Background: An efficient ambulance service is a vital component of emergency medical services. We determined the emergency ambulance response and transport times and ambulance exit outcomes in Bhutan. Methods: A cross-sectional study involving real-time monitoring of emergency ambulance deployments managed by a central toll-free (112) hotline (20 October 2021 to 20 January 2022) was carried out. Results: Of 5092 ambulance deployments, 4291 (84%) were inter-facility transfers, and 801 (16%) were for emergencies. Of the latter, 703 (88%) were for non-pregnancy-related emergencies (i.e., medical, surgical, and accidents), while 98 (12%) were for pregnancy-related emergencies. The median ambulance response and patient transport times were 42 (IQR 3–271) and 41 (IQR 2–272) minutes, respectively. The median round-trip distance travelled by ambulances was 18 km (range 1–186 km). For ambulance exit outcomes that were pregnancy-related (n = 98), 89 (91%) reached the health facility successfully, 8 delivered prior to ambulance arrival at the scene or in the ambulance during transport, and 1 had no outcome record. For the remaining 703 non-pregnancy deployments, 29 (4.1%) deployments were deemed not required or refusals, and 656 (93.3%) reached the health facility successfully; 16 (2.3%) died before the ambulance’s arrival at the scene, and 2 (0.3%) were not recorded. Conclusions: This first countrywide real-time operational research showed acceptable ambulance exit outcomes. Improving ambulance response and transport times might reduce morbidities and mortalities further.

Introduction: Compliance of community pharmacies with the national medicines law for proper storage and dispensing of medicines is crucial for ensuring the quality and safety of medicines. Community pharmacies in Bhutan are of two types: retail pharmacies and wholesale pharmacies. Objective: This study was aimed to assess the compliance of community pharmacies with the Medicines Act of the Kingdom of Bhutan 2003 and Bhutan Medicines Rules and Regulation 2012. Methods: This is a retrospective cross-sectional study from the inspection reports of community pharmacies inspected from January 2015 to December 2017. Descriptive statistics in frequency and percentage was used to report the results. Results: The overall compliance level for the regulatory provisions under critical and minor categories was 90.4% followed by 86.74% for major category. Around 32.99% of community pharmacies were found without standard operating procedures for storing and dispensing of medicines while 100% of community pharmacies had technical authorization from the Drug Regulatory Authority. Conclusion: Although the compliance level of community pharmacies in Bhutan for storing and dispensing of medicines was found to be above 80%, there are several areas that need to be corrected to ensure full compliance. This study will serve as a baseline for policymakers, managers, and researchers in developing designs for future interventions.

Natural saltlicks are used by mammal species mainly to supplement mineral deficiency playing critical role in animal ecology. There is information gap on the use of natural saltlicks by mammals in Bhutan. Nine natural saltlicks from Jomotsangkha Wildlife Sanctuary were purposively selected to fill this gap of information. The study aimed to assess mineral composition and ecological behaviour of mammals at natural saltlicks. Nine composite soil samples were randomly collected and nine camera traps were set up at nine saltlicks for a duration of 56 days from 2 January to 28 February, 2019. Data management and analysis were carried out using camerabase and R software. Potassium, phosphorus and sodium elements were found in the saltlicks. Camera traps yielded 419 independent events of 12 species under 10 families. Herbivores were most common (n = 390) and non-herbivores the least (n = 12). Wild dog was also captured licking salts (n = 1) which is least reported across the world. Mineral composition (r = 0.70, p < .05) and anthropogenic activities (r = 0.60, p < .05) were key factors affecting the visitation rate and ecological behaviour of mammal species. Disturbed saltlicks from Samdrupcholing Range revealed fewer individuals of mammals (n = 71) with disturbed ecological behaviour while undisturbed saltlicks from Jomotsangkha Range revealed higher individuals of mammals (n = 340) with undisturbed ecological behaviour. Therefore, anthropogenic activities at disturbed saltlicks call for planned monitoring.

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Background In Bhutan, where the Emergency Medical System is forming and evolving, the number of acutely ill patients requiring critical care, both in the emergency departments and intensive care units, is steadily increasing. Given the lack of baseline data and the ever-increasing number of critical care patients, this study was aimed at describing the characteristics and outcomes of patients triaged as critically ill in the emergency department. Methods An observational study was conducted over a yearlong period in the emergency department where all patients triaged as critically ill were approached for inclusion in the study. A case record form was used for the purpose of data collection. Epidata analysis was used for descriptive analysis and SPSS was used for binary logistic regression. Results A total of 657 critically ill patients of all age groups visited the emergency department over the 1-year study period, with adults constituting the majority (81%). The majority (67%) of these patients had a favorable outcome of surviving to discharge. The most common diagnosis among critically ill neonates was neonatal sepsis. Among the critically ill pediatrics and adults, sepsis, respiratory illnesses, and trauma were the most common diagnoses. Intubation followed by mechanical ventilation and blood product transfusion were the most common lifesaving interventions performed on critically ill patients. Conclusion The findings from this study constitute the first ever local database, at the national referral hospital in Bhutan, of critically ill patients treated in the emergency department. It highlights the central role the emergency department plays in their management and provides information for strengthening critical care services. It also highlights the areas of improvement and identifies high yield areas of training for the emergency department.

Aconite is widely used in both Chinese and Ayurvedic medications and therefore often used within the Himalayan Kingdom of Bhutan. Despite its use in traditional medicine, because of its narrow therapeutic index, significant cardiotoxic and neurotoxic events are documented due to both intentional and unintentional ingestion. In this case series we present 2 cases of bradycardia, hypotension and reversible conduction defects caused by prescribed aconite-based Bhutanese traditional medicines, for different therapeutic goals, who suffered cardiac dysrhythmias.

Background. In Bhutan, Traditional Medicine (TM) is a part of the government-sponsored free healthcare system and Traditional Medicine Units (TMUs) are colocated with allopathic hospitals. Prevention of healthcare-associated infections and patient safety must apply to all institutionalized healthcare settings including TMUs. This study assessed the knowledge, attitude, and practice of TM practitioners in Bhutan in the field of infection control and waste management practices. Methods. This was a descriptive study among TM practitioners selected through simple random sampling. Data were collected using a structured pro forma and entered in EpiData 3.1 and analyzed in STATA 13.1. Results. There were 132 respondents (response rate 98%). The majority (64%) knew the seven steps of handwashing but their knowledge of WHO’s Five Moments for Handwashing was poor, especially handwashing after aseptic procedures (17%) and handwashing after touching patient surroundings (5%). Handwashing before palpation of the pulse (37%) and using gloves while dispensing medicines (9%) were poor; but the proportions of handwashing before performing moxibustion (96%), correct disposal of sharps (84%), and disinfection of cupping sets (78%) were high. The majority of participants hold a positive attitude towards the adoption of infection control and waste management practices for the benefit of patients. Only 23% had received preservice and 44% had received in-service training on infection control. Conclusions. The knowledge and practices of infection control and waste management are optimal only in select domains of practice. The practitioners hold a positive attitude towards the adoption of infection control and waste management standards.

Non-pharmacological measures, such as hand hygiene and face mask use, continue to play an important role in the fight against the COVID-19 pandemic. However, there is a paucity of studies on the adherence to these measures among students in Bhutan. Therefore, we aimed to investigate hand hygiene and face mask-wearing behaviours, as well as their associated factors, among the students of Mongar Higher Secondary School, Bhutan. We conducted a cross-sectional study amongst the students of Mongar Higher Secondary School in Bhutan. The students self-answered the questionnaire on web-based Google Forms. Multivariable logistic regression for good hand washing and face mask use was conducted in order to identify statistically significant socio-demographic covariates. The correlation between hand hygiene and mask use was investigated using Pearson’s correlation coefficient. A total of 533 students completed the survey questionnaire, 52.9% (282) of whom were female students. Facebook (44.3%, 236) and TV (35.5%, 189) were the two most popular sources of information on COVID-19 prevention and control. Good (scores of ≥80% of total scores) hand hygiene and face mask use were reported in 33.6% (179) and 22.1% (118) of students. In multivariable logistic regression, male students presented 79% (adjusted odds ratio [AOR] = 1.79, 95% confidence interval [CI] = 1.23–2.613) odds of engaging in good hand hygiene, compared to female students. Compared to grade 9, those in grade 10 were 60% (AOR = 0.4, 95% CI 0.158–0.998) less likely to engage in good hand hygiene. Boarding students presented 68% (AOR = 1.68, 95% CI 1.001, 2.813) higher odds of wearing a face mask compared to day students. There was a significant positive correlation between good hand hygiene and face mask use (r = 0.3671, p-value < 0.001). Good hand hygiene and face mask use were reported in less than one-third of the study participants. It is recommended to continue educating students on good hand hygiene and face mask use through popular information sources.