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Jigme Dorji Wangchuk National Referral Hospital and Khesar Gyalpo University of Medical Sciences, Thimphu, Bhutan

Bhutan is a rural mountainous country with many remote agricultural communities connected by slowly improving dirt or paved roads, making timely access to emergency care difficult. To help address this challenge, Bhutan has set up a tiered system to access health care, starting with Basic Health Units (BHUs) that are generally staffed by community health workers. The next layer is the district hospitals, which are staffed by medical officers who have completed an MBBS degree followed by an intern year and have a wide range of experience. Lastly, there are three regional referral hospitals, one of which is Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), where the majority of specialized consultants are based. It is currently the country’s only teaching hospital.

The emergency department (ED) was initially established at JDWNRH in 2009 before there were any trained emergency specialists in the country—it was headed by the country’s only neurosurgeon and staffed by medical officers. Since then, the ED has gradually expanded and currently has 4 emergency consultants, approximately 12 medical officers, and nearly 40 nurses staffing 4 resuscitation beds, 13 acute care beds, and the capacity to flex approximately 10 more beds. In 2019, the ED patient census was approximately 45,000. The ED is supported by radiology services including ultrasound, CT, and MRI with frequent use of point-of-care ultrasound in the ED as the initial imaging modality. Critical patients are supported by an ICU, PICU, and NICU, and admission wards exist in medicine, surgery, ENT, orthopedics, OB/GYN, and pediatrics.

Over the years, a number of organizations have supported the ED. Medical volunteers have helped provide educational support through Health Volunteers Overseas, a US-based nonprofit organization, since 2010. Since 2013, the Bhutan Foundation has helped provide resources, equipment, and training.

More recently, formal paths for emergency medical education have been created. In 2017, the Faculty of Nursing and Public Health launched a three-year Emergency Medical Responder (EMR) program with an inaugural class of 20 students. Upon graduation, these medics will provide care in ambulances and as emergency technicians in EDs across the country as the emergency medical services gradually expand to the referral hospitals and potentially the district hospitals.

The ED at JDWNRH provides practical training to the EMR students over their last two years, covering anatomy, pathophysiology, and treatment protocols through a combination of didactic and simulation trainings. For direct patient care, students are primarily posted in the ED and ambulance, where they learn basic procedures—from IV placement to CPR—and assist with all basic patient care in addition to getting hands-on experience with patient assessment and triage.

The ED, with a staff of only four consultants and a regular flow of visiting volunteer consultants, is also responsible for the intern physicians’ education during their six- week posting in the ED. This is arguably the most important posting of their internship, as they are the front line for all medical complaints, from life-threatening emergencies to medication refill, once they are posted medical officers in either a BHU or district hospital at the end of intern year. Their ED posting allows the intern physicians to hone their skills at identifying critical patients, initiating time-sensitive treatments, performing procedures, and stabilizing and transferring patients through a course of regular formal didactic lectures, bedside teaching, simulation, and procedural teaching.

A four-year emergency medicine residency program was launched in July 2018 under the Faculty of Postgraduate Medicine, Khesar Gyalpo University of Medical Sciences, with the inaugural class hosting two emergency medicine residents. The residents partake in three didactic sessions weekly covering the emergency medicine course content over 1.5 years, after which it is repeated in further depth and detail. In addition to staffing the ED, the residents learn through clinical rotations in other departments of the hospital, including ICU, PICU, NICU, internal medicine, surgery, ENT, ophthalmology, orthopedics, OB/GYN, and pediatrics.

As the residency progresses to help standardize learning resources and assessment, it has been supported by the Rosh Review Global Foundation and EM:RAP GO. The program will use the resources from Rosh Review to expand learning and assessment methods.

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