Tashi Delek

I did not know what would lie ahead of me in Bhutan, but I did know that my decision was made with certainty. While I looked forward to sharing my knowledge as a physical therapist instructor in a developing country, I was especially intrigued by the mystery surrounding Bhutan. The prospect of living in a Buddhist kingdom at the foothills of the Himalayas was surreal. With intuition as my guide, I turned this prospect into my reality.

I feel so fortunate to have had the opportunity to spend time in this serene land with its gentle people. More than anything, I am so grateful for my life to have intertwined with the that of eight very special individuals ... while I taught them the scientific basis of evaluating and treating patients, they taught me that love is the foundation of healing. I helped them discover ways to study more effectively; they helped me discover ways to trek across mountains. I shared with them stories of my family and friends in America; they shared with me stories of their walks from the roadpoint to their villages. Many of my most treasured moments in Bhutan are those I enjoyed with my physiotherapy students ... Drukpa, Kinga, Sonam, Tshering, Lhakpa, Needup, Kuenzang, and Kinzang. They brought a smile to my face every morning, and a light upon my soul that will continuously shine.

Living in a remote country halfway across the world came with challenges, but being outside of the box is where the most growth can occur. In addition to my students finding a permanent place in my heart, the relationships I developed with hospital volunteers, co-workers, and locals blossomed into beautiful friendships, some of which I know will be lifelong. Walking through the Himalayan Hills deepened my appreciation of nature. Spinning prayer wheels at dawn gave me inspiration to continue on my path of spiritual study with greater dedication. What might life be like, if guided by the soul rather than the ego?

The dynamics of life are powerful, and again it is time for me to transition. Two new volunteers have arrived here in Bhutan. Their levels of enthusiasm are contagious and they have the biggest of hearts ... I know it is now their turn to serve as this country's physiotherapy mentors and experience the unique wonders of Bhutan. My journey will now take me to India to study at an ashram prior to beginning the next phase of my life in San Francisco. My time spent healing in the Himalayas was surreal. I hope to bring the magic of Bhutan with me wherever I go, and in whatever it is my heart leads me to do. Reflecting upon what the purpose was in coming to Bhutan as a volunteer physiotherapist instructor, I know there was not just one reason ... there were eight.

Thank you for sharing my life in Bhutan with me. Please email me at bernadeta@gmail.com if you would like to continue to follow the written tales of my travels to India and beyond. Tashi Delek (blessings and good luck).

Pictured above, from left:
My first year students - Drukpa (always with a clever smile on his face), Kinga (so gracious and humble), Sonam (so loving and graceful), and Tshering (so clever and hard working).
My second year students - Lhakpa (dedicated and compassionate), Needup (very smart and balanced), Kuenzang (so eager to learn and appreciative), and Kinzang (with such a sweet, gentle soul).

Picknicking with the Physios

I have never seen a stroller in Bhutan. Babies are carried on the backs of their older siblings, parents, and grandparents everywhere they go. "Barra," my student, Sonam, told me this act was called. As soon as I arrived to the JDWNR Hospital Physiotherapy Department picnic, 3 women immediately carried Jitson over to show me how one day I should use a scarf to fasten a baby on my back!

Last minute planning is not uncommon in Bhutan. I learned about this picnic Sunday morning at 7:30am through a wake up call from my student, Lhakpa. "Madam, are you ready for the picnic? We've gathered here at the hospital." Am I ready?! Of course I'm not ready! I'm still in bed! Showered and dressed by 10:00am, Heather and I joined the other physios who overslept or were also unaware of the picnic until the morning of, and together we wound up the mountain to reach Hongtsho.

Stepping onto an open area of the forest that had been transformed into our picnic grounds, I quickly recognized why 7:30am had been the call time. Marking the center of our land, a pile of heavy stones supported the logs that had just been chopped off of the surrounding trees. Ablaze with fire, cauldrons were set atop our man made stove, boiling water fetched from the nearby river. People were in action everywhere! Kneeling over pages of newspapers, one physio set out slices of onions and chili while another chopped asparagus. Carrots and cucumbers were peeled, cut, and tossed into a bucket to mix together for a fresh salad. Aloo dum (potato curry) was in the making as people grated ginger, chopped garlic, and heated soyabean oil to richly combine the ingredients with a nice saute. Having been boiled over the fire, cha (tea) together with sweet biscuits were offered around as we chatted and prepared the lunch.

We feasted on a variety of traditional Bhutanese dishes. Some enjoyed beef curry, dried fish, and eggs hard boiled then fried, and others preserved vegetarianism with rice and vegetable/cheese curries. I was thankful to have been advised ahead of time to bring my own plates and cutlery, but could have eaten off of the lids to pots with my hands just like some of the Bhutanese!

As we picknicked, natural incense (branches of trees lit with fire) sent smoke signals into the sky "to keep God happy", and students chanted prayers to keep the rain away. The fire pit continued to burn, and music began to play. Tunes of rigzar (contemporary Bhutanese music) set the stage for the women to dance freestyle while the men stepped aside for games of rock throwing and football.

Giggling and taking silly videos of one another, we took turns leading dances prior to persuading the men to join us. Coming together in a large circle, rigzar was replaced by traditional Bhutanese folk music. Holding hands, we sang and danced the afternoon away. Translations of the songs revealed messages of karma, reincarnation and goodwill to all. Slowly the circle opened and we shifted over to the fire, where we closed it hand in hand. One by one, my co-workers took turns speaking and dedicating this celebration to Heather and me in recognition of our volunteer work at JDWNR Hospital. Sanga, Head of the Physio Department and baby Jitson's father, played a farewell song on his wooden flute marking the end of our picnic. The wind gently carried the tunes up into the sky, and serenity was within and all around me. It was then that I realized this was only the beginning of my lifelong connection to the country of Bhutan and her beautiful people. My darling students asked that I return to Bhutan someday, and suggested that I come with a baby on my back!

(Photo snapped by Sonam Wangmo).

The Art of Healing

Over the last four months, I have been humbled by a physiotherapy student who has touched my heart in every way. At the age of 11, Lhakpa woke up one morning and was unable to see. While the cause was unknown, the result was clear. He had become blind.

Physiotherapy is the means through which Lhakpa has chosen to live his life for the purpose of serving others. Today, through my observation of a patient examination session serving as a test to determine his continuation in the physiotherapy program, I came to see what truly forms the core of effective physiotherapy practice. Dedication and compassion for all human beings is at the root of healing.

I was told on my first day at JDWNR Hospital that I would be teaching a student who is blind. I was initially shocked, and in time became worrisome and even fearful. How would I guide a young man with a visual impairment to effectively become a physiotherapist? With observation of movement at the core of my practice, how could I modify my practice and expectations to meet his needs?

Over the last four months, Lhakpa and I have developed a special relationship. He has taught me that the sense of touch is powerful, and perhaps even more revealing than the sense of sight. Lhakpa has taught me that individuals who are visually impaired can effectively join the health care profession, taking their patients to levels above and beyond what the average practitioner might be able to do. Lhakpa has demonstrated the ability to develop a rapport with his patients, to establish assessments that link their health conditions to their desired roles in life, and to design effective treatment programs. While science is the foundation of physiotherapy, the ability to connect with patients and understand movement strategies through physical contact is the true conduit to healing. Lhakpa has taught me that the art of physiotherapy lies within the heart of the clinician.

I feel so blessed to have become connected with Lhakpa, and am grateful for the renewed sense of dedication and inspiration he has given to me. Upon completing (and passing!!!) his practical examination, Lhakpa left me with these words ...

Respected madam,

I am not feeling depressed eventhough as i being a disabled boy for having such a great and kindness teacher in my life....

"ONLY MADAM YOUR THE ONE" who realy concern about me to make me independent as of being disabled thank you madam and when i come across this words I can't tolerate shedding tears from my eyes.

I beg madam to keep on touch with me for ever and ever and guide me through this profession.

"WITH WARM REGARDS"
Lhakpa Dorji

Healing in a District Hospital

I have been blessed for many years with an exceptionally talented physical therapist mentor. She provides her patients with just the right amount of challenge while guiding their movements in ways to instill confidence. Regained walking patterns, ability to reach for objects, and a newfound faith in themselves is the result. She encourages her students to find ways to provide patients with these "aha" moments ... moments when the patients experience that that they have performed a movement correctly, and if repeated in that fashion, will help them reach their goals and attain higher quality of lives.

I think I had my own "aha" moment while volunteering my services at the Punakha District Hospital. I found in Phuentsho, the one physiotherapy technician at this 40bed hospital, a burning desire to learn fueled by compassion for others. We saw several patients, and together I believe that each one is one step further on the road to their emotional and physical recoveries.

I've always had a soft spot for the elderly, and the patient in Bed A of the Intensive Care Unit stole my heart. Frequently admitted to the hospital for respiratory problems, Phuentsho has come to know this patient well. The patient looked quite pleased upon Phuentsho's arrival to the Unit, and reported compliance with the exercises Phuentsho had prescribed to aide him in his breathing capabilities. He reported that his family was coming to take him home, and he would be able to continue on his own with the physiotherapy.

A beautiful young woman entered the physiotherapy gym, heavily supported by the two nurses aiding her. Phuentsho and I reviewed the physio referral: "Inability to Walk due to Emotional Distress." During the subjective interview, we picked up on signs suggesting the possible presence of a psychiatric emergency. Discussing our findings with the head nurses, they came to agree with our findings. We requested the patient be transferred to Thimphu, where the 2 psychiatrists in Bhutan are posted. The nurses stated that every moment of the day, they are making the effort to demonstrate to her how much she is cared for and loved. Eventually she can be transferred to Thimphu, but what she needs now, is love ...

Originally from Nepal, a middle aged man was admitted to the hospital over one year ago. Given that this patient has no family in Bhutan, the Punakha District Hospital has allowed him to remain in the hospital as long as necessary, with government allottments and international donations funding his stay. With a progressive decline in his ability to walk, the patient now spends the majority of his time lying in bed. MRI and CT, imaging tests often used to aide in establishing diagnoses for patients, is unavailable outside of Thimphu. Upon presenting this patient's case to me, Phuentsho reasoned that he must have a cerebellar disorder due to intact strength with poor balance. We discussed additional tests he might perform to further aide in the diagnostic process, which would then target his treatment and help determine the patient's potential for recovery.

Observing Phuentsho's interactions with his patients renewed my own dedication to my physical therapy practice. A technician with less than one year of experience who has been working 100% independently since graduation, Phuentsho's patients are in extremely good hands...

"There was a foreigner here once before ..."

A day's journey brought me to the town of Gelephu, where a 60 bed regional hospital serving the population of Southern Bhutan was the site of my students' 2 week long clinical affiliations. Stepping off of the Bumpa Coaster without a clue as to where I'd stay that night or how I'd find my students or the hospital the next day, I discovered that a 2 minute walk oriented me just fine to this small town. I checked into a hotel and sat down with the owner to enjoy a cup of coffee and offer my advice regarding his father's recovery after having suffered a stroke several months back.

The following morning I was welcomed to the Gelephu Hospital with warmth and a bit of wonder. Travel to this region of Bhutan was opened up to foreigners a few years ago, but history of political unrest, conflicts with neighboring India, and a lack of tourist attractions has kept nearly all ex-pats and tourists away. However, my week in Gelephu was full of some of the most rewarding experiences I've had thus far in Bhutan. Together with my students, I evaluated and treated patients with diagnoses and clinical presentations I was very familiar with. I taught my students techniques to reduce shoulder pain in a middle aged woman from a nearby village who had sustained a stroke, and my students taught me how to use a simple scarf to function as an arm sling (note to all the PT's out there: try this! Scarves can easily be tied over the arm to give support, but even more importantly, maintain scapula retraction and humeral external rotation ... economical and much more effective than a givmor!). However, I was also faced with the challenge to work on patient cases I had never seen or heard of before. I was stumped when two young women entered the clinic, heavily aided by their husbands and walking sticks, with diagnoses of "post-partum neuropathy" lending to the inability to walk following labor and delivery. Evidently this is a condition not uncommon to Bhutanese women, and my research regarding possible causes of it has begun in earnest.

The time I spent treating the local villagers with my students was productive from a clinical standpoint, and I was grateful to have bonded with them on a personal level as well. One day after work they showed me to the town's main attraction, a fishing pond complete with a piggery. I felt a profound sense of peace as the sun was setting, being surrounded by the beauty of this land and having been given the opportunity to get to know my students on a deeper level. We talked about our personal lives and perspectives on various issues in Bhutan and America. Caught in the middle of apprecation and struggle though, I couldn't stave off the repeated question going through my mind ... "Bernadette, what are you doing at a fishing pond that could be full of mosquitos in a malaria infested area when you are not on malaria pills?!" I guess I'm still working on how to be at ease and let things go ... or, am I warranted in just asking myself logical questions???

My last afternoon at the hospital was spent enjoying tea and cake with the physiotherapist and hospital administrator. "There was a foreigner here once before ..." they mused, but without being able to recall any additional details, officially thanked me for being the first foreigner to volunteer my time at the Gelephu Hospital. I was invited to return, and if I can find some malaria pills, then I just may! Despite the lack of hot water, bugs in the hotel rooms, and difficulty digesting food from the local restaurants, the opportunity to treat these patients in Gelephu would undoubtedly make this experience worthwhile once again.

"Good Morning, Miss!"

“Good Morning, Miss!” was quickly replaced with the Bhutanese greeting of “Kuzuzangpo La” as soon as I requested that my 1st year physiotherapy technician students provide me with a Dzongkha word of the day. Adding a “la” and bowing, the students show me respect every time they see me. I have immediately taken a liking to each and every one of them, and look forward to this semester together.

Drukpa, Sonam, Tshering, and Kinga had received the appropriate merit marks in grades 11 and 12 to attend the Royal Institute of Health Sciences. They were given a list of approximately five areas of study appropriate for them to pursue, and they have chosen physiotherapy. Not being able to explain what physiotherapy is upon being questioned of this, my students’ first homework assignment was to come back the next day and explain what this profession is that they’ve entered school for! They are quickly picking up on the roles physios have in healthcare and appear to be enthusiastic about their future profession the more they learn about it.

While the four physiotherapists in Bhutan received government scholarships to attend university in India, the remaining individuals who work in physiotherapy are considered technicians. Upon completing this two-year program, the techs will either stay to work at the National Referral Hospital, or more likely, will be transferred to the district hospitals throughout the country where they must evaluate and treat patients independently. Thus, the goals for these students in the technician program currently taught by myself as well as two of the local physios are lofty. I’m excited to have the opportunity to teach the students within their first clinical semester in order to help establish the fundamentals of physiotherapy. We discuss the roles in life patients have, and how as physios or physio techs we decrease pain, enhance mobility, and improve quality of life.

On our first day of class, the students presented themselves in a very formal manner and took seats opposite me at the cold, square table in a room adjacent to the outpatient physiotherapy gym. However, after inviting them to join me next to the space heater, we’ve bonded over viewing either my laptop screen or a piece of paper I’ve handwritten that day’s objectives and key concepts on while sitting in a very tight circle with one towel spread over the heater and each of our laps. The students rarely receive handouts in school due to shortage of printers and copiers, and are thrilled to be able to take home the paper I’ve prepared to make copies for one another as study aides. We’ve also bonded over stories of our families, songs about California, and the similarities and differences between the trees in Bhutan and Muir Woods after viewing pictures on my computer. Needing to prepare this week’ss lessons now, I look forward to seeing Tshering, Sonam, Drugkpa, and Kinga, as well as meeting my class of 2nd year students tomorrow ... and, learning the next Dzongkha phrase of the day!

Dressed in kira and a white coat ...

… the purpose of my visit to Bhutan was revealed in the eyes of the patients before me today. After receiving a nod of approval for being in national dress on my first official day of work, the head surgeon took me under his wing and explained each patient’s case during Orthopedic Rounds. As I became a part of the team of fifteen clinicians caring for these patients, I caught myself demonstrating facial expressions of either absolute shock or sorrow. While being empathetic towards my patients, I also feel that I usually maintain an expression equal to that of my white coat … overall objective, but with a few wrinkles here and there that just make me human …

A 25 year-old male had been in a traffic accident and admitted to the hospital with a broken right leg and an inability to move his left leg. His right leg was put into a cast and was stable, but the etiology of the absent movement in his left leg was questionable. MRI and CT throughout the spine were unremarkable, but EMG/NCS testing for further investigation is not available in Bhutan. The orthopedic surgeon asked the patient’s physiotherapist if he could do any tests to help identify the cause of this patient’s absent leg movement, and as a team we performed clinical tests and hypothesized various causes. The diagnosis is still in question and I look forward to problem solving with the local docs and physios.

As we continued to round on the patients, I learned that it is orange season in southern Bhutan. The next individual before us had been working as an orchard farmer. A fall out of an orange tree had resulted in a broken neck and spinal cord injury. Adequate stabilization of his neck had not occurred during surgery and x-rays revealed continued instability, which could place him at risk for further damage to his spinal cord. This 34 year-old man had to have a halo brace donned, a heavy contraption made up of circular metal rings that connect to rods drilled into the skull, and the outcome appears questionable. After stating this however, the orthopedic surgeon told this patient and the medical team a story of a man from Poland who had once come to Bhutan … this man had a similar injury and used a wheelchair. Despite these conditions, he had been able to find a wife and together they had two children … thus, even in the face of a devastating bodily injury, opportunities can be had in life.

While my senses will need to accustom to the sights and smells that are new to me, I feel honored to be a part of the JDWNRH team. I think that mutual learning took place today. Based on my observations of the patients with spinal injury, I am planning to deliver an in-service on the ASIA scale (a standardized test for individuals with spinal cord injury) and hope this can contribute to the local clinicians' diagnoses and prognoses. What I learned and took home today is that respect, collaboration, and optimism are at the core of Bhutanese healthcare.

(Pictures: Top - Myself dressed in half kira (bottom only) outside of my apartment; Bottom - National Referral Hospital)

“Auntie, Where is my teddy bear?”

Word has spread that there is a new physio in town. Within my first few days of arrival, the owners of the local coffee shop I had begun to frequent for a warm drink and internet access asked if I wouldn’t mind looking at their 2 ½ year old son’s shoulder. They believed his shoulder was giving him pain when his hand was held tightly to protect him from road traffic while walking through the streets. Jigme was sleeping at the time, so the next day when I returned with a little teddy bear, Jigme became my first patient in Bhutan. After evaluating his shoulder using the teddy bear as incentive for him to put his arms in certain positions, I gave his mom suggestions for therapeutic activities to perform with him to reduce his pain. I then handed Jigme the teddy bear to keep, but his mom insisted I take it back, and upon distracting him placed the bear back into my hands. The following day as I was climbing up the stairs to the café, Jigme met me at the top of the stairwell and wouldn’t leave my side … “Auntie, Where is my teddy bear?” Jigme questioned repeatedly while sitting at the table with me. My excuse that he was at home napping didn’t seem to work! For our 1week PT follow up appointment over a latte and internet connectivity, I'll bring the teddy bear back and this time insist Jigme keep it.