Working in Bhutan

It has been a while since my last post as I have been busy preparing for the RANZCOG ASM here in Auckland. I am on the organising committee and at last count had 4 talks and three sessions to chair!
I am talking on a project that I was lucky enough to get funding for in Bhutan- a small country in the Himalayas. As part of this I went to Bhutan in 2006 for 3 months with my family. It was an amazing experience and the work I was involved in is still continuing with increased uptake of ultrasound scanning by women. Below is a report I wrote for ASUM (Australasian Society of USS in medicine):

ASUM report on Magee Family project- Development of Perinatal Services for Bhutan
Dr Emma Parry FRANZCOG

I am an obstetrician from Auckland who is lucky to be involved in a project to improve perinatal outcomes in Bhutan. Bhutan is a small Buddhist Kingdom in the Himalayas with a population of around 600,000, which has high maternal and perinatal mortality. From April to July this year I went to Bhutan with my husband and two children to work in a number of areas of the project, the main one being ultrasound training.
In Bhutan there are no formally trained sonographers. There is one Obstetrician with training in high-risk obstetrics and ultrasound - Dr Phurb Dorji who spent 18 months at National Women’s hospital in Auckland, New Zealand. He is the main resource in obstetric ultrasound in the country. There are 5 other Obstetrician and Gynaecologists, though none with an interest in ultrasound.
Bhutan has a free health system, with 3 referral hospitals, around 12 district hospitals and a large number of Basic Health Units. The geography is a major challenge, it takes 3-4 days to travel from one end of the country to another although it is only around 600 km, and around 40% of the population are more than one hours walk from a road.
In the district hospitals some ultrasound scanning is available and is performed by 12 X-ray technicians. These technicians have formal X-ray training. They are then selected for further ultrasound training. This entails observing scanning for 3 months in India, with no formal teaching or hands-on experience. They then return home and start scanning and in most cases there is no support or supervision.
Within the project, provision has been made for formal sonographer training and currently two former X-ray technicians are in India part way through a formal two-year training programme.
Whilst I was in Bhutan I ran two 4-week training courses for all the X-ray technicians. As half came to the capital (Thimphu) for four weeks, others went out to the busiest units from Thimphu to provide the ultrasound service whilst their colleague was on the course. This way all technicians were able to attend.
The number of years spent scanning ranged from 1 month to 8 years. This meant there were some hard habits to break! All the technicians were keen and enjoyed having the first ever formal teaching in ultrasound. At the start of the course all the students were given an MCQ-, which they all failed! This was given to them again at the end of the course.
The course comprised of daily lectures from 9:00 until 10:30. Topics included physics of ultrasound and Doppler, which were kindly given by my husband- Dr Dave Parry- who is a medical physicist. I gave lectures on early pregnancy, dating, biometry, assessment of fetal wellbeing, Doppler and gynaecological scanning. I also gave a brief lecture on anomoly scanning and Dr Phurb Dorji gave lectures on fetal anomalies. We didn’t expect the students to be able to do anomoly screening, but hoped that they would be able to identify major anomalies so that decisions could be made about where to deliver and transfer for a second opinion to Dr Phurb Dorji as necessary. One needs to bear in mind that some of the units are a two-day drive away!
After the lecture the students split into two groups of mixed ability. Some went to the main hospital scan department where there were two machines. General scans, gynae and early pregnancy scans were done here. The other half went to the maternity outpatients where obstetric scanning was performed. As part of the project a portable ultrasound machine had been purchased- a Terason- and taken to Bhutan in our hand luggage! This machine proved to be excellent and we were able to have this and the small Aloka in the maternity outpatients, so two students could scan at once in both sites. I swapped between the two sites and provided hands-on supervision, which the students quickly got used to. Students were encouraged to critique each other whenever not being directly supervised by Phurb Dorji or myself.
Students kept a logbook and at the end of each week we reviewed their progress and range of cases. In the last week a series of tests were held including a practical exam. The MCQ was run again on the penultimate day. All twelve students passed the final exam and all improved! Student feedback was very good and despite having to come to Thimphu for a month they all really enjoyed the course.
Part of the concern is the ongoing lack of supervision and collegiality. We provided a number of support materials and are trying to maintain contact with the students via email. Thanks to ASUM, we were able to provide an excellent physics CD-rom for them free of charge. We very much appreciate this generous contribution.
Lessons learned:
• Linking theory and practice is important
• Relatively short interventions appear to be successful
• Both parties learn a lot from these activities

Also, Dave Parry (my husband and co-developer) has placed all our materials we used for the project on a server if you wish to use them. Please feel free to use, though we'd appreciate a mention and any feedback!

http://elena.aut.ac.nz/homepages/staff/Dave-Parry/docs.html

Emma