

the medical situation in Bhutan, facing a shortage of doctors. For example,

marked in rural areas, highlighting the necessity of doctor support fromthe number of surgeons engaged in medical services on a nationwide basis,other countries to address this.

including those specializing in neurology, urology, and pediatrics, wasNot only surgical departments, but also others were facing resource, inlimited to 6; therefore, we also assisted in open surgery and a large number

addition to doctor, shortages. Referral meetings to identify patients requiringof urological procedures. Fur thermore, with the aim of reducing

transfer to other countries (mainly India) were held weekly, andunnecessar y patient transfers, we promoted the clear classification of

approximately 15 to 20 patients were transferred abroad. The costs of suchpatients into those requiring and not requiring transfer to India or othertransfers, including treatment, were fully covered by the government,

countries for treatment that is difficult to perform in Bhutan by providing

revealing a heavy burden to it.

advice on preoperative assessment and treatment policies. We also avoided

The quantities of surgical and suture instruments were also limited; expired

such transfers by performing surgery while providing technical guidanceor reused products were routinely used. As we may have been able towhen treating domestically unmanageable patients requiring hepato-biliary-provide more advanced ser vices if only there had been slightly morepancreatic surger y. Due to doctor shor tages, patients throughout thesufficient instruments and supplies, ensuring the availability of sufficientcountry are transferred to Thimphu, taking several days, and, sadly, some of

medical resources may be another challenge.

them lose their lives before arrival. To resolve such a situation, surgicalcamps to provide surgical services on a 24-hour basis for several weeks in
hospitals located in rural areas are established, and we participated in some

Future perspectivesof them. The majority of surgeons, nurses, and anesthesiologists
participating in surgical camps held in diverse areas to perform surgery arevolunteers. We chose relatively mild cases to perform same-day or overnight
surger y. We also made ef for ts to clarify the current status of medical
education systems, in addition to points of improving them, and increase thequality of medical services in Bhutan.

Although this report focuses on surgery, as we were dispatched as a surgicalteam, it may be necessary to regularly dispatch medical teams, covering as
diverse fields as possible, and comprehensively clarify the current status, inorder to develop future perspectives on medical ser vices in Bhutan byidentifying problems and points of improvement in each medical
department.

Impressions
I was anxious about the provision of medical services in an unfamiliar place
without preparation before being dispatched, but Bhutanese people received
us ver y warmly. The current status of medical ser vices in Bhutan was
similar to that in Japan when I was a resident or even earlier. We
encountered diseases that are uncommon in present Japan. Although I was
occasionally confused, I was able to receive support from other members of
the first medical team and kind Bhutanese people. This was one of the mostvaluable experiences in my life. Thank you.

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Kyoto University Hospital
Nursing Department

Report of the Activities in Bhutan of the first and second teams
Term: October 27, 2013 ‑ January 3, 2014,

Nurse, Nursing Department

Sae Maeda
Content of activity

January 19 ‑ April 14, 2014

to 3 months.
In Bhutan, as is the case with physicians, the number of nurses isinsuf ficient. I had the impression that much of the hospital’s medical
practice was divided to perform, and that the hospital’s medical setting was
supported mainly by professionals other than physicians. At my workplace,patients are cared for by various healthcare providers, such as nurses
specialized in dressings, otolaryngologists performing the management ofpatients undergoing tracheotomy, orthopedists, and physical therapists who
help postoperative patients regain their ability to walk; however, because
patient information is not sufficiently shared, it is difficult for nursing staff tounderstand patient characteristics, which hinders the practice of EBN.

Future perspectives
I worked on the surgery ward for 6 months with the first and second teams.
When I came to Bhutan with the first team, I did not know details regarding
healthcare in Bhutan. Therefore, initially, I obtained necessary informationby checking the environment of my workplace, and by visiting a suburban
healthcare facility (BHU). I spent days understanding the healthcare
systems of Bhutan, as well as having discussions with other team members
about what kind of inter vention we could provide.Our activity base was
National Referral Hospital (JDW Hospital), one of the three main hospitals in
Bhutan. Although this hospital was a top-rated medical center in the country,
it lacked in some infrastructure, such as medical equipment and supplies,
and the center’s sanitary conditions were poor. Therefore, we nurtured thehospital environment, and organized medical supplies based on theprinciples of 5S in a manner so that these supplies could be used without
wasting them.
When I came to Bhutan with the second team, we promoted the provision oftechnical skills regarding ERCP. Previously, all Bhutanese patients requiring
ERCP were transferred to hospitals in India, and so the medical staff in
Bhutan had never dealt with such patients. Therefore, we provided themwith necessar y information using relevant materials and through study
meetings. In addition, we created postoperative checklists to facilitate
postoperative patient management after surger y. Initially, these staf fmembers often missed checking items. However, as they accumulated
experience with patients, they became able to understand the points thatshould be monitored, as well as to complete a checklist without missed
items. On a daily basis, I encountered various nursing care-related cases at
my workplace. As the second team, we have successfully contributed tosuction procedures and respiratory management. At the early stage, several
bedridden patients with a histor y of tracheostomy were hospitalized;
however, due to a lack of manpower in the hospital, their family members
were generally in charge of some medical procedures (e.g., suction) for
these patients. As we perceived the need for providing the nursing staff withknowledge in a manner enabling them to acknowledge the importance ofmanaging patients undergoing tracheotomy, we held study meetings withthe local staff, and gave demonstrations using a model. Many staff members
actively participated in these meetings, which covered not only tracheotomy,
but also respiratory management for postoperative patients. Although it wasmeaningful to provide such knowledge, the lack of manpower made me
recognize the need for fur ther inter vention in order to utilize thatknowledge in the hospital.

Challenges and problems

Bhutan is a small Himalayan country ranging from subtropical thick forests,
whose sea level is approximately 200 m, to a mountainous region whose sea
level is over 7,000 m. Many citizens of the countr y practice Tibetan
Buddhism. Bhutan is renowned for placing emphasis on GNH (Gross
National Happiness) instead of on GDP. In fact, as I stayed in the country, I
often encountered cases in which I felt that Bhutanese people were happy.
They are not materialistic or restricted by time, and such a lifestyle may not
be familiar to Japanese people. However, it may be possible to understandthem by enjoying the lifestyle differences and learning the country’s culture.
Furthermore, although local nursing schools provide systematized nursing
education, postgraduate education(e.g., OJT) aimed at improving knowledge
and skills at a working level has yet to become a common practice. I thought
that, to help local healthcare providers to advance their expertise, it isnecessar y to implement OJT led mainly by these workers, and perform
other activities in cooperation with them, instead of providing them withknowledge and skills based only on the ideas of our teams.

Impressions
When I was dispatched to Bhutan with the first team, I was constantly
distressed about my new life and how to provide nursing care. The local staff
was also distressed about how to communicate with us, the two Japanesenurses who popped up. However, as we carried out what we could do, ourrelationship with these staff members became closer, and we became able toenjoy our activities. This was significantly attributable to Japanese physicians
who worked with us and provided medical tips for local nursing staff as well
as for us.
Both before and during my stay in Bhutan, I received support from many
people. For example, the nursing staf f of the Radiology Depar tment
encouraged my challenge, and the personnel of the Clerical Department
made the necessary adjustments with our activity base (JDW Hospital) andmedical universities.
In addition, staff of the Nursing Department gave me activity-related advice,
relevant materials, and support for living in Bhutan. Furthermore, I was
informed about the current state of healthcare in Bhutan by professors fromthe Center for Southeast Asian Studies (Kyoto University), and I also
learned about the countr y’s school education and architecture during
interaction with members of the JICA. These experiences became the basis
for our project, and made my life in Bhutan productive. I am really gratefulfor this wonderful opportunity to work in Bhutan.

In Bhutan, all individuals are able to receive medical care for free. Because
all medical costs are borne by the government, hospital staff commonly haveno interest in the financial aspect of hospital operations, and do not pay
enough attention to the costs of medical supplies. Therefore, I felt that the
medical staff in Bhutan are less likely to develop the idea of appropriately
managing these supplies and to know where the supplies are when they
have to be used. However, it may be possible to help these staff members tounderstand the importance of supply management by performing 5S-based
activities. In addition, one of the major tasks in future activities is to securesuf ficient drugs and medical supplies; however, Bhutan has a unique
distribution system, and the government plays a significant role in hospital
operations, including the distribution of resources. Therefore, I thought that
it is difficult for our teams to establish a connection and obtain reliable
information, as team member turnover occurs at intervals of several weeks

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Kyoto University Hospital
Nursing Department

Report of the Activities in Bhutan of the first and third teams
Term: October 27, 2013 ‑ January 25, 2014,

June 30 ‑ October 2, 2015

Nurse, Nursing Department

Kanami Muramoto
Content of activity
In Bhutan, where the number of physicians is insufficient, I thought that
nurses had a wider range of duties (e.g., suturing, removing drains, andprescribing drugs) than in Japan. I had various surprising experiences at myworkplace, and even felt that the local staff performing ward duties did not
require our support. I often talked with another member of the first team
about what kind of inter vention we could provide. As we obser ved eachdepartment of the hospital with the aim of finding what we could do, we
realized that pre- and post-operative nursing care was only a part of ourduties on the surgery ward. This is why we began to promote the principles
of 5S.
The local staff was surprised when I carried infusion equipment by myself,
and when I performed hospital room-related duties that were not familiar tothese staff members, such as changing suction bottles and checking theoutlets. As I continued to work on things that I thought should be improved,
local staff members increasingly helped me when they had a spare moment
during their work. We promoted many different things from the viewpoints
of inventory count for hygiene materials, regular checking of emergency
carts, infection control, medical safety, as well as the organization of linen
closets and medical records. However, the in-ward 5S principles werehanded over to the second team before the local staff became accustomed tothese principles. In spite of the inter val between the second and third
dispatches, the principles were still followed by these personnel when I cameto this hospital with the third team, which made me glad and impressed. In
addition, when the chief nurse of the surgery ward visited the ward, she
stated that our activities aided in the operation of the entire ward. I was very
happy to hear that.
The third team provided necessary supplies, and opportunities to hold study
meetings regarding the: principles of 5S, handling of CVC, management ofgastric tubes, and stoma control. In addition, the team routinely provided
nursing care in cooperation with local staff. From the second team, the third
team took over information/duties regarding urologic patients andregarding nursing care provided both before and after ERCP. I learned a lot
through such information and duties.
The environment of patients should be nurtured according to the level of
medical care they receive, and such an environment is markedly influenced
by the quality of nursing care. Even if an attempt is made to improve medical
practice in Bhutan by explaining the need for EBM- and EBN-based care,which is commonly provided in Japan, this attempt would not necessarily be
accepted by healthcare providers in Bhutan. Through trial and error, I
experienced challenges in having our ideas accepted and ensuring thecontinuity of nursing care, and I could learn a lot through these challenges.
In addition to our activities in the hospital, we visited local hospitals and a
medical center referred to as BHU, in order to understand the medical
conditions of Bhutan. I learned that the country’s community healthcare is
suppor ted not only by health assistants, who are in charge of such
healthcare, but also by all other medical professionals, such as nurses andtechnicians. In Bhutan, where family and other interpersonal relationships
are usually close, many residents are willing to preser ve their own
community regardless of the presence or absence of access to medical carein the community. Such relationships and willingness may facilitate medical
development in the country.

Challenges and problems
In Bhutan, patients generally take their medical records home at discharge,
therefore, these records do not remain in hospitals. After wards, somepatients lose their medical records, or forget to bring them at the time of a
medical consultation or re-admission. To follow patients constantly, there is aneed to store their medical records, and improve the methods to store them.
Furthermore, in Bhutan, nursing records are not being made appropriately;
therefore, the continuity of nursing care may be ensured by improving
education on how to extract, resolve, and record nursing problems.
In addition, the percentage of nursing aides is lower in Bhutan than in Japan,
and so Bhutanese nurses are very busy with various duties. By appointing
ward clerical workers, such as ward clerks, it may be possible for thesenurses to share some duties (e.g., answering telephone calls and organizing
paperwork) with these workers, as well as to spend more time doing nursing
work.

Future perspectives
Life in Bhutan can be exciting for foreigners in various ways, such as
working in a cross-cultural setting, and eating various spices on a daily basis.
In addition, Bhutanese people are usually gentle, helpful, and interested inmany things.
Because our activity base is located in the capital city of Bhutan, we seldom
feel inconvenienced in life. In local areas, we can refresh ourselves byappreciating the beauty of nature or the stateliness of temples.
Our project may be further improved by involving more staff members.
Although dispatched workers would likely face hardships, they could
accumulate valuable experience, and forge special bonds with local people. I
wish success to members who will be dispatched in the future. Tashi Delek!!

Impressions
In Bhutan, families commonly stay close to their patients to provide personalcare. Therefore, when I provided patients with certain types of nursing care,particularly when performing hygiene maintenance or cleaning up after adiaper change, I was always told that these types of work were not myduties, but were their families’ duties. However, when I was fighting over
who should deal with dirty sheets and used diapers, other families in thesame hospital room, which had no partitions, laughed at me. In addition,
they began to treat us warmly despite the language barrier. Thus, on a daily
basis, I learned a lot through my work in the hospital.
The activities of our team were suppor ted not only by general af fairs
department staff of Kyoto University Hospital, and relevant parties from the
Nursing Department, but also by the nursing department general chief of
JDWNRH, the chief nurse of the surgery ward, and other ward staff. Our
accomplishments were also attributable to the understanding andcooperation of both patients and their families. We are grateful for ouropportunity to participate in this dispatch project, and will value the bondsthat we forged in Bhutan.

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Kyoto University Hospital
Department of Surger y

Report of the activities of the second team
Term: January 19, 2014 ‑ March 28, 2014

Assistant Professor,
Department of Surgery

Shigeru Tsunoda
Content of activity
The second team was made up of Doctor Nikaido of the Department of
Gastroenterology and Hepatology and I, Tsunoda of the Department ofSurger y, based on the information that gastric cancer was prevalent in
Bhutan, and we were introduced by Doctors Okajima and Uemura who weremembers of the previously dispatched first team. As first team members had
already established a favorable relationship with each department of thehospital, particularly in the same field of gastrointestinal disorders, we could
start our clinical duties, including the handover process, very smoothly.
Similarly to the first team, we mainly provided medical services in Jigme
Dorji Wangchuck National Referral Hospital (JDWNRH) within the capital
Thimphu. In Bhutan with a population size of slightly less than 700,000, thiswas the only general hospital having full-time surgeons. Therefore, patientswith diverse diseases were transferred to it not only from adjacent areas, butalso throughout the country. The country is smaller than Kyushu in Japan,
with an east-west length of approximately 200 km, and there are no tunnels
for domestic roads; so, it takes a couple of days to cross a mountain passfrom an eastern town to Thimphu by car. Even patients living in suburban
areas of Thimphu need 1 or 2 days to visit this hospital on foot and using
other means of transport. In such a situation, the majority of patients withmalignant tumors were transferred to the hospital after the progression to
the markedly advanced, and frequently end stage, and the number of thosereceiving radical surgery was limited.
The surgical team consisted of 1 oncological surgeon, 1 neurosurgeon,
1pediatric surgeon 2 urologists and other 2, who had not yet establishedtheir subspecialties, to per form outpatient and ward management,
endoscopy, and outpatient chemotherapy. All members could manage
general surgical procedures, such as appendicitis, gut perforation, andinguinal hernia, while specialized cases were treated by the specialists.
Regarding the number of surgeries for malignant tumors in thegastrointestinal region as my specialty, 11 and 4 surgeries were performed
for gastric and colon cancers, respectively. We also provided consultation onvarious surgical problems, including consultation about CT images from the
Depar tment of Radiology. In addition to duties in JDWNRH, we also
participated in surgical camps established by hospitals located in areas out
side of Thimphu, such as Punakha and Haa. In such camps, we performed
dozens of endoscopies from early in the morning, as well as general surgicalprocedures such as inguinal hernia treatment and cholecystectomy tomidnight. During our 10-week stay in Bhutan, we performed approximately
70 surgeries and 180 endoscopies in total. We experienced a variety oftreatments that are rarely per formed in Japan, such as surgeries forechinococcosis and tuberculous lymphadenitis.
As patients with domestically unmanageable diseases (such as thoserequiring hepat- or pneumonectomy, radiotherapy, heart surgery, or renaltransplantation) were transferred to Kolkata of India, we also had theopportunity to visit MEDICA Superspecialty Hospital and TATA Medical
Center within the city to observe their services. The costs of treatments for
Bhutanese and their families to stay in India were fully covered by thegovernment. It was impressive that administrative officers in charge of
medical services visited inpatients daily, and systematically arranged fortheir transfers. On the other hand, treatment seemed to be unfeasible for alarge number of transferred patients, indicating the necessity of establishingsystems for appropriate patient selection and transfer as part of advanced
and specialized treatment. Hopefully, this cooperative dispatch program will
promote the provision of treatment within Bhutan, consequently reducing
the heavy financial burden of transferring patients to other countries in the
future.

Challenges and problems
The levels of doctors and individual staff members were generally high, andwe could learn a lot from them. However, when focusing on hospitalsystems, we realized that various problems had yet to be addressed.
Sufficient medical resources, such as drugs, medical supplies, surgicalgowns, and suture materials, were not available at all times. For example, in

the ICU, noradrenaline or adrenaline were frequently unavailable, whileshor tages of aspirin, PPI, or carbapenem antibiotics occurred without
notification. In the operating room, surgical masks or gowns weresometimes missing.....such a situation confused us at the beginning. In
contrast, local staff remained calm. When surgical masks were unavailable,some staf f members personally covered the shor tage. Similarly, otherpr oblems wer e somehow r esolved. In the absent of a domestic
manufacturing industry, all items, including medical supplies, were imported
after following bidding procedures, presumably as part of governmentoperated systems, and this was likely to further increase the burden of
obtaining necessary resources. When X-ray was in need of repair, it wasnecessary to askIndian service providers to repair, and this also seemed to
be burdensome in terms of the time and cost.
Work arrangements in the operating room, such as assigning morning ornight shift, was also dif ficult, possibly due to chronic staf f shor tages.
Consequently, almost all operating room staff members worked only from 9
to 15 as a fixed work schedule, making it difficult to admit patients to theoperating room at 9 in the morning. Furthermore, they took a rest for lunch
at a fixed time, and made a complained if surgery was not completed by
15:00. In addition to such “bureaucratic” behavior, inefficient systems were
frequently observed. On the other hand, the avoidance of extended work
hours may have been inevitable, as there was no overtime payment.
Behavioral variations among staff members were also noted, as some werehighly motivated, while others were not. Such variations may have been
associated with the absence of competition among hospitals or doctors.

Future perspectives
Coming from Japan with a well-established medical environment, we were
confused at the beginning to see different medical and social systems withmarked limitations. However, such experience provides us with theopportunity to review our daily practice in Japan’s extensive medical service
system, promoting the development of insights as a medical professional.
Regarding communication, local medical staff members had been educatedin English, so all of them were able to speak it fluently, and create medical
records in it. In contrast, while English daily conversation was possible to acertain extent among younger generations, only a limited proportion ofpatients comprehended detailed explanations of treatment in English.
Therefore, we needed to ask local staff to interpret our instructions in thelocal language (Dzongka). Although direct oral communication was difficult,this was not a problem for us, as patients seemed to highly trust foreign
doctors in general, and all staff members showed a cooperative attitude
toward us.
Regarding living conditions, we rarely became tired of local food. There
were also various types of restaurant. As foods, excluding seafood, arerelatively easily available, it is possible to cook dishes similar to Japanese
meals. If miso and soy sauce are indispensable, it is advisable to bring themfrom Japan.

Impressions
As I recognized when I previously studied abroad, common sense among
Japanese is only specific to Japan. Bhutanese people certainly have their own
methods and rules. So, my daily practice in Bhutan was a series of new
experiences and confusions. However, once I learned the beneficial
challenging aspects of each method, I became able to adopt more
multifaceted perspectives, and this may have provided me with theopportunity to grow as a person. Before being dispatched, insufficient
information and other factors made me quite anxious, but such anxiety wascompletely unnecessary. I could learn a lot of the “country of happiness”,
including its culture, in 3 months as a valuable experience.
Regarding the cultural aspects of Bhutan, I was impressed by strong familybonds (the concept of family extensively covers relatives). Even patientsliving in remote areas came to visit the hospital in Thimphu, relying on theirrelatives living in the city, and all of them were accompanied by theirfamilies; if such families were absent, their friends accompanied them. In
short, those without relatives were rarely observed there, unlike Japan.
Lastly, I would like to express my deep gratitude to Professor Kazuo
Matsubara of the Department of Pharmacy as the team leader, Doctor
Mitsuhiro Nikaido of the Department of Gastroenterology and Hepatology,
Nurses Sae Meda and Yoko Takahashi of the Department of Nursing, andStaff Yusuke Sakai of the Section of General Affairs for sharing such exciting
experiences in Bhutan as the second team. I also thank Professor Yoshiharu
Sakai and staff of the Department of Surger y who agreeably sent us off
despite their busy schedules, as well as my family who took care of ourhouse during my 3-month absence.

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Kyoto University Hospital
Department of Gastroenterology and Hepatology

Report of the activities of the second and third teams
Term: January 19, 2014 ‑ March 28, 2014,

June 30, 2014 ‑ September 20, 2014

Clinical Fellow, Department of
Gastroenterology and Hepatology

Assistant Professor, Department of
Gastroenterology and Hepatology

Assistant Professor, Department of Assistant Professor, Department of
Gastroenterology and Hepatology Gastroenterology and Hepatology

Mitsuhiro Nikaido

Yuzo Kodama

Yoshihisa Tsuji

Content of activity
Doctors of the Depar tment of Hepatobiliar y Pancreatic Surger y andTransplantation as first team members had previously reported to us thatthey had to give up the adoption of ERCP in Bhutan due to difficult manualtechniques, and, therefore, the procedure was not feasible at that time
despite the availability of exclusive endoscopy devices and related
instruments. This had led to the necessity of transferring 1 or 2 patientsmonthly to other countries, including India, to undergo ERCP. Based onsuch information, we, gastroenterologists, performed endoscopy and othermedical activities for 6 months, with the aim of suppor ting again the
adoption ERCP in Bhutan.
In Bhutan, endoscopy was feasible only in Jigme Dorji Wangchuck National
Referral Hospital (JDWNRH) within the capital Thimphu and a generalpractitioner’s office. In JDWNRH as a base for our activities, endoscopic
examinations were conducted by a surgeon and a gastroenterologist
alternatively every day. The daily number of examinations ranged from 15 to40, and the main procedure was gastroscopy.
As the surgeon who had previously attempted to adopt ERCP was busy withthe provision of surgical or urological treatment for out- and inpatients, we
mainly provided guidance for the gastroenterologist, in addition to nurses
and technologists in charge of the endoscopy room, while supporting themto adopt ERCP.
During our stay, we performed ERCP for 33 patients (41 cases). While
improvements were observed in local doctors’ and staff’s skills related topre-examination procedures, intraoperative monitoring, and endoscopy, as
well as X-ray fluoroscopy and related instrument handling, they seemed toneed fur ther experience in medical practice to appropriately provide
diagnosis and select/use related instruments. We also provided guidance on
postoperative management for local doctors and nurses throughcollaboration with dispatched nurses.
When there were no appropriate patients for ERCP, we actively participatedin and supervised other examinations, such as gastroscopy and colonoscopy.
In JDWNRH, more than 4,000 endoscopies were performed annually, andgastroscopy accounted for the majority. Similarly to Japan, Helicobacter
pylori infection was prevalent; however, despite a high incidence of gastriccancer, awareness of the impor tance of early diagnosis was poor.
Considering such a situation, we developed a diagnostic manual, andprovided guidance in using it, setting the early identification of gastriccancer as the main goal. We also created an original model for gastroscope
insertion, and helped young doctors master techniques to appropriately
manipulate gastroscopes.

Challenges and problems
While approximately 180 doctors were based in Bhutan, there was only 1
gastroenterologist who was simultaneously engaged in general internal
medicine-related duties, such as treating more than 50 out- and 60 inpatients
while supervising doctors in training daily. Under such a condition, it wasdifficult to sufficiently deal with gastrointestinal diseases and perform
endoscopy. Unlike in Japan, emergency cases, such as gastrointestinal
hemorrhage and obstructive and suppurative cholangitis, and malignant
diseases, were mostly dealt with by surgeons. As there was only 1 portable

Norimitsu Uza

X-ray fluoroscopy device, it was frequently unavailable, being used forsurger y or other purposes. In addition, it went malfunctioned on someoccasions, interfering with examination. Systems to stably supply related
instruments were also insufficient, and this made it difficult to conduct
blood testing and CT examination or immediately obtain test results for
emergency patients. The other problems we faced included the markedly
limited availability of drugs. In order to continue ERCP use that may involve
serious complications such as pancreatitis, it may be necessary to resolvethese problems, and further improve systems.

Future perspectives
During our approximately 6-month activities as gastroenterologists, the levelof demands for our services seemed to have gradually increased. Therefore,
it is strongly recommended that an exclusive department be organizedwithin our hospital to regularly dispatch medical teams. While it isnecessar y to continue to provide technical guidance, such as that for
appropriate ERCP use, and improve the quality of medical ser vices in
Bhutan, it should be noted that the availability of domestic medical
resources is limited due to the current economic and other conditions,consequently limiting the feasibility of on-site technical support. In 2012
when the Khesar Gyalpo University of Medical Sciences of Bhutan was
founded, intern training was initiated in JDWNRH as a domestic medical
training system. As resident training also started during the third team’s
stay, it may be desirable to similarly suppor t the establishment ofeducational systems. To help Bhutanese people doctors and staff learn
specialized techniques, the provision of training for them in Japan for acertain period may be effective.

Impressions
As this was my first medical activity abroad, I was markedly anxious before
depar ture. However, thanks to first team members’ practice withenthusiasm, Kyoto University Hospital staff was highly trusted by local
staff, and, therefore, we were warmly welcomed. Some patients visited thehospital, wishing to undergo treatment with a good reputation by Japanese
doctors. It was very useful for us, third team members, to contact first teammembers by e-mail to previously clarify necessary supplies, and work withthem for several days in Bhutan, covering the handover process. Previously
dispatched team members’ efforts and active practice were also beneficial to
the third team, as they were able to more smoothly perform their practicalactivities, such as providing medical ser vices in actual settings andeducation.
Communication with simple, genial, and warm-hearted Bhutanese people
was indeed refreshing. Observing the families of patients to stay in hospitals
all day long, and cooperate with nurses, I realized the importance of familybonds, which is being underrated in Japan’s modern society with anincreasing number of nuclear families.
The presence of wonderful staff members who were dispatched with me, as
well as the consultation and support provided by my colleagues in Japan bye-mail, helped me perform such productive activities, and obtain more newexperiences than expected. Thank you very much.

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Kyoto University Hospital
Nursing Department

Report of the Activities in Bhutan of the second teams
Term: January 19, 2014 ‑ April 14, 2014

Nurse, Nursing Department

Yoko Takahashi
Content of activity

Challenges and problems

I worked as a nurse on the surgery ward for 3 months. My main duties were

In Bhutan, where physician shortages exist and nurses do not spend muchto support patients for their daily lives, promote the in-ward 5S principles

time for each patient, hospitals can hardly afford to use enough time andhanded over from the first team, provide nursing care for patients who had

human resource staff in order to guarantee patient safety and the quality ofundergone surgery involving ERCP, improve suction procedures, and give

medical/nursing care. It is difficult to ensure a sufficient number of trained

presentations on the management of tracheal cannulas. We wanted toand licensed medical staff members. However, by appointing nursing aides,

introduce Japanese nursing techniques; however, due to a lack of necessary

it may be possible to improve the quality of care, and to reduce the burdenmaterials, we had dif ficulty advancing ideas about how to adapt theseon patients’ families. For this purpose, there is a need to develop concepts,

techniques to Bhutan. In addition, our attempts to introduce suchbased on which trained personnel provide education for staff members, andtechniques and to help local staf f use them independently were morethese members then educate other workers. By doing so, the quality ofchallenging than we had expected, because of the language barrier and thenursing care may be improved within a short time and at a low cost.

different attitude towards work between Japanese and Bhutanese healthcare
providers. For example, when I checked patients who were using a tracheal
cannula, a decreased cuff pressure was sometimes noted, or suction was
sometimes not appropriately performed due to sputum attached on the

Future perspectives

mouth of their cannula. When I reported these problems to ward staff
members, they told me that the management of tracheal cannulas was not

As many projects implemented in Bhutan are run by foreign volunteers,

performed by them, but by otological professionals referred to as ENT

dispatched members may be simply treated as a par t of the county’s

technicians, and that these professionals did not on a daily basis check

workforce, depending on how they work. In general, Bhutanese people arepatients using a tracheal cannula. Under such circumstances, patients are atproud of themselves, and act at their own pace. While keeping theserisk for sputum-associated accidental swallowing or choking. Essentially,

characteristics in mind, dispatched members should clarify their needs. I

ENT technicians should ideally educate ward staff on the daily management

hope that, by introducing the merits of approaches used in Japan, and byof tracheal cannulas. However, on the basis of my experience withaccepting opinions given by local people, these approaches will be adopted

Bhutanese people, I realized that they do not often teach other people, orby them. I recommend that dispatched staf f begin their work byshare their knowledge with each other. The chief nurse of the surgery ward

understanding local people with the motto “equal partnership”. Because

also felt the same way, and requested us to teach the ward staff the methods

Bhutanese people are usually pro-Japanese, dispatched Japanese staff would

for suction and cannula control. We created a suction model, and preparedlikely be accepted by them, and build a favorable relationship with them.

English-language material in cooperation with local staff. When we held aseminar to teach these methods, many local staff members attended.
Furthermore, compared with Japan, Bhutan’s lack of manpower is more

Impressions

marked and family/relative bonds are stronger, and so families of patientsusually stay close to them 24 hours a day. I noticed that families were very
dedicated to their patients. As we considered that patients may be able toreceive higher-quality care by giving appropriate guidance for their families,
we decided to do so. After we (second team) went back to Japan, membersof the third team told us that these families were still following the guidance
we had provided. I was very happy to hear that.

Bhutan is renowned for high-level GNH, and I understood this as I stayed
there for 3 months. I noticed that Bhutanese people live a slow life, and are
kind, warm-hear ted, and strongly devoted to Buddhism. My dailyexperience with these people markedly changed my sense of values, andmade me realize how immature I was as a human. In addition, by working ina different medical environment than in Japan, I was able to clarify mystrengths and weaknesses, as well as to begin considering my orientation as
a nurse. I am really grateful that department staff in my hospital supported
and advised me on the dispatch project, and that local staff and the memberson the second team assisted me with our activities. I hope that the bonds
between our medical center and JDWNR Hospital will become evenstronger, the newly established organization aimed at fostering Bhutanesephysicians will operate successfully, the level of nursing care will improve,and Bhutanese citizens will be able to receive high-quality medical andnursing care.

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Kyoto University Hospital
Department of Urology

Report of the activities of the third team
Term: June 30, 2014 ‑ September 20, 2014

Senior Lecturer,
Department of Urology

Yoshiyuki Matsui
Content of activity
In Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and
Military Hospital of Bhutan, we mainly supported urological surgery. When
limited to surgeries performed in operating rooms, we participated in a totalof 114 surgeries, 62 (ureteral double-J stentings and replacements) of which
we performed as operating surgeons. Our surgeries were mainly to address
urolithiasis and prostatic hyperplasia, and we frequently per formed
transurethral ureterolithotripsy (TUL), urolithotomy, and transurethralresection of the prostate (TURP). At the same time, we occasionallyprovided surgical treatment for malignant tumors, such as TUR for bladdercancer, total cystectomy, nephrectomy for renal tumors, and inguinal
orchiectomy for testicular tumors. We also participated as assistants inlaparoscopic surgeries (lithotomy and renal cyst fenestration) and shunting
per formed by Doctor Lotay, in addition to a large number of generalabdominal surgeries, including laparoscopic cholecystectomy and surgery
for inguinal hernia.
We initially examined methods to adopt percutaneous nephrolithotripsy(PNL) for nephrolithiasis in Bhutan; however, considering the insufficientavailability of equipment, such as fluoroscopy and ultrasound devices, and alimited time frame for each surgery due to an excessively large number ofsurgical patients, we had to give up this idea. When surger y was notscheduled, we were engaged in outpatient ser vices in JDWNRH, mainlyminor surgeries (lipoma and atheroma removal) through collaboration withnurses or doctors in training. Furthermore, as the residency system started

Challenges and problems
Regarding PNL use in Bhutan we considered before being dispatched, we
judged it dif ficult to safely per form the technique with insuf ficient
fluoroscopy and ultrasound devices, as previously mentioned. Similarly,
ureteroscopes, laser products, guidewires, or ureteral stents were notsufficiently available, suggesting difficulty in stably performing endoscopy.
The use of extracorporeal shock wave lithotripsy (ESWL) may havemarkedly reduced the number of surgeries; this reveals a limitation of
personal support. Renal transplantation was likely to be technically feasible,
but priority had been given to the establishment of perioperative
management systems (blood collection, dialysis, pathological diagnosis,
immunosuppressant dose adjustment, and infection control). The current
surgical situation may also have prevented renal transplantation from being
promoted. As an overall challenge of surgery, marked differences between
the numbers of scheduled and actually performed surgeries were noted; inshort, a large number of patients were discharged on the same day, andreadmitted on following days. Therefore, it may be important to establish
systems for appropriate surgical scheduling on a hospital-wide basis.

in Bhutan from this period, we frequently held medical conferences withstaff, residents, and interns before and after surgical rounds. We also gave
lectures on urology to enhance their understanding of urologic diseases.

Future perspectives
In an environment that is completely different from Japan, there seem to be
more for us to learn from Bhutanese people than to teach them. In thisrespect, this stay has been a very valuable experience for us. On the other
hand, when considering appropriate methods to contribute to Bhutan, it may
be effective to set goals for each period and throughout this program, andpreviously discuss approaches to achieve them, in order to establish
cooperative systems more smoothly in actual settings.

Impressions
We could accomplish our 3-month tasks, thanks to support from Bhutanesepeople and other dispatched members. For me personally, meeting Doctor
Lotay as the only urologist in Bhutan and learning from his attitude toward
surger y and medical ser vices has been a par ticularly ir replaceable
experience. On the other hand, from a critical viewpoint, I regret my limited
contribution to Bhutan’ medical systems, and expect that this dispatch
program will further expand based on our experiences.

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Kyoto University Hospital
Nursing Department

Report of the Activities in Bhutan of the third and fifth teams

Term: June 30, 2014 ‑ September 20, 2014, December 26, 2014 ‑ March 13, 2015

nurses share necessar y patient information with one another. From thisperspective, we created a framework regarding these records, as well as
examples for producing them. However, we first needed to ensure that
auscultation is performed as a common practice. In addition to this, we could
only familiarize local staff with recording the length of the inserted part ofgastric tubes before tube feeding is performed for patients with a history ofaccidental swallowing.
In Bhutan, infection control is also important. We encountered several
situations which could have caused the spread of infection. For example, agown used by an infant with resistant bacteria was reused by a parent ofanother newborn. Therefore, in cooperation with the chief nurse, weassigned a gown to each bed with the aim of promoting individual use.

Nurse, Nursing Department

Ayuko Ishii
Content of activity

Challenges and problems

I worked at JDW Hospital, the largest general hospital in Bhutan, for 6
months. When I came here with the third team, I worked on the surgery
ward for approximately 1 month. After that, to obtain information needed forsuppor t activities at the NICU, I visited perinatal settings in Bhutan,
including pediatric wards, obstetrics/gynecology wards, and child birthcenters. In 2013, the annual number of births at JDW Hospital was 4,248.
Thus, this hospital plays a major role in perinatal care in Bhutan. I met
several families who came to the hospital after a two-day journey fromeastern Bhutan, in order to give birth there. The perinatal mortality rate has
decreased annually, and the number of patients admitted to the NEONATE
AND NICU is showing a tendency to increase (number of admitted patientsin 2014: 2,016). In addition, as a perinatal medical center is planned to beconstructed, it is expected that the perinatal mortality rate will further
decrease along with improvement in the medical environment of thehospital. Furthermore, in Bhutan, tubal ligation is being actively performed
as encouraged by the Bhutanese government and, and so the birth rate isshowing a tendency to decrease.
Annual number of child births, Perinatal mortality rate,
Rate of cesarean section (JDW Hospital)

2011
2012
2013

Number ofchild births

Perinatal
mortality rate

Rate ofcesarean section

3557
4052
4248

23.6%
21.5%
19.5%

22.8%
22.2%
25.9%

At my workplace, I identified several issues, such as a limited number ofavailable respirators due to frequent malfunction of these devices. When I
stayed in Bhutan with the third team, I often perceived the importance of
medical devices that are kept clean and ready for use at all times. Undercircumstances where the number of available respirators was insufficient,
we per formed 5S-based activities, such as placing dr ying racks forrespirators in a manner facilitating their re-assembly immediately after
washing them, and nurturing an environment in which the parts of CPAP
devices are all dried together. As medical care advances, it may become
more important to nurture the healthcare providers’ working environment
in order for them to understand the location and number/amount of medical
supplies. In cooperation with local staff, I provided daily nursing care in thesame way as I do in Japan, such as measuring vital signs, managing
respirators, preparing and administering long-acting drugs, implementing
pre- and post-operative patient management, and taking patients out of theirwards for thoracic/abdominal ultrasound examination. On the basis of theseexperiences, we improved our movement, kept infusion tables tidy, andplaced injectors in a manner facilitating the preparation of drugs within ashort time.
When I came to Bhutan with the third and fifth teams, we introduced
developmental care to the hospital. Because bedsores were noted in some
newborns, we mainly promoted changes in posture by adopting a prone
position. These bedsores were cured early after initiating the promotion of
posture changes. A prone posture has many beneficial effects in prematureinfants, such as protecting their skin, preventing respiratory complications,and reducing gastric residuals. On the other hand, compared with when
adopting a spine position, higher skills are required of nurses, and moreequipment is needed in order to stabilize children’s posture. Therefore, it
took a certain amount of time for us to adapt prone position-based posturechanges to the hospital. To facilitate this, using dishwashing sponges, wemade pillows and cushions for infants with low birth weight. Concerning
diapers, previously, because a cloth was simply placed beneath the breech,
the use of a prone position often resulted in breech and thoraco-abdominal
contamination. This issue was also needed to be resolved. In Bhutan, where
supply shortages are common, it would take a long time to adopt carerelated approaches used in Japan. In addition, it took a long time for us tostandardize the methods of nursing care as well as of information sharing
among healthcare providers, because there was a great disparity in theirskills and experience, and because the ways in which they produced records
markedly dif fered between them, regardless of their age. By giving
presentations, and by having one-to-one conversations with local healthcare
workers after giving a brief demonstration, the members of our dispatch
project teams have continued inter vening for these workers in order topromote their shared awareness. Furthermore, we assumed that, by treatingrecords made at the NICU as those of severely-ill patients, it would become
easier to keep track of changes in their medical conditions, and to help

Some local staff had received nursing education in Bhutan, while others haddone so in other countries, such as India or Thailand; hence, there was adisparity in their expertise. This hampered standardization of the methods
for nursing care and information sharing among these staff members. As
exemplified by the establishment of the Highly-Professional Physician
Fostering System, the medical education of Bhutan has improved each year.
Along with this, advancement in the country’s nursing education may beachieved. For such advancement, experienced healthcare providers need toeducate less experienced staff members; however, currently, there arelimited opportunities for such education. In Bhutan, nursing students spend
much time in their clinical training, which is a good thing. However, I noted
that, during their training, many students were simply working as caregivers
without understanding the principles of nursing care.

Future perspectives
As exemplified by new living-body monitoring devices that were introduced
during my dispatch period, Bhutan is in the process of medical development.
Hence, it is important to ensure that supply management is conducted
appropriately, and that necessary patient information is shared among thehealthcare providers involved. As the 5S promotion activities are performed
differently by dispatched members depending on their clinical experience(medical department to which they belong in Japan), I expect that various
ideas will be generated by them.
In Bhutan, where supply shortages are common, it took a long time for us toadopt care-related approaches used in Japan. As we patiently and repeatedly
showed local staf f how to replenish supplies and do cleaning up, they
became accustomed to these routines as well as to the idea that these
supplies should be accessible at all times. Although our duties werechallenging, we strongly perceived the significance of continuing them when
we noted that severe bedsores in an adult patient, which had been deemed
difficult to treat, were alleviated. Thus, even when facing a hardship during adispatch project, it is important to wait for things to favorably change.
If the number of physicians increases, it may be possible to provide medicalcare which is currently unavailable, and to meet a wider range of patients’needs. In that case, nurses may be required to make more repor ts tophysicians than they do now. To facilitate such reporting, there is a need todevelop tools that enable senior-level nurses to help newly hired nurses toimprove their assessment skills, including the ability to make nursing
records.

Impressions
During this dispatch project in Bhutan, I was able to re-recognize theconcept of infection control and safety management that I had developed inJapan. In addition, I often encountered cases in which I reflected on mywork, and recalled the motto “Patients’ basic desires should be met, andtheir safety should be protected”, which is the principle of nursing care. As
patients’ desires could be met frequently at my workplace despite supply
shortages, I thought that nursing care is practicable almost anywhere. On
the other hand, I sometimes felt that not all proposals, including thoseregarding points to be improved, were acceptable to the local staff. However,in spite of the cross-cultural differences, these staff members and we hadcommon values; for example, both local staff and we congratulated thegrowth of low birth-weight infants with their families, and felt good after
doing cleaning up. Initially, I was shocked at the different views regarding
death between Japanese and Bhutanese people, but I learned a lot about theviews of life and death that are characteristic of Buddhism, and these views
help me to organize my thoughts. In addition, in Bhutan, families of patientsusually stay close to them 24 hours a day in order to provide nursing care.
For example, tube feeding for premature infants is performed by theirfamilies. As is the case with Japanese individuals, upon delivering apremature newborn, Bhutanese parents showed a sense of fear. However,they were actively involved in treatment, and supported the growth of theirchildren in cooperation with nurses. These attitudes were beneficial indeveloping mothers’ sense of tenderness towards their children. Thus, thetime these parents spent with their children must have been valuable, evenwhen it was short.

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Kyoto University Hospital
Department of Nephrology

Report of the activities of the fourth team

Term: September 16, 2014 ‑ December 15, 2014

Associate Professor,
Department of Nephrology

Clinical Fellow,
Department of Nephrology

Assistant Professor,
Department of Nephrology

Tatsuo Tsukamoto

Hiroyuki Yamada

Hirotaka Imamaki

Content of activity
We mainly per formed treatment while conducting sur veillance in the
dialysis unit of Jigme Dorji Wangchuck National Refer ral Hospital(JDWNRH) that is playing a central role in the Kingdom of Bhutan, being
located in its capital, Thimphu. To domestically provide dialysis treatment, 1
nurse had already been dispatched from the JICA, who had offered thefollowing information by web mail to us before our departure: 1) the dialysis
unit was mainly managed by nurses in the absence of nephrologists, 2) it
was difficult to sufficiently provide dialysis services due to a limited numberof available dialysis devices, 3) dialysis was mostly per formed using
catheters, frequently causing infectious diseases and thrombosis, and 4) theinsufficient prescription of hematopoietic medications led to increases in thenumber of patients with anemia. As the Khesar Gyalpo University of Medical
Sciences of Bhutan does not have a medical school, it is necessar y for
Bhutanese students to graduate from such schools in other countries, andreceive training in or outside Bhutan after obtaining a medical license, inorder to become a doctor. Immediately before our dispatch, a nephrologist(Dr. Minjyu) had returned from Bangladesh to Bhutan, and we started
collaborative work. Local dialysis nurses had been trained in Thailand for 3
months. Although they needed to update their knowledge and skills, they
were ver y highly interested in new medical information. So, we held 2seminars on dialysis treatment for them.
Regarding the dialysis modality, hemodialysis was performed in all cases.
The total number of patients was approximately 90; for these, a 4-hoursession was repeated 3 and 2 times on Mon/Wed/Friday and Tue/Thu/
Saturday, respectively. Due to insufficient numbers of dialysis staff members
and devices, the mean number of dialysis was limited to 1.5. Periodic blood
testing revealed a high incidence of renal anemia associated with persistentelevations in the CRP level, in addition to an increased urea level. Skin color
specific to chronic uremia, which had been reported 30 years ago in Japan,
was obser ved. Hemodialysis ser vices were available in this and 2 otherfacilities (in Mongar and Sarpang, each of which had 2 dialysis devices).
However, during our stay, 20 patients were transferred from Mongar due todevice failure. Even in JDWNRH, systems to appropriately manage chronic
diseases had yet to be established, resulting in an extensive loss ofimportant documents. For example, blood test results were simply handed
over to patients without storing their copies. In contrast, in district hospitals
and basic health units (BHU), community residents’ detailed medical
records were maintained. It was also clarified that the prevalence of lifestylerelated diseases was increasing with rapid modernization in Bhutan, and,
when we exchanged information with local registered dietitians, they noted a
relatively high salt intake among Bhutanese people.

Challenges and problems
As the numbers of dialysis staff members and devices were insufficientcompared with that of dialysis patients, the extension of the dialysis unit withan increased number of beds was being considered. While support for such
equipment and devices should also be provided, it may be necessar y tonurture staff with maintenance skills, considering the presence of a large
number of unrepaired medical devices. The reuse of dialyzers is not rare on
a global basis, but even dialysis circuits were reused in Bhutan, possiblyinterfering with the prevention of infectious diseases. Furthermore, water
distributed through indoor plumbing was hard water, requiring large-scale
soft water generators and reverse osmosis equipment for dialysis waterproduction. However, purified water was not appropriately stored, and it wasused as sterilized water on wards, indicating the necessity of fur ther
improving water management systems. Similarly, although the rate ofcatheter-based dialysis was limited to 30%, which is a globally standard level,
it may be desirable to newly install angiography equipment in considerationof the possible usefulness of inter vention by vascular surgeons andpercutaneous balloon dilatation to improve the prognosis of dialysis patientsby improving vascular access.
Storing data related to patients’ lifelong medical histories is crucial for the
management of chr onic r enal diseases. In or der to make r enaltransplantation feasible, it may be necessary to create environments thatallow the accurate diagnosis of renal diseases, covering renal biopsy, as wellas sufficient dialysis treatment and pathological diagnosis. In Bhutan, theestablishment of Wi-Fi networks has predated the generalization of landline
communication systems; therefore, mobile- and smartphones are widelyused. In this respect, medical information infrastructures for it should be
developed using its unique methods.

Future perspectives
As all medical resources are insufficient, dispatched teams cannot expect
clear instructions from local staf f. While previously dispatched teammembers were mainly engaged in the providing technical guidance forsurgery and related care, it is necessary for us to make common proposals
on our ser vices, including cancer treatment, with teams specializing ininternal medicine dispatched in the future when dealing with chronic
diseases in this field. The development of medical infor mation
infrastructures to share specimen examination and diagnostic imaging
results is likely to be par ticularly impor tant. In line with this, werecommended the initiation and continuation of epidemiological studies
based on the patient data collected by us during our stay. It should also be
noted that Japanese companies are engaged in dialysis-related businesses inall countries, except Bhutan and the Kingdom of Nepal. At this point, ouractivities were limited, highlighting the benefit of collecting information ineach medical depar tment and exchanging information with previously
dispatched team members prior to departure.
During our stay, dialysis nursing procedures were reviewed in JDWNRH.
Considering the cultural background of Bhutan, this was a unique
opportunity to improve their systems. So, we advised local staff to refer tothe procedures implemented in our facility. As communication with them by
e-mail has been maintained to the present, we will continue making
proposals based on equal partnerships.

Impressions
I was occasionally confused when facing dif ferences between myperspectives on medical services and the reality of such services in Bhutan,
but Bhutanese patients and staff of good character frequently helped me. At
the same time, I realized that we, Japanese, are really lucky to have suchfavorable medical environments compared with those in other countries. It isneedless to say that this stay has provided us with a very important basis for
medical practice. It has been a productive experience to observe of medical
services in Bhutan.
As the adoption of doctor helicopters was under consideration, it seems tobecome possible to more promptly transfer patients in the future. If a
medical school is organized in the University of Medical Sciences, doctor
training will also become feasible, markedly improving Bhutan’s medical
environments. In terms of medical services, Bhutan is a young country. I
could recognize that its national and medical systems were rapidly
developing. It is interesting how it will change from now on. Although ouractivities in Bhutan were limited, I hope that such activities have contributed
to its process of change as much as possible. Lastly, we would like to express
our deep appreciation to all the people who provided advice on this dispatch,as well as doctors, clerical staf f, and others of Kyoto University andJDWNRH for providing us with the oppor tunity to par ticipate ininternational grassroots medical support.

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Kyoto University Hospital
Department of Pediatrics

Report of the activities of the fourth team

Term: September 16, 2014 ‑ December 15, 2014

Clinical Fellow,
Department of Pediatrics

Clinical Fellow,
Department of Pediatrics

Tomoyoshi Matsui

Yuri Dowa

Content of activity
From the Neonatal Intensive Care Unit, 2 pediatricians, Dowa (September 16
to November 5, 2014) and Matsui (November 10 to December 15, 2014),
were dispatched to JDWNRH to mainly provide pediatric services on the
neonatal ward. The ward had been managed by Doctor Nishizawa of thePrimate Research Institute of Kyoto University as a medical volunteer since2011. The number of local pediatricians was 2, and they were in charge ofward and outpatients ser vices, respectively. There were also 2 residents(doctors in training specializing in pediatrics after completing internshipprograms) and 1 rotating intern. Duties on the neonatal ward included:
academic activities from 8:00 AM (grand rounds and case presentations);
management of the NICU (acute conditions), HDCU (chronic or mild
conditions), phototherapy/infection unit, and kangaroo-mother care (KMC)
unit; ward rounds for newborns in normal conditions staying with theirmothers; and outpatient treatment for newborns. Doctor Nishizawa alone
had treated 60 to 100 in- and outpatients daily.
While implementing part of round-related duties, we supported both medical
ser vices and educational activities, such as creating written operational
procedures and flowchar ts, providing case consultations, super visingresidents and interns, and giving lectures.
The neonatal ward consisted of 35 beds in total. In the NICU, there were 7
beds, to all of which an SpO2 monitor was attached. Incubators andrespirator y systems were similar to those used in Japan, suggesting a
relatively high quality of services, although incubators for inpatients were
not regularly replaced due to their limited number. Most of premature
newborns were aged approximately 30 weeks or older. Patients withdiseases, such as surgical and neurosurgical diseases, sepsis, neonatal
asphyxia, and severe jaundice, were admitted almost every day. The type ofsepsis was generally early-onset, but the late-onset type also seemed to beprevalent. Suspected congenital heart diseases were also observed among
inpatients; however, some of such patients died undiagnosed due to theunavailability of ultrasound devices on the ward. There were also premature
newborns and patients with neonatal asphyxia or shock, transferred fromrural areas. In some of such cases, patients were not admitted despite
notification of transfer, as they died before arrival.
All patients were accompanied by their families almost on a 24-hour basis.
The families were fully in charge of the administration of breast milk,
medication, and diaper change. All nurses possessed a midwife licence, andthey notified families of the doctor’s instr uctions, assisted lactation,
performed routing for infusion, and collected blood samples. The proportionof male nurses was high, and they also directly assisted lactation.
Basically, parents fed their children with fresh breast milk using spoons ororogastric tubes. It was impressive that all parents were able to feed theirchildren without spilling milk from spoons, as it has been reported thatnearly 30% of milk is spilt when lactating by this method.
Newborns in normal conditions were discharged within 12 hours after
delivery; therefore, in many cases, lactation guidance had not been directly
provided before discharge, and patients were re-admitted in the presence of
neonatal jaundice or poor weight gain. Similarly to in Japan, a high incidenceof neonatal jaundice associated with ethnic factors was noted. On the other
hand, severe jaundice seemed to be frequently derived from blood group
incompatibility or infectious diseases.

Challenges and problems
The number of doctors was insufficient, and they were occupied with giving
instructions daily. In order to effectively carr y out short-term dispatch
projects like this under these circumstances, rather than simply assisting
local medical practice, it is necessary to sufficiently discuss the content ofactivity with the host facility prior to dispatch. In line with this, annual
dispatch plans should be developed and sufficiently examined with the hostfacility, while the dispatched team should appropriately prepare before
depar ture. At a meeting on the initial day in Bhutan, Dr. Mimi as the

Director of the Depar tment of Pediatrics clarified their need for thesupervision of pediatric cardiac ultrasonography by pediatric cardiologists toimprove local technicians’ diagnostic skills, suggesting that the dispatch of aneonatal care group did not accommodate their intention. To dispatch
medical teams based on host facilities’ desires, an accurate understanding of
their needs and the development long-term dispatch plans may be
indispensable.
Although Doctor Nishizawa had continuously been engaged in medical
practice on the neonatal ward for a long period of time with a nurse from the
JICA, it seemed to take further years to generalize the basics of nursing,
represented by the maintenance of cleanliness, differentiation between
cleanliness and uncleanliness, and obser vation of vital signs, among
Bhutanese people. Similarly to the late Kyoji Nishioka, an agricultural
engineer of the JICA who improved agricultural productivity in Bhutan
based on his positivist policies, we also observed that Bhutanese adopt new
methods if they consider such methods useful. Therefore, in order tocontribute to the improved quality of medical services in Bhutan within aspan of 10 year, it may be appropriate to provide suppor t that helps
Bhutanese people recognize the usefulness of proposals and guidance by
Kyoto University Hospital to benefit them and improve the quality of theirwork and lives, rather than forcing them to adopt our methods.

Future perspectives
As previously mentioned, active contact with local staff should start as soon
as dispatch is determined to previously clarify key issues, such as theavailability of medical devices and examination/treatment materials, as well
as needs and feasible approaches in actual settings. It should be noted that,
due to markedly insufficient numbers of doctors and nurses in all medical
departments, dispatched members of Kyoto University Hospital, similarly tovolunteers from other NGOs, may be simply regarded as helpful labor force
participants. Although such a situation is possibly unavoidable even when
dispatched with clear objectives, it is necessar y for the members to
sufficiently prepare for the providing support, such as technical guidance
and lectures, in consideration of their needs. Regarding medical technicalsupport and education, the Bangkok Hospital and UMSB singed an MoU in
September 2014 to train Bhutanese staf f in Bangkok at the former’s
expense. However, it may not necessarily appropriate for us to provide
similar approaches, as the Director of Kyoto University Hospital mentioned
at a meeting before our departure that it is difficult for the hospital to accept
Bhutanese staff at present. From a doctor viewpoint, different focuses forsupport than those of other facilities, such as organizing academic events inconsideration of the absence of any medical or nursing associations in
Bhutan, are likely to be more useful for Kyoto University Hospital.

Impressions
As mentioned in the books regarding Bhutan I (Dowa) read before
departure, Bhutanese people were proud of their nationality. While being
markedly conservative, they seemed to adopt new methods, and improvetheir systems on a step-by-step basis. As there are many similarities between
Bhutanese and Japanese people, such as similar countenances and the samereligion (Mahayana Buddhism), I had a friendly feeling toward them. As I
had previously heard that they are educated in English, I initially supposed
all of them to comprehend English, but a large number of Bhutanese people,
particularly females, did not, presumably due to difficulty in receiving school
education. Although my fluent speech was limited to the Kansai dialect, I
could support medical practice in Bhutan to some extent, thanks to local
staff’s high level of understanding. Lastly, we would like to express our
gratitude to local staff, Doctor Nishizawa, Sister Emi (JICA), and Japanese
residents in Bhutan, as well as staf f of Kyoto University Hospital who
agreeably sent us off.

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Kyoto University Hospital
Nursing Department

Report of the Activities in Bhutan the fourth and fifth teams
Term: September 30, 2014 ‑ December 15, 2014, January 7, 2014 ‑ March 13, 2015

Nurse, Nursing Department

Yoko Nishi
Content of activity
For 6 months, I performed support activities on the surgery ward of JDWNR
Hospital, which was situated in Thimphu, the capital of Bhutan. We provided
training exercises in nursing care for the ward staff and nursing trainees. In
particular, from the viewpoint of neurosurgical nursing care, which is myexpertise, I provided education in daily life support and perioperative patientmanagement. At the hospital, surgery is performed 3 times a week, for up to
20 patients a day, and ward staff are very busy on operation days. We taught
the ward staff the importance of providing postoperative care (e.g., checking
patients’ general status and bedsores, as well as managing drains) no matter
how busy they are, and instructed them to make nursing records about
anything they noted during their work. In addition, we worked towards
improving the 5S activities that had been handed over from the first team.
By adopting necessary approaches, particularly by managing the infusionlines and intravenous routes of postoperative and severely-ill patients, and bykeeping medical supplies tidy and in order, we improved the environment of
their hospital rooms. In addition, every morning, we performed in-hospitalrounds with ward staff and nursing students, and informed each other ofwhat we had noted about the patients’ environment. In Bhutan, instead ofnurses, families of patients usually stay close to them 24 hours a day in orderto provide nursing care. Therefore, I often had opportunities to provide
these families with care-related guidance, which covered from daily life
support (e.g., eating, hygiene, and excretion) to medical procedures, such as
suction, bedsore care, and nutritional management. As many patients having
dif ficulty with their daily lives were discharged and went home, theirfamilies often asked me clarifying questions. Thus, I had the impression thatthese families were very serious about caring for their patients. On a daily
basis, we encouraged the ward staf f to be aware of the impor tance ofindividually provided nursing care. We also discussed the need for personalcare with these staff members, and instructed them to always note theprocess in which an evaluation is conducted after providing such care. In
addition, with the aim of advancing their expertise, we gave ward staff
technical guidance on bedside care, and held study meetings according totheir field. Furthermore, considering that postoperative patients are at riskof rapid changes in their conditions, we held seminars aimed at educating all
ward staff members to become able to appropriately respond to emergency
cases. Through these seminars, they learned about BLS and ACLS, as well
as how to monitor these patients’ ECG, consciousness levels, and neurologic
findings. I hope that, by promoting the above-mentioned activities, thequality of medical care in Bhutan will improve.

Challenges and problems
Although JDWNR Hospital is the largest medical center in Bhutan, thehospital’s wards are not divided according to the medical fields. Therefore,
the surgery ward is used by all postoperative patients and those for whomsurgery is indicated, regardless of the department to which they belong(General Surger y, T rauma Surger y [emergency], Neurosurger y,
Gastrointestinal Surger y, Respirator y Surger y, or Pediatric Surger y).
Because each department covers more than one medical field, nurses are
required to have a wide range of exper tise. However, because suchprofessionals did not previously exist at the hospital, I perceived thenecessity of educating ward staff, mainly senior-level nurses, in order toprovide highly-professional nursing care. In addition, there is a need toestablish education systems enabling experienced nurses to pass on theirknowledge and skills to less experienced nurses. Furthermore, the surgery
ward did not have some of the minimally required medical supplies (e.g.,soap or gloves), which frequently hindered nursing care and other medical
duties. This was also a major medical issue.

Future perspectives
In Bhutan, there are many chances of having to provide nursing care andtreatment using limited medical supplies. Dispatched members always must
consider what they can do using the available supplies, as well as the best
way to provide nursing care, and should provide education for local staff.
They may experience dif ficulty using unfamiliar care approaches andsupplies. On a daily basis, many patients are admitted to or discharged fromthe hospital, or undergo examination or surger y. Some patients aredischarged after achieving recovery, while others are at the end of life. As
with the case with Japanese healthcare workers, Bhutanese nurses listened
to patients’ worries, and laughed with patients at their bedside. In spite ofthe differences in the culture and lifestyle, it is important to be aware that
Bhutanese patients and their families have desires in the same way asJapanese patients and their families do, and to continue our dispatch projectbased on the principles of nursing care.

Impressions
Originally, I did not even know where Bhutan was situated. The only thing I
knew about the countr y was that citizens are happy. Because of thedifferences in the culture, language, and lifestyle, I felt very anxious aboutliving in Bhutan, let alone working there as a nurse. Initially, I was shocked
at the differences in lifestyle as well as in the level of medical care, and so it
took a certain amount of time for me to become accustomed to the local
nursing practices. However, the ward staff and patients treated me ver y
warmly and kindly. I was able to manage life and work in this unfamiliar
environment, due to local people who were always friendly to me, professors
who worked with me, and staff of the Nursing Department who often gaveme advice. I am very grateful for my opportunities to spend a meaningfultime in Bhutan.

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Kyoto University Hospital
Department of Orthopaedic Surger y

Report of the activities of the fi fth team
Term: December 15, 2014 ‑ March 14, 2015

Challenges and problems
Assistant Professor,
Department of Orthopaedic Surgery

Bungo Otsuki
Content of activity
I arrived in Bhutan on December 15, and started to work in the Departmentof Orthopedic Surgery of JDWNRH from the next day. Orthopedic surgery
was being mainly per formed for trauma treatment. As 3 out of the 4orthopedic surgeons based in Bhutan belonged to JDWNRH, I had theimpression that services were being provided very systematically. As the 3surgeons treated more than 1,000 surgical patients annually, an exclusive
ward had been organized within the department, in which surger y was
performed on Mon/Thu/Saturday, outpatient consultation was provided on
the remaining days of the week, and emergency ser vices were provided
whenever necessary. On outpatient consultation days, a morning ward round
was made with orthotists and physical/occupational therapists to discuss
patients’ conditions. They seemed to have made arrangements for me to deal
with a large number of spinal diseases; for example, I was also scheduled toperform spinal surger y out of surger y days. During my 2-month stay, I
performed approximately 40 lumbar decompressions and herniotomies, 2lumbar fixations for spondylolisthesis, and 2 surgeries for thoracic spine
injury, while supervising 1 surgery for cervical dislocation, and satisfactory
outcomes were obtained in almost all cases in the absence of infection. On
the other hand, in 1 case, the level of lumbar vertebra was not accurately
identified due to C-arm failure, resulting in the development of complications
specific to Bhutan. I also participated in approximately 60 surgeries fortrauma treatment. Regarding outpatient services, the limited availability of
medications was noted. Criteria for CT and MRI use seemed to be markedly
stricter than those in Japan; from a dif ferent viewpoint, they may be
excessively used in Japan compared with other countries. I was mainly incharge of outpatients with spinal diseases, in half of whom low back or
related pain was present, similarly to Japanese patients. There was no
difficulty in communicating with patients, in general, if they were able tospeak English. If they were Dzongkha, Shashop, Nepali, or Hindi speakers, I
needed an intern or technician as an interpreter. While occasionally facing
culture shock when treating Bhutanese patients who stated that they had
suffered from pain ever since “7 years ago” (Japanese patients may express
this as “a couple of days ago”), I enjoyed my daily practice there.
I also had the opportunity to make a presentation at an annual meeting of the
only medical association in Bhutan as a valuable experience.

The level of clinical services was not low, equivalent to the level of mid-scale
hospitals in Japan. The youngest local doctor was interested in spinal
treatment, showing an active attitude toward learning about it, and thisfurther motivated me. The most important problem was a shortage of highquality, appropriate implants due to a limited budget. Intramedullary nails
and plates were frequently bent, forcing local doctors to repeat procedures.
Similarly, regarding spinal implants, although pedicle screws were available,
their quantity was limited, making it necessar y to minimize its use. The
unavailability of set screw drivers was a critical problem, suggesting thenecessity of charging medical costs, rather than providing all citizens withfree medical services, for the further development of medical systems in
Bhutan.
As another problem, volunteer doctors were also regularly dispatched fromother countries to Bhutan to support all medical departments. In otherwords, Bhutanese staff were accustomed to receiving such doctors as guests
or, to an extent, mere labor force par ticipants. Doctors (and nurses)
dispatched from Kyoto University Hospital are no exception. Despite theintention of all dispatched members (including me) to improve the level of
medical technology in Bhutan, local staff engaged in limited practice due toinsufficient equipment do not necessarily desire such improvement as amatter of fact. New medical technology requires new equipment anddevices, indicating the necessity of facility support, in addition to doctor
dispatch, to ensure the effectiveness of this program.

Future perspectives
I present my opinion on the premise that the dispatch program aims to
suppor t the development of medical technology and preparation forfounding medical schools in Bhutan. First, it may be generally useless todispatch doctors of medical departments that are not organized in hostfacilities. Even if they are organized, doctors should be dispatched only aftersufficiently clarifying host families’ intentions. While budgets should also be
considered, it may not have much significance in dispatching doctors(volunteer doctors are also regularly dispatched from other countries)
without facility support, as medical services develop with the progress of
medical technology. Fur thermore, on comparing suppor t from Kyoto
University Hospital and the JICA, there are marked dif ferences inapproaches from the assignment of local coordinators to risk management.
As the medical office’s burden of dispatching doctors engaged in specialized
fields is markedly heavy, it may be more appropriate to put doctor dispatch
projects into the JICA’s hands if the current situation remains unchanged.

Impressions
Despite an unfamiliar work environment, I began to enjoy my daily work in amonth, being attracted by warm-hearted Bhutanese people and the grandeurof nature. Although I have presented critical perspectives on dispatch
programs, I personally appreciate being provided with the opportunity toobtain new experiences in Bhutan, while feeling sorry for having increased
Kyoto University Hospital staff’s burden. If the purpose of such programs is
to obtain medical experiences in developing countries, I am all for them.
Thank you.

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Kyoto University Hospital
Department of Cardiovascular Medicine

Report of the activities of the fi fth team
Term: December 26, 2014 ‑ March 7, 2015

Senior Lecturer,
Department of
Cardiovascular Medicine

Assistant Professor,
Department of
Cardiovascular Medicine

Assistant Professor,
Department of
Cardiovascular Medicine

Tetsuo Shioi

Masao Imai

Junichi Tazaki

Content of activity
The provision of cardiology services in Bhutan was limited to JDWNRH witha single cardiologist (Doctor Yeshey Penjore), whose main duty was treating
ward and outpatients. The types of heart disease were markedly different
from those in Japan; for example, ischemic heart diseases were not yet so
prevalent. Even in the capital Thimphu, the monthly number of acute
myocardial infarctions was 1 or lower. It was explained that patients withacute myocardial infarction was initially treated with fibrinolytic therapy
only, and, after approximately 1 week when the condition had stabilized, they
were transferred to India for coronar y angiography. Those requiring
pacemaker insertion were also transferred to India due to difficulty indomestically performing it. In such cases, it was necessary for medical staff
to visit India for follow-up.
Feasible cardiac examinations were limited to electrocardiography,
echocardiography, and chest radiography. Swan-Ganz catheters were notused even in the intensive care unit. Furthermore, as X-ray fluoroscopy
devices for portable C-arms were unavailable, examinations or treatments
requiring catheterization were not feasible at that time. Although there were
exercise electrocardiographs and Holter monitors, all of them were in needof repair.
On the other hand, there were 2 cardiac sonography devices of relatively
high quality, and they were being used by 2 technologists. Service hours in
the hospital and sonography unit were from 9 to 15, and it was difficult for
local staff to meet all examinations requests; this had prolonged the waitingtime to 1 to 2 months since some time ago. Doctors were not present in the
cardiac sonography unit at all times, and there were no systems to supervise
and evaluate reports submitted by technologists. So, we were mainly incharge of echocardiography for adult patients in the echography unit during
our stay. While performing 7 to 8 echocardiographies and preparing reports,
we super vised technologists daily. In the sonography unit, we provided
guidance on on-site evaluation and repor ting methods. We advised
technologists to refer to echo reports used in Kyoto University Hospital for
appropriate entry, but they seemed to need enhanced awareness and further
time to improve their reporting styles.
The majority of heart diseases dealt with in the sonography unit wererheumatic. Patients who had undergone valve replacement due tovalvulopathy around the age of 20 were frequently obser ved. As cardiac
surgery was not performed in JDWNRH, those requiring it were transferred
to India at the gover nment’s expense. The type of valves used wasbioprosthetic despite the large number of young patients. Some patients
visited the hospital several years after valve replacement in the presence of
prosthetic valve stenosis. One of the factors associated with such frequent
use of bioprosthetic valves for cardiac surgery in India was the feasibility of
warfarin control in Bhutan limited to 3 hospitals, including JDWNRH.
Among pediatric patients, congenital hear t diseases were markedly
prevalent. Such patients visited the sonography unit for examination almost
ever y day. Whenever they visited, we super vised technologists, whileanswering their questions regarding the shunt ratio, evaluation method, anddisease. Due to the absence of domestic doctors specializing in pediatriccardiology, diagnosis was provided by technologists, based on which general
pediatricians examined patients’ conditions, and deter mined theappropriateness of surgery. This indicates a high level of need for doctors
specializing in pediatric cardiology in Bhutan.
In shor t, considering the markedly high incidences of rheumatic andcongenital heart diseases, the establishment of a center specializing in heartdiseases with a department of cardiovascular surgery and catheterization
unit is likely to be sufficiently cost-effective.

Challenges and problems
While differences in customs between Bhutan and Japan should also be
considered, the major problem we noted was the absence of medical records
within the hospital, forcing patients to independently manage their medical
information using notebooks. The purpose of each request for examination
was also unclear, as cardiac sonography order sheets were not used.

Furthermore, previous examination results were frequently unavailable,highlighting the necessity of supporting the establishment of methods tosystematically store medical records and examination results within thehospital as a future goal of this dispatch program.
Although some of the cardiac sonography devices were similar to those usedin Kyoto University Hospital, they were in need of repair. We also heard that
half of the respiratory systems in the intensive care unit were in need ofrepair. Despite the availability of high-level medical devices supported byother countries, systems to maintain and repair them in the event of failure
had yet to be established. This may be another problem.
In Bhutan, high lipid and salt intakes have resulted in increased numbers ofpatients with hypertension, chronic renal diseases, and diabetes. In addition,in the capital Thimphu with rapid modernization, increased automobile use
has led to a decreased exercise level, suggesting an increased risk of heartdiseases involved in ar teriosclerosis. However, due to the absence of
cauterization units within the country, reperfusion therapy for such diseases
has remained unfeasible, leading to the necessity of transferring patients to
India, taking several hours. The establishment of cauterization units may be
a solution to this. The initiation of approaches to prevent heart diseases,
such as reducing the salt and lipid intakes, may also be an impor tantchallenge. Fur thermore, the presence of ward patients with cerebral
infarction due to atrial fibrillation involved in rheumatic hear t disease
indicates the necessity of sufficient anticoagulant therapy. In line with this, it
may be necessary to disseminate anticoagulant therapy monitoring systems
in Bhutan.
At the same time, considering that there were only 2 domestic cardiologists,
Doctors Yeshey Penjore and Mahasi Gurung, it may be necessary to further
elevate manpower by providing suppor t that comprehensively covers
Bhutan’s medical education systems, with a view to improving the quality ofthese cardiology services.

Future perspectives
While there were facility and equipment shortages, some medical staff
members were highly motivated, suggesting that Kyoto University
Hospital’s active commitments will further improve the status of medical
services in Bhutan. Personally, I could refresh myself by enjoying abundantnature and visiting magnificent temples on holidays. Despite confusing
factors, such as insufficient cleanliness in the hospital and different dietary
habits, being dispatched is a very valuable experience, and it provides theopportunity to develop objective perspectives on Japan.
On the other hand, for medical team members dispatched without theirfamilies, sufficient health management is crucial to continuously perform
activities in an environment that markedly differs from Japan. In the current
situation, this dispatch program is supported by the volunteering spirit of
dispatched members and their families. If one of the main purposes of
medical exchange with Bhutan is to promote interpersonal communication
between the 2 countries, the program should be more “dispatched membercentered”, and be organized with improved systems to support the mental
and physical health of such members and their families before, during, andafter being dispatched.

Impressions
Visiting the Kingdom of Bhutan for the first time, I found it very attractive.
With rapid modernization, streets were full of vehicles, and everyone had asmartphone around in cities. In contrast, in adjacent, vast rural areas, people
were kind and pious Buddhists. I also met a large number of people devoted
to activities to improve the domestic situation. I would be glad if wecontributed to such improvement to some extent during our stay. In the
future, it may be desirable for Kyoto University Hospital to not only dispatch
doctors, but also provide bidirectional approaches, such as inviting
Bhutanese staff for long-term training within the facility. It may also be
impor tant to suppor t their systems, including those for information
management, in addition to medical technology, and establish methods tocontinuously provide such support.

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Kyoto University Hospital
Department of Primar y Care and Emergency Medicine

Report of the activities of the sixth team

Term: September 16, 2015 ‑ December 1, 2015

Clinical Fellow,
Department of Primary Careand Emergency Medicine

Assistant Professor,
Department of Primary Careand Emergency Medicine

Senior Lecturer,
Department of Primary Careand Emergency Medicine

Tomoharu Mori

Manabu Shimoto

Shigeru Ohtsuru

Content of activity
Inspired by activity reports from previously dispatched teams, we had been
waiting for a long time for being dispatched to Bhutan. From the
Department of the Primar y Care and Emergency Medicine, 3 members,
Tomoharu Mori (September 7 to October 7), Manabu Shimoto (October 5 toNovember 6), and Shigeru Ohtsuru (October 27 to December 1) weredispatched as the sixth team to support emergency medical ser vices in
JDWNRH, the largest hospital of the Kingdom of Bhutan.
The Depar tment of Emergency of JDWNRH had been organizedapproximately 5 years ago, with 1 neurosurgeon as the director, 2 physicians
specializing in emergency medicine, 5 medical officers, and 2 interns. When
we arrived, 1 international volunteer (emergency physician) was supporting
their practice by turns.
Patients visiting the emergency outpatient division initially under wentassessment by triage nurses on a 24-hour duty to determine the severity.
Based on the results of such assessment, they were admitted to units for
mild, moderate, or severe conditions to receive basic medical consultationand examination services.
In the emergency outpatient division, patients with diverse chief complaints
were observed throughout the day. To deal with from patients with common
diseases, such as CPA, systemic burns, drowning, sepsis, and shock, tothose with puncture wounds, bruises, fractures, and dislocations related toarcher y and large darts as national sports, respirator y diseases such as
pulmonar y tuberculosis, bronchial asthma, and COPD, and digestive
diseases such as hepatic cir rhosis and peptic ulcers, in addition topregnancy females, par turients, newborns, and pediatric emergency
patients, outpatient beds were rarely vacant.
In such settings, extensive knowledge, skills, and experience related todiverse types of disease are required, similarly to the case of ER in the
United States. Nurses in the emergency outpatient division were qualified toperform the triage process, as well as intravenous line puncture, woundcare, and suture, and this system enabled doctors to allocate more time totreatment for patients in severe conditions.
Regarding training for emergency physicians, training systems had yet to beestablished, unlike the Depar tments of Internal Medicine, Surger y,Ophthalmology, Pediatrics, and Obstetrics/Gynecology, in which related
programs had already been developed, and such a situation was associatedwith chronic doctor shortages and limited service hours (9:00-15:00 or 13:0019:00). Education for interns immediately after graduation tended to depend
on volunteers, and local staff seemed to be expecting us to offer the latest
findings on the contents of such education. Twice (Wednesday and Friday) aweek, 30- to 60-minute post-graduation education seminars for doctors intraining were held in the afternoon, during which we also gave lectures on
various topics. Such topics included: Advanced Cardiac Life Support (ACLS),
bone marrow needles, Advanced Burn Life Support (ABLS), and Japan
Advanced Trauma Evaluation and Care (JATEC). On some occasions, we
provided guidance on echography necessary for emergency care at patients’
bedsides with their cooperation.

Challenges and problems
Basically, families attended patients at their bedsides, rather than staying in
the waiting room, and they usually provided cooperation with transfer to a
stretcher and transport to the examination room. However, even with suchcooperation, the length of the waiting time for emergency outpatients was
generally 6 hours or longer. In some cases, it exceeded 18 hours. When CT
examination was required, in addition to other time-consuming procedures
such as blood testing, radiography, and ultrasonography, patients had to wait
for a markedly long time, possibly increasing not only the risk of poor safety
management, but also their and their families’ physical and mental burdens.
Furthermore, as it takes several days by car from eastern areas of Bhutan tothe capital Thimphu where JDWNRH is located, some patients arrived at thehospital in advanced pathological conditions, as the time had passed since
the onset. Under these circumstances, it is expected that the use ofhelicopters for patient transfer, which started from November, will improve
the lifesaving rate, particularly for patients in severe conditions from rural
areas.

Future perspectives
In JDWNRH, we entertained a strong impression that those dispatched fromother countries, including us, are still needed to educate not only doctors,
but also nurses and other hospital staff working there, using their skills andexpertise to share “something important”.
During our stay, we had the opportunity to hold a seminar on BLS for 15
faculty staff members, thanks to kind arrangements by Doctor Chencho
Dorjee as the Dean of the Faculty of Nursing. However, while donatedtraining dolls and AED and other devices were qualitatively andquantitatively satisfactory, most of them were in mint condition. There werealso a large number of supplies that had been stored unused.
Seminar participants were very eager in learning. The light and joy in theeyes of those who had rarely participated in such training when pushing the
button of an AED for simulation were particularly impressive. After theseminar, they stated that the training was very enjoyable, and they indeed
appreciated detailed guidance provided by individual instructors. The
experience of holding such an event through collaboration among nursing
staff and medical students of Kyoto University Hospital, doctors from theUnited States, and others as a team was also very productive for us.
At the same time, this indicates the necessity of supporting them by sharing
something important with them through “invisible approaches”, rather than“visible approaches”.

Impressions
When we were dispatched to Bhutan, a climatic change from the rainy to dry
season was taking place there, with various festival events. To participate in
Tshechu, the largest festival in Thimphu, people came from throughout thecountry, and, wearing colorful national costumes, males and females of allages enjoyed folk dances and songs for 3 days. JDWNRH was also out ofservice during this period, and the majority of staff took time off from work.
Seeing a number of monks in the city, we observed that Tibetan Buddhism
has taken root firmly in people’s daily lives.
We had the opportunity to talk about benevolence with young monks at
Phajoding Monastery. They expressed medical professionals as “practicing
benevolence at all times from immediately after waking up in the morning”,
as patients visiting hospitals rely on them, and they make their best efforts
to benefit such patients. This is the practice of benevolence, and all deeds
leading to it are good, according to the monks, who welcomed us from aremote countr y, stating “all deeds lead to such benevolence fromimmediately after waking up in the morning”, with their faces beaming withsmiles.

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Kyoto University Hospital
Clinical Radiology Ser vice Unit

Report of the activities of the sixth team
Term: October 12, 2015 ‑ 20 November, 2015

Associate Professor,
Clinical Radiology Service Unit

Assistant Professor,
Clinical Radiology Service Unit

Assistant Professor,
Clinical Radiology Service Unit

Toshiya Shibata

Akihiro Furuta

Rinpei Imamine

Content of activity
The main purpose of dispatching members of the Department of Diagnostic
Radiology was to perform echographically-guided biopsy and treatment.
During our stay, while only radiologists specializing in diagnostic imaging
were working in JDWNRH, instruments for treatment, such as biopsy orpuncture needles and drainage catheters, were available, allowing theimplementation of related procedures. After arrival, we initially madearrangements to ensure the availability of an X-ray fluoroscopy unit,
echography devices, and monitors, as well as appropriate emergency
management. The quality of images obtained using old X-ray fluoroscopy
devices with very narrow visual fields was poor, but echography devices
were relatively new-type, with sufficient durability. Although we were forced
to perform unfamiliar freehand procedures, fortunately, we could obtaincooperation from a technologist showing much enthusiasm for practice. The
procedures we performed include: biopsies for conditions, such as hepaticmass, percutaneous transhepatic biliary drainage, drainage for hepatic or
subphrenic abscess, percutaneous nephrostomy, and pleural ef fusion
drainage. As we were also in charge of the management of drainage
catheters, we frequently visited patients to confirm their conditions. We
could complete these procedures without complications; however, concerns
over puncture-related bleeding remained, as an endovascular therapy unit or
instruments for hemostasis were unavailable within the hospital. During ourstay, we received a large number of requests for echographically-guided
procedures. As drainage for hepatic or renal cysts unexpectedly identified byimaging and contraindicated procedures were included in such requests, theprovision of explanations regarding the unnecessar y treatment andcontraindications to doctors in charge and patients was also part of ourduties.
Being frequently consulted about reading for CT and MRI by local
radiologists, we made efforts to discuss imaging findings to the maximum
extent possible whenever echographically-guided procedures were notscheduled. The experience of dealing with a variety of infectious diseases
that are rarely observed in Japan, such as parasites, and discussing suchcases with local staff was very productive for us.
Ultrasonography was frequently used for screening by specialized
technologists. We also occasionally provided consultation for them, andperformed echography together, in addition to supervising and discussing
with them.

Challenges and problems
There were 3 problems: insufficient reading environments, procedural
instruments, and manpower development. Regarding reading environments,
it was necessary to create reading reports only using Word, rather than an
exclusive template, consequently requiring considerable time to complete
each report. In addition, as related data were not appropriately classified, it
was dif ficult to find past images. As a solution, the use of appropriate
applications, such as FileMaker, may be effective to shorten the time neededfor entry and classify cases. This may also enable staff to allocate more time
to diagnostic imaging education for young members, possibly promoting theachievement of a domestic radiologist license in the future.
Secondly, regarding procedural instrument shortages, the unavailability ofprobe attachments to assist in the direction of puncture was an associatedfactor. Puncture was also performed by surgeons and emergency physicians;
they seemed to perform it blindly after confirming targets and determining
directions under ultrasound guidance. Considering the necessity ofconfirming the position of blood vessels in real time at the time of needle
insertion to avoid complications, the use of probe attachments is likely tocontribute to safer puncture.
Lastly, regarding manpower development, the absence of domestic
radiologists or doctors specializing in other fields, qualified to appropriately
perform relatively low-invasive and -cost echographically-guided procedures,
highlights the necessity of nurturing these professionals (in the last days ofour stay, one of the radiologists who obser ved our procedures showedinterest in this area).

Future perspectives
Similarly to our case, those who stay in Bhutan for the first time may needsome time to become accustomed to Bhutanese staff’s working hours andstyles. As life rhythms there are slower than in Japan, a sense of
insufficiency may grow. On the other hand, living in such rhythms has
significance, as it enhances our awareness.
Local radiologists and technologists were very friendly. Doctors of otherdepar tments frequently visited us to consult about imaging. They willcertainly show cooperative attitudes toward any dispatched team members
in need of advice.
As only a single device for each CT and MRI were domestically available,both of which belonged to JDWNRH, imaging was performed after carefully
examining the necessity of these techniques. Observing this, we realized theimportance of conducting examination with clear purposes, rather thanscreening patients just routinely.
As future perspectives, we hope that safe echographically-guided procedures
will be disseminated in Bhutan. Such procedures are likely to be sufficiently
cost-effective even in countries without sufficient medical supplies, as they
are feasible in any settings if ultrasonography devices and minimum
necessary instruments are available.

Impressions
We could become familiar with new environments, and start our jobs earlier
than expected, thanks to the efforts made by a large number of previously
dispatched doctors and nurses. In the Department of Radiology, it was
frequently necessary to manage requests from other departments, but wewere able to smoothly accomplish our tasks with cooperation fromsimultaneously dispatched doctors of the Department of the Primary Careand Emergency Medicine and nurses. We thank them Bhutaneseradiologists greatly helped us in both work and personal life. We deeply
appreciate their considerations for our comfort throughout our stay. We will
be grateful if our practice contributed to Bhutan’s medical services to someextent.
Although radiology departments are rarely involved with international
medical support, we realized the importance of such support through theexperience of being dispatched to Bhutan. We would like to express our
deep gratitude to those involved of Kyoto University and JDWNRH for
offering such an opportunity to us.

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Kyoto University Hospital
Department of Respirator y Medicine

Report of the activities of the sixth and seventh teams
Term: September 16 ‑ 23,2015 ‑ February 19, 2016 ‑ March 11, 2016

Senior Lecturer,
Department ofRespiratory Medicine

Clinical Fellow,
Department ofRespiratory Medicine

Clinical Fellow,
Department ofRespiratory Medicine

Shigeo Muro

Tadao Nagasaki

Shinsaku Tokuda

Content of activity
From our depar tment, 3 members were individually dispatched in
September 2015 and from February to March 2016. As there was no partner(local pulmonologist) in the beginning of September, the first member
started his activities in Bhutan with examining appropriate methods tocontribute to local pulmonological services, while consulting Doctor Yeshey
Penjor, a cardiologist, and Doctor Tashi Wangdi, the Director of the
Department of Internal Medicine. It regarded the following activities as his
main tasks: inspecting each section of the hospital to clarify the current
status of pulmonological services and related affairs; and extracting futurechallenges. In line with this, he examined statistics based on the ICD-10
Classification in 2014, and confirmed that respiratory diseases accounted forapproximately 25% of all disorders treated in departments specializing ininternal medicine (possibly including pediatrics), indicating a high level ofneed for the management of such diseases. Until that time, respirator ydiseases had been treated by general physicians due to insuf ficient
manpower in the field of internal medicine, and this suggested the necessityof enhancing awareness of respirator y diseases among all physicians,
including residents and young doctors. Fortunately, as Doctor Gaki wasnewly assigned as a full-time pulmonologist in Februar y 2016 when thesecond member was dispatched from our department (when this report was
written), it was expected that he would be a core parson in the future. The
detailed contents of the first member’s activity on wards included: observing
ICU/ward rounds and providing related consultation; and inspecting related
procedures, such as endoscopy, respirator y function examination, anddiagnostic imaging, to clarify the current status. Impressive cases heobserved immediately after being dispatched in September are represented
by: a case of COPD deterioration requiring inpatient treatment; amacrotumor that occupied the almost entire left lung; and a female in her
thirties with idiopathic hypoxemia (PAH?). He also inspected the ER on
some occasions; he realized the necessity of respirator y disease
management particularly on September 18, when he observed 3 patientswith COPD deterioration, in addition to a young male with miliar ytuberculosis involving pneumothorax, within that day. Similarly, the second
member dispatched in February provided consultation for 8 inpatients with
COPD (5 of whom were female, indicating a high prevalence of the disease
among Bhutanese females), as well as 1 with COPD involving asthma, 1 withpleural empyema, 1 with pneumonia, 1 with suspected tuberculosis, 2 withpulmonary embolism, and 3 with pulmonary hypertension in only 2 days.
Furthermore, the opportunity to give a 45-minute lecture (on COPD andasthma) at an adjacent nursing school was offered (see Photo).

Challenges and problems
While it is expected that the presence of the newly assigned full-time
pulmonologist will contribute to future improvements, we noted thefollowing challenges/problems during our stay in Bhutan:• Bronchoscopy was not sufﬁciently performed. In addition, biopsy forceps
for upper endoscopy were repeatedly used after being soaked in a pink
disinfection solution. Endoscopes were manually washed. In the
Depar tment of Otolar yngology, there seemed to be only a single

laryngoscope for all outpatients.
• The Physiological Function Examination Room also seemed to be out ofservice. Considering the number of potential patients with chronic air
diseases, such as asthma, COPD, and bronchiectasis, education for local
doctors and technologists to appropriately use spirometers may be ofmarked significance. We made arrangements to train local staff using
portable spirometers brought from Japan in February 2016.
• Although there was an NPPV system in the ER, ICU doctors stated thatthey had never seen it, indicating the necessity of also improving internal
information management systems.
• In one of the 2 cases in which we provided consultation, the Department ofRadiology entered “ILD” (interstitial lung disease) in the comment box.
When we visited the department with residents to confirm the relevant
images, a doctor of the Department of Diagnostic Radiology said that he
was glad to hold a discussion with us. Considering the characteristics ofthis medical depar tment, it may be necessar y to fur ther promotecollaboration with radiological diagnosticians. Otherwise, minor points wenoted include: there was no Schaukasten in the room for case studies; andit was necessary to access the CT Room located downstairs to read CT
images, although they were planning to adopt PACS with a monitor ineach section in the future (according to a doctor of the CT Room).
• Intradermal antibiotic testing was being conducted.
• A patient diagnosed with pneumonia on admission was treated withciprofloxacin therapy. There were also some cases of suspectedpulmonary tuberculosis.
• While conducting a bacterial culture test on admission, the results were
not confirmed in many cases.
• Elastic stockings were not available within the hospital despite thepresence of multiple patients with pulmonary embolism.
• Acid-fast bacillus culture was not performed in many cases of acid-fastbacillus smear ordering.
• On the tuberculosis ward, although patients were accompanied by theirfamilies, similarly to those on general wards, windows were left open.
When we explained the necessity of maintaining them closed, ward staff
understood, and began to do so. Some staff members wore a surgicalmask upon an N95. The latter was also used by patients. Therefore, weplanned to make a presentation for local doctors using YouTube or othermethods to explain the feasibility of preventing droplet expansion onlywith surgical masks.

Future perspectives
Although tendencies were different from those in Japan, as represented by
the high incidences of tuberculosis and COPD among young individuals andfemales, respectively, the presence of a large number of patients withrespiratory diseases highlights the necessity of continuing to interact with
Bhutan. At the same time, as medical resources were limited, it may also benecessar y to nur ture doctors specializing in pulmonology, or provide
general physicians with education to enhance their awareness of
pulmonological ser vices or training. The feasibility of improving theavailability of examination devices should also be confirmed. In any case, it
may be important to provide support in consideration of the actual situationof each host facility. As the number of pulmonologists is also insufficient inJapan, long-term strategies to harness limited manpower to the fullest may
be needed to continuously interact with Bhutan, and obtain favorable
outcomes for both parties. Now that a full-time pulmonologist is present, it
may be possible to further enhance the effect of such interactions by closelycontacting him as a core person.

Impressions
Since some time ago, it has been difficult for our department to dispatch its
members for a long period of time due to internal affairs. Therefore, themembers have been individually dispatched for a short term, leading to thenecessity of determining the contents of their activities upon deliberations
with local staf f after arrival. Under these circumstances, dispatchedmembers frequently need to make requests, for example, those forobservation, on the same day, and this may increase local staff’s burdens.
However, during our stay, local staf f agreeably made arrangements toaccommodate our needs, while actively following our advice, and this helped
us very much. If we express their characteristics based on our experience,
they were flexible, but, from a critical viewpoint, hindsight. They managed
situations as soon as they recognized the necessity of such management (inother words, it is likely that they will never address them if they do notrecognize the necessity at once). If we continue to interact with them fromlong-term perspectives, their pulmonological service systems will further
improve. Considering the possible prevalence of respiratory diseases, suchas respirator y infection and COPD in housewives due to biomass fuelexhaustion, we hope that productive interactions with Bhutan will continue.

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Shizuoka Children’s Hospital
Department of Neonatology

Report of the activities of the sixth team
Term: October 5 ‑ 17, 2015

Head, Department of Neonatology
Shizuoka Children’s Hospital

Yasuhiko Tanaka
Content of activity
Although the period was limited to 2 weeks from October 5 2015, I
performed activities to support pediatric cardiology and neonatal medicine
in JDWNRH.
Up to that time, neonatal medicine in Bhutan had been supported by Doctor
Yoriko Nishizawa from Japan. Doctor Nishizawa was originally dispatchedfrom the Primate Research Institute of Kyoto University as a volunteer in
2011. When I arrived, she was fully engaged in her activities as the person
responsible for the Neonatal Department of JDWNRH.
The neonatal division was managed by a very limited number of staff; Doctor
Nishizawa and 2 residents. They were in charge of more than 50 patients in 5
units: NICU (acute/severe conditions), HDCU (mild conditions),
phototherapy unit, kangaroo-mother care (KMC) unit, and unit for newborns
in normal conditions. In 2013, the number of inpatients admitted to the
NICU was 450, and that to the phototherapy and KMC units was 1,600 in
total, in addition to 36 very-low-birth-weight inpatients weighing less than
1,500 g. I was surprised to hear such a markedly higher number of NICU
patients in Bhutan compared with Japan.
My activities included: (1) making rounds in the NICU and HDCU, (2)providing ultrasonography guidance in the NICU, (3) treating pediatric ward
and PICU patients and pediatric outpatients with congenital heart diseases,and (4) giving lectures. Among these, I gave importance to the promotion ofultrasonography use in the NICU. In Japan, all doctors in charge of theneonatal ward independently per form hear t, head, and abdominal
ultrasonographies to clarify the presence/absence of congenital hear t
disease and evaluate hemodynamics for premature infants, in addition totissue bloodstream measurement and intraventricular hemor rhage
diagnosis. This tendency is globally unique, and regarded as a factor
contributing to the lowest newborn mortality rate in Japan compared withother countries. Expensive echography devices are not necessar y. It issufficient only with 2-dimensional and Doppler systems. As a portableechography device was available, I conducted examination for NICU and
HDCU patients using it. While super vising residents, I examined all
inpatients admitted to the NICU daily. In the second week, I could see theresidents independently perform echography when I visited the ward before
making a round. Although it was not feasible to provide technical guidance
for accurate diagnosis within the 2-week period, I had the impression that
their level of medical practice for newborns will improve if they begin to use
ultrasonography as a daily diagnostic instrument, similarly to stethoscopes.
While implementing my duties in the NICU, I also received a large numberof requests from the pediatric ward and outpatient division for examining
patients with hear t diseases. As cardiac surger y was not domesticallyfeasible, such patients were transferred to India; to my surprise, pulmonary

hypertension as a complication was markedly prevalent among both pre- andpostoperative patients, regardless of the age or severity of anatomical
abnormalities. This may be associated with Bhutanese patients’ tendency tochronically be in a hypoxic condition due to the high altitude of the capital
Thimphu, at 2,300 m.

Challenges and problems
Insuf ficient doctors and medical resources was a major problem. The
number of pediatricians based in Bhutan limited to 8, including Doctor
Nishizawa who was the only neonatal medicine specialist available, revealing
her heavy burden. Monitors were also insufficient, making it difficult tomonitor the heart rate and SpO2 level outside the NICU or HDCU; this led
to sudden changes in the condition or death in the latter. In-hospital infection
was also prevalent, particularly among premature infants admitted to the
NICU. Fur thermore, detected bacteria showed a high level of dr ugresistance, making some cases refractor y to treatment. In the NICU,
although guidelines on the use of antimicrobial agents had been established,
ICT-based approaches to fur ther promote hand disinfection andenvironmental arrangements seemed to be useful.
Pediatric patients with heart diseases were referred to Indian hospital forsurgery. However, half of such patients were regarded as inappropriate forsurgery, and returned untreated, indicating the necessity of training for theappropriate diagnosis and management of congenital heart diseases.
Another point I noted was occasionally insufficient collaboration amonginternal departments. In perinatal medicine, collaboration between the
Department of Obstetrics and neonatal ward is particularly important;however, in the hospital, it seemed to be frequently necessar y to attend
delivery using the cesarean method without sufficient information from the
Department of Obstetrics. It may also be effective to promote cooperation
between the Departments of Pediatrics and Pediatric Surgery and between
the Depar tments of Pediatrics and neonatal ward, in order tocomprehensively improve their level, as I emphasized during my lastlecture.

Future perspectives
Bhutanese doctors’ level of medical practice was generally high, and they
showed active attitudes toward standardized practice based on appropriate
guidelines and literature. On the other hand, also receiving a large numberof volunteer doctors from the United States and Europe, their demands for
us seemed to be high. As feasible medical practice is limited due toinsufficient human and physical resources in Bhutan at present, it may bedesirable to provide suppor t for medical practice that is feasible andsustainable for a long period of time by clarifying the actual situation andclassifying problems.
Dispatched team members usually discuss the content of support with hostfacilities before depar ture. However, actual settings may be markedly
different from those expected. This frequently happens when working
abroad, including in Bhutan. So, it is important to adopt flexible perspectives
on each country, rather than attaching to common senses in Japan.
To those dispatched to Bhutan to suppor t neonatal medicine in the
Department of Pediatrics, the presence of Doctor Nishizawa may be of great
advantage when discussing before and performing activities after being
dispatched.
Please also take this opportunity to enjoy the beautiful nature, majestic
temples, and nostalgic town landscapes of Bhutan, as well as delicious
Bhutanese cuisine.

Impressions
I would like to express my sincere gratitude to those involved of Kyoto
University Hospital, Shizuoka Children’s Hospital, and JDWNRH for
providing me with such a valuable opportunity. When based on economic
indices, Bhutan is among the poorest countries. However, Bhutanese people
I met were religious, respected nature and gods, and gave importance tofamily and community bonds. They were also proud of their nationality.
These characteristics seemed to explain why Bhutan is called the “countryof happiness”. Hospital staff were highly motivated, and showed enthusiasm
for improving the quality of domestic medical services. My contribution to
Bhutan during a short period of 2 weeks was very limited; I rather learned alot from it.

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Kyoto University Hospital
Nursing Department

Report of the activities of the sixth team

Term: September 16, 2015 ‑ December 1, 2015

Challenges and problems
Nurse, Nursing Department

Ai Matsuyama
Content of activity
I worked as a nurse on the surgery ward for 3 months. Our duties included
welfare support for postoperative patients (mainly the monitoring of theirgeneral status, drain management, and hygiene maintenance), and theprovision of knowledge and skills regarding actions to be taken when their
physical condition rapidly changes. The coming and going of patients due tosurgery and admission/discharge frequently occurred on the ward, and so
we were always aware of the significance of safety management. We
repeatedly taught ward staf f and nursing students the impor tance ofpredicting and avoiding potential risks, nurturing a safe environment forpatients, and considering what to do to achieve these purposes. In Bhutan,
physical care for patients is provided mainly by their families. To prevent
indwelling needle- or tube-related accidents and infectious diseases, we
provided such families with guidance laminates showing the methods forappropriate patient management.
In addition, instead of leaving patient care entirely up to families, weroutinely assessed whether or not the needs of patients were being met, andprovided these families with necessary explanations. When we performed
hygiene maintenance with nursing students, they realized from experience
that, such maintenance not only keeps patients’ sanitary conditions, but also
provides oppor tunities to monitor their general skin condition andcommunicate with their families. I was glad about this.
Although study meetings on BLS were conducted by the fi fth team, suchmeetings were also held by the sixth team in cooperation with emergency
physicians with the aim of advancing staf f members’ exper tise.
Furthermore, in a practical setting, we learned about necessary actions to betaken on the surgery ward. In addition to organizing the materials on theemergency carts, we equipped these carts with supplies needed at the timeof intubation, as well as with laminates showing how to fix intubation tubes,
in order to facilitate prompt responses in emergency cases.
As the 5S activities have become a common practice since the intervention
by the first team, I often noted ward staff spontaneously keeping supplies
tidy and ordered when they had spare time.
As an out-of-hospital activity, we attended Bhutan’s first ever international
medical conference, during which time we were able to deepen our
knowledge regarding the countr y’s medical practice, related issues, andtraditional medicine. During the conference, we perceived participants’seriousness and enthusiasm, as they actively asked questions andexchanged opinions.

At the hospital, surgery is performed 3 days a week, nearly 20 times a day.
Many patients undergoing surgery are admitted the day before surgery, andwill be discharged the day after surgery if their clinical course is normal.
Nurses spend much time doing paper work for admitted/discharged
patients, and transcribing data from the specified manual for drugs andinjections. Hence, there is a need to promote efficiency and rationalization in
their duties in order to improve the quality of nursing practice.
In addition, the surgery ward lacks in biological information monitors; forexample, the ward has only one ECG monitor and one SpO2 monitor. As
malfunction of these devices frequently occurred due to the absence ofregular checking, ward staff perceived that values shown by the devices
were not fully reliable. On the other hand, they tended to rely on biologicalinformation monitors instead of supervising patients through basic physicalassessment. Although it is impor tant to procure necessar y medical
equipment and improve its quality, postoperative acute-phase management
may be conducted more safely by improving practical skills for physicalassessment with 5 senses (e.g., visual examination and auscultation). Somestaf f members had such skills, but they generally did not share theirknowledge or skills with other healthcare providers. Thus, there was a
critical need to produce leaders from ward staff, and facilitate education for
current nurses as a common practice.

Future perspectives
During my dispatch period, the radiologists and emergency physicians fromthe same team sometimes provided medical care for patients on the surgery
ward. These physicians taught me about expected complications and thedetailed procedures for treatment, and such knowledge was very useful for
nursing practice. If using handwriting medical records or delivering patient
information orally, it would be difficult to keep track of patients’ treatment
courses and medical conditions. I hope that physicians and nurses will bedispatched together to the surger y ward so that they will be able toef fectively per form a series of procedures from treatment, to patientmanagement, and then to nursing care in a cooperative manner.
Of all our activities in Bhutan, the most challenging task was to consider
how and in which order the identified issues should be tackled inconsideration of the countr y’s culture, medical practice, and healthcare
systems. Initially in the dispatch period, we aimed to nurture a favorable
relationship with ward staff, nursing students, patients, and their families,
and understand our daily duties with the help of these staff members. Thus,
it was not until we became familiar with these duties that we began toeducate ward staff and nursing students. These staff members are generally
warm-hearted and easygoing, and it may be better to approach them in amanner so that they will be able to note and tackle medical issues bythemselves.

Impressions
In Bhutan, we met many local people with different cultures and habits,
realized that they greatly value ethnicity (pride and history), and visited
various local places, such as grand temples situated on a steep mountainsurface. All these experiences were fresh and impressive for us. We also felt
these people’s kindness and thoughtfulness frequently. For example, apatrolling hospital guard provided translation for me and patients when we
had difficulty communicating with each other, and local children showed me
the way when I became lost outside the hospital. Such kindness andthoughtfulness gave me valuable opportunities to reflect on my humanityand views of nursing practice.
I am grateful that we were able to complete our 3-momth project due tosupport from many people involved in the dispatch project. I am also gratefulto other members of my team, patients, and their families. Thank you very
much.

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Kyoto University Hospital
Nursing Department

Report of the activities of the sixth team

Term: September 16, 2015 ‑ December 1, 2015

Challenges and problems
Nurse, Nursing Department

Ikumi Ueda
Content of activity
I worked on the pediatric ward of JDW Hospital for 3 months. In addition tothis ward, the hospital has a neonatal ward, NICU, and PICU adjacent to the
obstetric ward. On the pediatric ward, many patients had infectious diseases(respiratory and gastrointestinal), low birth weight, malnutrition associatedwith developmental retardation, fever convulsion, burns, or injuries. In
general, Bhutanese patients with hernia or relatively mild diseases undergo
surgery in Bhutan, and those with severe diseases, including heart disease,
undergo surger y outside the countr y. In JDW Hospital, nurses are
responsible for the admission procedure and other daily routines (e.g.,measurement of body temperature, medication, blood collection, and injury
treatment); however, personal concerns, which are within the scope ofnurses’ duties in Japan, are taken care of by families in Bhutan. I often saw
Bhutanese families devotedly looking after their children in the hospital.
Initially in the dispatch period, we aimed to understand the current state of
the pediatric ward with the help of ward nurses. In addition, as a part of the
5S activities, we made ef for ts to improve the environment of patients’bedrooms and care rooms. Because we often noted that medical supplies
were lacking when they were needed, we organized the repositories forthese supplies, and made labels showing their designated position.
Furthermore, we created a form facilitating the prevention of supplies frombeing out of stock at the care rooms.
Concerning needles, we often had difficulty collecting blood from pediatricpatients and securing their intravenous route. Previously, needles used for asingle patient were collectively stored in a tray, which imposed a high risk ofneedlestick accidents on nurses. The number of needle boxes was not
sufficient, and they were too large and breakable to be portable. Against thisbackground, we created simple mobile needle boxes using cups located on
the pediatric ward.
In addition, we prepared brochures used to educate patients’ families. In
Bhutan, consulting a hospital is not as common as it is in Japan, maybe
because the number of hospitals is limited, and maybe because patients do
not know on what basis they need to go to a hospital. The above-mentioned
brochures cover pediatric patients’ common symptoms (e.g., a fever andrashes) and childraising-related information (e.g., bathing, suction, andimmunization). We helped nurses to provide patients’ families withappropriate guidance using these brochures.

In Bhutan, a shortage of both hospitals and medical staff (e.g., physicians
and nurses) exists. Similarly, hospitals lack of drugs, medical equipment,
and linen needed to nurture a favorable care environment. It has not been
many years since the education of nurses began in Bhutan, and I perceived
that the country was still in the process of developing methods to educatethese healthcare workers. In addition, although nursing students were
provided with many opportunities for clinical training, I felt that they had
difficulty receiving education from nurses. The major reasons for this were
because nurses were too busy with their work to educate these students, andbecause they did not know appropriate education approaches due to theirlimited teaching experience, as well as to the fact that providing sucheducation was not a common practice in Bhutan. By establishing systems
facilitating the fostering of college professors, and by developing education
systems for nurses, it may become possible to provide high-quality nursing
care in the future. In addition, I thought that the quality of medical careprovided at JDW Hospital may improve if information sharing is promoted
not only among nurses, but also between nurses and other professionals aswell as workers from other wards/departments. Furthermore, as Bhutan
heavily depends on the import of medical supplies from other countries, it
requires large amounts of money and time to procure them; therefore, thehospital often lacks such supplies. Because the presence or absence of
medical supplies significantly influences medical care, it is important toconsistently obtain these supplies, and appropriately manage their stock.

Future perspectives
I thought that it was difficult to understand and practice the medical care of
Bhutan soon after arriving there. It may be important to first understandlocal people and the countr y’s cultures, such as customs, religions, andlifestyle. In general, Bhutanese people are ver y kind and religious, andgreatly value their bonds with families. In addition, they have the cultural
perception that families should be prioritized over work. Furthermore, themedical techniques and equipment of Bhutan have rapidly advanced. The
countr y is aiming to improve the quality of medical care while actively
receiving various types of support from other countries.
During the 3-month dispatch period, I re-recognized that, in Japan, medicalcare is advanced in various ways and careful attention is being paid topatients, their families, and healthcare providers. When I stayed in Bhutan,
the development of ideas in an unfamiliar medical environment was morechallenging than I had expected.
I thought that the roles of dispatched members are to understand thecurrent state of Bhutan’s nursing and medical care with the help of local
staff, and to consider how medical care ought to be in the country based on
its future prospects.

Impressions
I originally did not expect that I would be provided with an opportunity topractice medical care outside Japan. I was glad that I was able to work in
Bhutan as a member of the dispatch teams mediating between Kyoto
University Hospital and JDW Hospital. Although I did not know anything
about Bhutan at first, during the 3-month dispatch project, I was able tospend a meaningful time due to support from many different people, such asstaff members of both JDW Hospital and University of Medical Sciences of
Bhutan, patients, and their families. In addition, before going to Bhutan, thenursing chief and other staff members of the pediatric ward encouraged meon the dispatch project, and staff members of the nursing and administrative
affairs departments helped me in various ways. I am really grateful to thesepeople.
During my stay in Bhutan, I had many different experiences, ranging fromliving a local life to working in an unfamiliar medical setting. Through theseexperiences, I was able to re-recognize the importance of interpersonal
relationships and mutual cooperation. I hope that these relationships willcontinue to deepen between Kyoto University Hospital and Bhutan.

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Kyoto University Hospital
Department of Diagnostic Pathology

Report of the activities of the seventh team
Term: January 8 ‑ 29, 2016

Senior Lecturer,
Department of Diagnostic Pathology

Clinical Laboratory Technician,
Department of Diagnostic Pathology

Akihiko Yoshizawa

Masahiro Hirata

Content of activity
I worked at the JDWNRH Depar tment of Pathology and Laborator y
Medicine from January 8 to 28. This department had 3 pathologists. The
Histology/Cytology Unit had 10 medical laboratory technologists, and 6 ofthem were also cytotechnologists. Some of these staff members belonged tothe military.
In addition to duties similar to those performed by Japanese pathologists,
local pathologists were required to perform fine-needle aspiration cytology(FNAC) [e.g., puncture of head/neck tumors and the mammary gland] atthe specified place within the above-mentioned unit. They also provided
direct consultations for patients and their families regarding pathology
repor ts. No specific requests were made to us by these pathologists;
however, with the aim of understanding the current state of the hospital,
Yoshizawa excised surgical samples, prepared pathology reports regarding
biopsy and surgical materials, assessed the quality of immunostaining, gave
advice to local pathologists, and provided consultations for patients’ families(hospital staf f). Although pathology and cytodiagnosis repor ts weremanaged using a laborator y information system (LIS), it was not userfriendly, and these reported were generally managed using record books. As
such books are not suitable for retrieving data or performing analyses, we
proposed report management using MS Access databases on PCs in thelaboratories. However, we were not able to create such databases because ofa lack of time and other reasons.
Hirata was requested to cooperate in various activities, particularly helping
local staf f improve skills for histopathological sample preparation andimmunohistochemical analysis (immunostaining) at the Histology Unit. In
addition, this member proposed appropriate sample treatment, as well as
special staining per formed in a simple and convenient manner. At thehospital, immunostaining was previously per formed by only 1 local
technologist who had undergone just 1 week of training. While working on
staining with this local staff member, Hirata advised them on the methods
for condition settings, as well as on how to appropriately choose antibodies
and detection systems. Our time working at the Cytology Unit was short,during which we mainly per formed cytological and microscopic test
(screening). In spite of slight dif ferences in the methods of sample
preparation and staining between Japan and Bhutan, we had no difficulty
making diagnoses. Unlike our medical center in Japan, at the hospital in
Bhutan, cytodiagnosis was mostly given to gynecological patients, and mostof the non-gynecological samples were used to give needle aspiration
cytodiagnosis for people with suspected tuberculosis. These findings were
not familiar to us. Concerning the accuracy management of cytodiagnosis,
the hospital maintained a quality similar to that of our medical center inJapan. Multiple local cytotechnologists performed double-screening for all
patients requiring cytodiagnosis, including those with negative results in thefirst screening, which was noteworthy.

Challenges and problems
If the medical care of Bhutan continues to develop, the need for pathologicaldiagnosis would grow, in which case the largest issue would be a shortage ofpathologists. Of the 3 above-mentioned pathologists, 1 was a former
physician who had already retired, and 1 was a soldier. Thus, the remaining
chief pathologist had ultimate responsibility. Similarly, in the accuracy
management of cytodiagnosis, the shor tage of pathologists may
preferentially need to be addressed.
There is also a need to procure necessar y supplies and help local staff
develop their medical skills. At the Histology/Cytology Unit, to which the
majority of Bhutanese samples are transported despite unfavorable traffic
conditions, we noted a disparity in the quality of samples particularly due to adifference in sample fixation conditions. In addition, although the hospital
had basic medical equipment, it was difficult to obtain some reagents,
devices, and books, which was another issue. Furthermore, as only theminimally required tests are ordered because of the pathologists’ time
restraints, they have limited oppor tunities to develop their skills for
immunostaining and special staining. Moreover, we suggest room for
improvement in the hospital’s occupational safety and health, such ascountermeasures against harmful substances (e.g., formalin and organic
solvents) and the prevention of incised wounds.

Future perspectives
Our dispatch team may not have markedly contributed to the Histology/
Cytology Unit. When I talked to the local chief pathologist about our team’s
per formance, I found out that they desired the long-term dispatch ofJapanese pathologists, or the introduction of other pathologists from Japan.
This desire may be the most important consideration in our pathologistdispatch project.
The Histology/Cytology Unit had highly-skilled staff and basic equipment,
but it was difficult to obtain some supplies needed by the unit. In general,
supplies used at such units are not expensive or difficult to utilize. The work
per formance of the Histology/Cytology Unit may markedly improvethrough procuring such supplies (e.g., knifes used for sampling). In
addition, as it is expected that the number of samples will increase in
Bhutan, there is a definite need to create databases accordingly. For thispurpose, it may be necessary to provide both physical and human resource
support.
Long-term dispatch project places a burden on our colleagues during ourabsence. Concerning technical education for technologists at the hospital, it
may be reasonable to invite them, and conduct technical training at our
hospital.

Impressions
In Bhutan, where I had the impression that citizens were commonly very
gentle, things were not abundant, and the lack of social infrastructure andmedical resources was significant; however, I felt that citizens’ lives were
nowhere near poverty, which could not simply be explained by free medicalcare and education. While reflecting on the situation of Japan, in whichmental illness is prevalent partially due to a vast amount of unnecessary
information (although financial poverty also exists), I constantly considered
my duties in Bhutan, and was personally able to spend a meaningful time.
Although not sure whether our dispatch team has contributed to Bhutan andlocal hospitals, I strongly felt the need to maintain our bonds in various
senses. (Yoshizawa)
I was able to learn a lot from our dispatch project, in which local staff
regarded accuracy management and medical safety as of major importancedespite limited supplies and staff members. At Kyoto University Hospital,
accuracy management and double-checking are not fully practicable due toinappropriate role-sharing and pathological diagnosis division staf f
assignment (double-screening is performed for 10-20% of the individuals
requiring cytodiagnosis). For example, pathological depar tment staf fmembers are required to do things other than their own work, such as beingon night/day shift. From the perspective of ensuring medical safety(prevention of sample mix-up and missed malignant cells), I re-recognized
the need to review the operation systems of our hospital. (Hirata)

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Kyoto University Hospital
Department of Otolar yngology

Report of the activities of the seventh team
Term: January 11, 2016 ‑ March 19, 2016

Clinical Fellow,
Department of Otolaryngology
Head and Neck Surgery

Assistant Professor,
Department of Otolaryngology
Head and Neck Surgery

Assistant Professor,
Department of Otolaryngology
Head and Neck Surgery

Chiaki Suzuki

Morimasa Kitamura

Tatsunori Sakamoto

Content of activity
From the Department of Otolar yngology, 3 members were individuallydispatched for approximately 1 month (Januar y 12 to Februar y 4, 2016:
Suzuki; Febr uar y 2 to 28: Kitamura; and Febr uar y 24 to March 18:
Sakamoto). Before starting to assist surgical and outpatient procedures, we
confirmed the current status of otolaryngological services in Bhutan, suchas the skills and knowledge of domestic otolaryngologists, availability ofnecessary instruments and supplies, and medical service systems.
At that time, there were 5 otolaryngologists based in Bhutan; 3 in JDWNRH,
1 in Military Hospital, and 1 who was absent to participate in training related
to head and neck cancer treatment in India. In JDWNRH, the 3 doctors had
performed approximately 850 surgeries annually. Surgery was performed on
Wednesday and Friday, and the other days of the week were allocated to
outpatient ser vices. While general otolar yngological diseases were wellmanaged, local staff’s technical skills to deal with more specialized fields
were slightly insuf ficient, possibly due to the absence of domestic
supervisors. Furthermore, Bhutan’s dusty and dry climate was associatedwith the development of upper respiratory tract diseases, resulting in a highprevalence of otorhinological diseases. Thyroid diseases were alsofrequently obser ved, presumably due to a limited seafood intake.
Considering such a situation, we aimed to improve local staff’s technicalskills by providing guidance mainly on otology, rhinology, and craniocervicalhead and neck surgery.
In surgery, otological, rhinological, and head and neck minor procedures
accounted for the majority. As radiotherapy devices were unavailable,
treatment for patients with head and neck cancer was not feasible, leading to
the necessity of transferring most of them to hospitals in India; when the
doctor in training in India returns, surgical treatment for such patients may
become feasible. We also discussed dif ferences in surgical techniques
between Japan and Bhutan, with a view to improving systems to provide
medical services in local environments. While endoscopic sinus surgeries
are becoming standard treatment methods on a global basis, particularly inthe field of rhinology, such procedures were still unfamiliar to local doctors.
Thus, we gave lectures on methods and techniques for them to appropriately
use endoscopy, with explanations of related anatomy.
A 3-month period was too short for us to provide sufficient guidance, making
us realize the necessity of continuing to provide support.

Challenges and problems
Local doctors’ expertise seemed not to be insufficient, as they had been
trained abroad. They also appeared to be sufficiently motivated to educateinterns. On the other hand, although they had mastered methods to deal
with general otolaryngological diseases, they had not completed fellowship
programs in more specialized fields (otology, rhinology, head and necksurgery, and laryngology). Therefore, they tended to use techniques in theirown, immature ways. As they showed active attitudes toward the provision of
medical services, such as asking doctors from other countries to cooperatewith them to improve their technical skills and adopt new techniques, it may
be possible to improve the situation by providing guidance in each field.
Local staff also had difficulty in appropriately using diagnostic imaging
techniques, such as CT, and the preoperative confirmation process using
anatomical images was frequently omitted. At this point, technicalimprovement is likely to be further promoted if we also provide approaches
for local staff to develop appropriate attitudes and planning skills in the fieldof surgery, as well as diagnostic imaging.
Outpatient ser vices were being provided without major problems, ingeneral, but there was a serious shortage of instruments, and they werereused after simple sterilization. As the department of otolaryngology also
treats a number of patients with a chief complaint of airway symptoms ortumors of the cervical lymph node in the presence of tuberculosis, it seemed
to be desirable for local staff to disinfect instruments more appropriately,
and avoid reusing them. This also highlights the necessity of not only
personnel, but also equipment support for Bhutan.

Future perspectives
In order to improve Bhutanese doctors’ skills, it is necessary to understandthe national trait of this country. Bhutanese people are very religious, giveimportance to the proprieties, and treat others with broad-mindedness;therefore, they sincerely listen to our opinions. However, considering
differences in cultural and economic conditions between Bhutan and Japan,
it may be inappropriate for us to force them to accept our opinions, andperform their activities in the same manner as we do. What we should dofirst may be to confirm their actual situation, and consider together
appropriate methods to improve their medical service systems on a step-bystep basis. In this respect, continued support is necessary, and we have todevelop a positive view of this country through active communication with
Bhutanese people.
In Bhutan, nature remains intact, and trekking and sightseeing arerecommended. Staying in Bhutan is a valuable experience in terms of not
only the provision of support, but also personal life.

Impressions
We visited Bhutan with anxiety about our abilities to sufficiently support its
medical ser vice systems. Although we had physically and mentally hardtimes at the beginning, we could get through with warm-hearted support
from local staff. All of them were very kind and friendly, and they seemed to
be proud of being Bhutanese. We were also helped and gently treated bymany people outside the hospital. Through these experiences, we becamefond of the character of Bhutanese people.
Local staff were making efforts to provide treatment to the possible extent,
while fully recognizing insufficient medical devices and drugs within the
country compared with others. We assisted them, considered appropriate
methods of treatment together, and realized that it is also necessar y tosupport their equipment and devices, in addition to providing personnel
support.
Lastly, we would like to express our deep appreciation to Kyoto University
Hospital staff who agreeably sent us off, as well as Bhutanese doctors,
technologists, nurses, and clerical staf f who suppor ted us to manage
situations during our stay. Hopefully, support for Bhutan to improve its
medical service systems will be continuously provided.

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Kyoto University Hospital
Microbiology Laborator y, Department of Clinical Laborator yReport of the activities of the seventh team
Term: January 8, 2016 ‑ February 5, 2016

Future perspectives
Clinical Laboratory Technician,
Department of Clinical Laboratory

Yoko Tanaka
Content of activity
I was engaged in clinical laborator y ser vices in the Microbiology
Laborator y, Depar tment of Clinical Laborator y for 1 month. The local
coordinator retired during the coordination of my duties, and I was
dispatched before the appointment of his successor. So, I did not knowwhom I should contact to confirm the contents of my activities, but I went
anyway to the Microbiology Laborator y. Local staf f treated me gently,
although they had possibly not been notified of my arrival in advance.
As I had never been dispatched to a laboratory department until that time,
the current status of laboratory services in Bhutan was unclear. Therefore, I
visited the BHU (Basic Health Unit) and Wangdicholing Hospital in the
Bumthang area, in addition to JDWNRH as the largest medical institution in
Bhutan and main base for my activities, to collect information.
During my stay, I mostly worked in the Microbiology Laborator y of
JDWNRH. The Microbiology Laboratory consists of 4 sections: SerologicalTest, Parasitology Test, General Bacterial Examination, and Mycobacterial
Examination. I was assigned to the Section of General Bacterial
Examination. Similarly to those in Japan, my duties included: culture media
preparation, Gram staining, cultivation, colony picking, and identificationand susceptibility tests. However, unlike in the Department of ClinicalLaboratory of Kyoto University Hospital, most procedures were manually
performed. On the other hand, SOPs (Standard Operating Procedures) were
well-established, and external accuracy management was performed basedon the PPTC Quality Assessment Programme. WHONET had also beenused to enter test results and print them out since 2015.
Specimens were transported from wards, and collected after the terminationof outpatient ser vices by ward staff. In some cases, they were directlyreturned by patients themselves or their families. As test results were notshared using online systems, it was necessary for ward staff to receive ward
patients’ results at appropriate times. In the case of outpatients, patientsthemselves or their families had to visit the Outpatient Reception or
Department of Laboratory Medicine to receive their results.
In such an environment, I realized my dependence on equipment in Japan inwhich systems are frequently automated. As I was unaccustomed to manual
procedures, local staff taught me various points while working together.
Actually, there was much more for me to learn from their enthusiasm andsincere attitude toward their duties despite insufficient equipment andhuman resources than to teach them.

On the other hand, in 2015, the use of software WHONET star ted,
facilitating the development of antibiograms with extensive data. In line with
this, analysis to use such data in clinical environments was launched.
However, as patient identification numbers are not used for patientmanagement, it may be difficult to collect detailed data, such as thoseregarding a single specimen of a single patient. They were also considering
electronic medical recording system use in the future; such systems may
enable them to perform patient identification procedures more appropriately
and perform higher-accuracy analysis.
In Wangdicholing Hospital located in the Bumthang area I visited, there
were 3 medical technologists, including 1 Japan Overseas Cooperation
Volunteer. Being shy, Bhutanese technologists did not ask me anything
directly, but the Japanese volunteer told me that they were eager learners,
and they wanted to discuss various issues with me. I also heard that a staff
member in charge of Papanicolaou staining in the Depar tment of
Gynecology was ver y eager to meet the Japanese medical technologist
dispatched from the Department of Diagnostic Pathology with me.
JDWNRH is the highest-level medical institution in Bhutan. In order tocontribute to medical services in this country, it may be effective to support
technologists working in prefectural hospitals, as a few are assigned to eachof such hospitals.
It may also be necessary for Kyoto University Hospital to invite Bhutanese
staff for training, and provide them with the opportunity to observe actuallaboratory services in Japan.

Impressions
Bhutan is a country with abundant nature, located at the eastern end of theHimalayan mountain district and based on GNH (Gross National
Happiness). I had been looking forward to visiting it ever since I initially
heard of this dispatch plan. I became anxious when contact with the local
coordinator was interrupted, but local staff treated me gently and kindly
after receiving me warmly.
Even before departure, I had been supported by many people. For example,
explanatory meetings and gatherings for communication with previously
dispatched team members were held for me. I would also like to express mygratitude to my colleagues for sending me off agreeably despite their busy
schedules. Although the period was limited, I could spend enjoyable andproductive days. Thank you.

Challenges and problems
I noted insuf ficient specimen preser vation and culture media storage
periods, as well as inappropriate bacterial strain storage, fungi-, andanaerobic culture methods, presumably due to limited budgets andequipment. There were also occasional reagent shortages, indicating thenecessity of storage management to ensure stable supply throughout theyear. However, it seemed to be difficult to resolve this, as medical supplies
are inevitably imported from other countries, and delivery times influencesuch supply.
Furthermore, in order to implement standard precautions on a facility-widebasis, it may be necessary to improve the layout of the laboratory, as somepatients or their families unintentionly entered it when submitting their
specimens or receiving test results. While limited budgets should also be
considered, the implementation of feasible improvement plans may benecessary.

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Kyoto University Hospital
Department of Infection Control and Prevention

Report of the activities of the seventh team
Term: February 2 ‑ 29, 2016

Graduate Fellow/Doctor
Department of Infection Control and Prevention

Yasuhiro Tsuchido
Content of activity
Representing the Depar tment of Infection Control and Prevention, I
performed activities for 1 month to comprehensively evaluate the current
status of infection-related services in JDWNRH. In the absence of domestic
doctors specializing in infectious diseases, a clinical microbiologist had
belonged to the hospital, and participated in the infection control team (ICT)
until the last year. When I was dispatched, he was absent to study abroad,and ICT activities were being per for med by nurses and medical
technologists in charge of bacteriological examination. Thus, during my stay,
I mainly obser ved the duties of medical technologists in charge ofbacteriological examination, and participated in ward ser vices, such as
rounds made by the Department of Internal Medicine, to clarify the statusesof their bacteriological examination and infectious disease treatment/
infection control systems
According to the data collected by the WHO, lower respirator y tract
infection was the third leading cause of death, at 6.5% (the first and second
leading causes were ischemic heart and chronic obstructive pulmonar ydiseases, respectively, at 8.2 and 7.3%, respectively) in 2012 in Bhutan. In
actual inpatient settings, the incidence of pneumonia was also markedly
high. Similarly, based on the statistics published by the organization,
tuberculosis had also been a problem in this country, as its incidence of per
100,000 persons was as high as 190. In line with this, there were increased
concerns over multidrug-resistant tuberculosis that was observed among 2.2
and 35% of patients with new onset and recurrence, respectively. Multidrugresistance was also a serious issue in the area of general bacteria, and theMinistr y of Health had begun to adopt countermeasures against drugresistant bacteria.
Regarding multidr ug-resistant bacteria, accurate data were not yet
sufficiently available, as appropriate examination or surveillance had notbeen conducted up until that time. Based on the antibiograms (antibiotic
sensitivity test results) obtained during my stay, while the prevalence of
MRSA remained at 20%, nearly half of E. coli and Klebsiella spp. were notsusceptible to third-generation cephalosporins, suggesting high-level
resistance to ESBL and other antibiotics. However, as ESBL- or carbapenemresistance tests were not conducted in the microbiology laboratory, they
were not recognized as drug-resistant bacteria. A similar situation wasobser ved on wards with poor infection control. Furthermore, althoughcarbapenem-resistant Enterobacteriaceae (CRE), multidr ug-resistantPseudomonas aeruginosa, and multidrug-resistant Acinetobacter spp. weredetected in some cases, their prevalences were likely to have been
underestimated, as sensitivity examination was not conducted for all
antibiotics in all cases. In short, the prevalence of drug-resistant bacteria washigher than expected. In addition, in the area of tuberculosis, only smearpositive specimens were targeted for culture, and data related to smear or
culture sensitivity were not appropriately shared, indicating the presence ofvarious systematic problems.

Challenges and problems
In the Department of Internal Medicine, there were a large number of
inpatients with community-acquired pneumonia, and common infectious
diseases, such as urinar y tract infection and cellulitis, were occasionallyobser ved. Local staff’s policy on antibiotic use for community-acquired
infection was reasonable, but the examination of fever among inpatients wasinsufficient (only a single set of blood culture; blood collection was even not
performed in some cases), and antibiotics were extensively administered,revealing non-compliance with the principle of identifying infected organs
and microbial pathogens. The implementation of cleanliness procedures was
also insufficient; for example, during central venous catheterization, only

sterilized gloves were worn without gowns.
Regarding countermeasures against drug-resistant bacteria, as previously
mentioned, such bacteria were frequently overlooked, as appropriate
examination was not conducted in the microbiology laboratory. On the other
hand, the purchasing of new examination devices was being considered to
improve the situation. On wards, hand-washing equipment was limited, but
alcohol solutions to disinfect the fingers were sufficiently stored (although
staff’s compliance with the hand hygiene process was insufficient). Drugresistant bacteria-carriers were not appropriately isolated, and preventive
measures against contact transmission were rarely implemented. The
prevention of tuberculosis transmission through the air was also a major
challenge. The tuberculosis ward was located at some distance from otherwards on the premises; however, it was not managed under negative
pressure. Windows and doors were left open, while patients used N95
masks, rather than surgical masks, indicating the absence of appropriate
preventive measures. Medical device sterilization and disinfection were also
insufficient. In addition, cotton was soaked in alcohol before use. In order toaddress such a large number of challenges, it may be necessary to initiallyestablish appropriate systems for the identification and reporting of drugresistant bacteria, as well as infection control and surveillance in medical
services, with a view to comparing between before and after intervention.

Future perspectives
From the viewpoint of infectious disease treatment and infection control,
dispatching doctors specializing in infectious diseases to provide education
regarding infectious disease treatment, infection control doctors (ICD) andnurses (ICN) to provide education for infection control improvement, andmedical technologists specializing in bacteriological examination to establish
appropriate bacteriological examination systems (to manage both generaland acid-fast bacteria) may have sufficient significance, and local staff’s
demand for this seemed to be high. In order to provide infection control
education for local staff, it may also be appropriate to invite them to Kyoto
University. With system improvement in multiple medical departments, it islikely that the importance of infectious disease treatment and infection
control will further increase in the future.
While the provision of guidance for local staff by dispatched members as
human resources is important, the review and improvement of infectious
disease treatment and infection control systems from more extensive
perspectives are also essential. As medical costs are fully covered as anational expenditure at present, cooperation with the Ministry of Health andGovernment is indispensable to ensure the availability of necessary drugs,in addition to the feasibility of examination/surveillance. During my stay, I
had the oppor tunity to hold a brief discussion with the person of the
Ministr y of Health in charge of countermeasures against drug-resistantbacteria. From now on, continued discussions with not only JDWNRH, butalso the Ministry of Health, to address major challenges such as: improving
methods to examine general and acid-fast bacteria and systems to report theresults of such examination, as well as surveillance systems; determining
policies on the approval of antibiotics; and ensuring the availability ofsufficient manpower for infection control and supplies, may be necessary.

Impressions
I found daily life and medical services in Bhutan unexpectedly advanced insome aspects, and amazingly simple in others. In short, a 1-month stay inthis countr y was a ver y exciting experience for me. Although I initially
doubted whether it is appropriate to help the “Nation of Happiness” for theadvancement of its medical systems, the provision of support may havesignificance as long as JDWNRH staff and the person of the Ministr y of
Health in charge desire improved infection control.
This stay was also productive for me personally in terms of knowledge andskills, enhancing my motivation to participate in medical support activities
again in Bhutan or other countries if given the opportunity. Lastly, I would
like to express my sincere gratitude to those involved of Kyoto University
and JDWNRH for giving me such a valuable opportunity, as well as doctors
and other members of the Department of Infection Control and Prevention
who agreeably sent me off.

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Jigme Dorji Wangchuck National Referral Hospital

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Kyoto University Hospital

Report of the Activities in Bhutan
10. Our Exchanges
develop medical service. At the same time, I stated out expectation

Dean of the Graduate School of Medicine andthe Faculty of Medicine, Kyoto University
Prof., Department of Hepatobiliary
Pancreatic Surgery and Transplantation

for the Kyoto University Hospital's global progress based on the
career development of the medical staff dispatched from Kyoto
University Hospital thr ough the experience of working
internationally. In the afternoon, we learned about the traditional

Shinji Uemoto

medicine taught at the University of Medical Sciences of Bhutan. (ItIn the evening of October 28, 2013, I departed from Kansai Airportthat it is more advanced.) It is a profound study backed with a longas the leader of the 1st team to the Kingdom of Bhutan, and thenhistory deeply related to the Tibetan Buddhism, and the students

arrived at Paro Airport in a surprising valley. On the day of ourappeared to be very talented individuals who were specially chosen.

arrival, the president of the University of Medical Sciences ofAt night we were invited to a welcome party around a bonfire on

Bhutan as well as other people from the university visited us andthe university campus. We enjoyed the spicy Bhutanese dishes,

explained to us the schedule of our stay in Bhutan. I went to bed

strong Bhutanese original whisky, folk music, and folk dance.

quite early at night, but I woke up surprised by the howling of dogs

The next day we were guided to clinics in mountainous region andat midnight. I had heard that in this countr y of ver y religious

Buddhist institutions, where we felt the feelings of gratitude held byTibetan Buddhism, killing is forbidden and it has led to an

the people of Bhutan. Even in a humble state, I felt that the care,increasing number of dogs, but the howling in big chorus at

including the minimum required medical care, provided for eachmidnight was a surprise in Bhutan. On the next day, we signed an

citizen in this country, provides a sense of security which support

MOU at the royal hospital. The MOU between three par ties,

happiness. I believe that we can learn many things from thenamely the Ministry of Health of Bhutan, the University of Medical

Kingdom of Bhutan while continuing our support for educating

Sciences of Bhutan, and Kyoto University Hospital, states

medical staff in Bhutan.

is similar to the Sino-Japanese traditional medicine, but I believe

promotion of mutual exchange involving medical care and medical
research. The people of Bhutan spoke about the long history offriendship between Kyoto University and the Kingdom of Bhutan indisaster prevention and agriculture, and gave a message ofgratitude concerning the eventual collaboration in the medical field
thanks to the effort of Prof. Michiaki Mishima, the director of the
Kyoto University Hospital then. I spoke about Kyoto University
Hospital's plan to provide help in introducing clinical training
system for medical school graduates in Bhutan as a starting point
for helping the Kingdom of Bhutan train doctors in the country and32

From left in the ﬁrst row: Dr. Pakila Drukpa (Registrar, Secretariat, University of Medical Sciences of Bhutan), Mr. Nima Wangdi (Secretary, Ministry of Health),
Prof. Shinji Uemoto, Mr. Tandin Wangchuk (Minister, Ministry of Health), Dr. Kinzang P. Tshering (President, University of Medical Sciences of Bhutan)

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Kyoto University Hospital

Report of the Activities in Bhutan

CONTENTS

1. Message from the Director - Prof. Nobyua Inagaki - ……………………………………………………… P1
2. Message from the ex-Director - Prof. Michiaki Mishima - ……………………………………………… P1
3. Clinical Practice and Field Medicine in Bhutan - Prof. Kozo Matsubayashi - ………………………… P2
4. Contribution
Dr. Kinzang P. Tshering President, Khesar Gyalpo University of Medical Sciences of Bhutan - … P2
5. Message from Chairperson, KUH-Bhutan Medical Exchange Working Gzroup- Prof. Shuichi Matsuda - ……………………………………………………………………………………… P3
6. Message from Chairperson, KUH-Bhutan Medical Exchange Subcommittee- Associate Prof. Hideaki Okajima - ………………………………………………………………………… P3
7. Outline and the Condition of Medical Service in the Kingdom of Bhutan - …………………………… P4
8. Kyoto University Hospital Delegation ………………………………………………………………………… P5
9. Reports of Activities in Bhutan - ……………………………………………………………………………… P7
1st team - Department of Hepatobiliary Pancreatic Surgery and Transplantation - ……………………………… P8
1st and 2nd teams - Sae Maeda, Nursing Department - ……………………………………………………………………………………………… P9
1st and 3rd teams - Kanami Muramoto, Nursing Department - …………………………………………………………………………… P10
2nd team - Department of Surgery - ……………………………………………………………………………………………………………………………………… P11
2nd and 3rd teams - Department of Gastroenterology and Hepatology - ……………………………………………………… P12
2nd team - Yoko Takahashi, Nursing Department - …………………………………………………………………………………………………… P13
3rd team - Department of Urology - ……………………………………………………………………………………………………………………………………… P14
3rd and 5th teams - Ayuko Ishii, Nursing Department - …………………………………………………………………………………………… P15
4th team - Department of Nephrology - ……………………………………………………………………………………………………………………………… P16
4th team - Department of Pediatrics - …………………………………………………………………………………………………………………………………… P17
4th and 5th teams - Yoko Nishi, Nursing Department - ……………………………………………………………………………………………… P18
5th team - Department of Orthopedic Surgery - ……………………………………………………………………………………………………………… P19
5th team - Department of Cardiovascular Medicine - ………………………………………………………………………………………………… P20
6th team - Department of Primary Care and Emergency Medicine - ………………………………………………………………… P21
6th team - Clinical Radiology Service Unit - ……………………………………………………………………………………………………………………… P22
6th and 7th teams - Department of Respiratory Medicine - …………………………………………………………………………………… P23
6th team - Shizuoka Childrenʼs Hospital - …………………………………………………………………………………………………………………………… P24
6th team - Ai Matsuyama, Nursing Department - …………………………………………………………………………………………………………… P25
6th team - Ikumi Ueda, Nursing Department - ………………………………………………………………………………………………………………… P26
7th team - Department of Diagnostic Pathology - ………………………………………………………………………………………………………… P27
7th team - Department of Otolaryngology - ……………………………………………………………………………………………………………………… P28
7th team - Microbiology Laboratory, Department of Clinical Laboratory - ………………………………………………… P29
7th team - Department of Infection Control and Prevention - ……………………………………………………………………………… P30
10. Our Exchanges- Prof. Shinji Uemoto, Dean of the Graduate School of Medicine and the Faculty of Medicine - … P31

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Kyoto University Hospital

Report of the Activities in Bhutan
October, 2013 ‑ March, 2016

Published in March, 2016
Oﬃce of Secretarial Work and Information Service
Kyoto University Hospital
54 Kawaharacho, Shogoin, Sakyo-ku, 606-8507, Japan
TEL : +81-(0)75-751-4334

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Kyoto University Hospital

Report of the Activities in Bhutan
October, 2013 ‑ March, 2016

MoU Signing Ceremony, October 29, 2013

Kyoto University Hospital

54 Kawaharacho, Shogoin, Sakyo-ku Kyoto,606-8507, JAPANTEL : +81-(0)75-751-3111 (Reception)

京都大学医学部附属病院

Kyoto University Hospital
KYOTO UNIVERSITY FOUNDED 1897

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