Bhutan for the Active Traveler Wilderness Medicine CME

This Wilderness Medicine CME course takes place in the remote Buddhist kingdom of Bhutan. It is a country of mountains, untouched forests, and fortified monasteries that lies nestled in the high Himalaya. A country the size of Switzerland with a population of less than one million, it vigilantly protects it ancient traditions, religion and culture. Traveling there is like visiting Nepal or Tibet forty years ago. National Geographic has called it the last “Shangri-La.”

Our seminar will take us on a journey that will travel through the heart of Bhutan visiting the famous monasteries and villages at Paro, Thimphu, Bumthang, Trongsa, and Punakha. We will cross the 10,200 foot Dochu La Pass with its spectacular views of Bhutan’s Himalaya as we travel from Thimphu to the famous Punakha monastery.

The culmination of our journey will come at the end of our trip when we hike for 3 hours to visit the “Tigers Nest” of Takstang, the most famous and sacred of Bhutan’s monasteries, perched on side of a sheer cliff 3,000 ft above the Paro valley. No other monastery in the world can match the grandeur of Takstang’s natural setting. This wilderness medicine course is designed for the active traveler. Bhutan’s spectacular mountain scenery provides the perfect setting for day hikers to explore its remote villages and mountain paths.

WILDERNESS & TRAVEL MEDICINE CLASSES: COURSE INFORMATION

Accreditation 15 Hours AMA PRA Category 1 Credits

WILDERNESS MEDICINE COURSE CONTENT INCLUDES:

• Altitude Illness
• Hypothermia
• Frostbite
• Heat Illness
• Snakebites
• Travelers Illnesses
• Marine Envenomations
• Trauma Management
• Wilderness Orthopedics
• Water Disinfection
• Swiftwater Safety and Rescue
• Basic Wilderness Survival
• Wilderness Medical Kits
• Wound Management
• Patient Assessment
• Wilderness Dermatology
• Wilderness Pediatrics

CME ACCREDITATION INFORMATION
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Center for Emergency Medical Education and Wilderness and Travel Medicine. The Center for Emergency Medical Education is accredited by the ACCME to provide continuing medical education for physicians.

The Center for Emergency Medical Education designates this live activity for a maximum of 15 AMA PRA Category 1 CreditsTM.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DAY 1
PARO, BHUTAN / THIMPHU
Arrive in Paro, Bhutan, from Bangkok, Thailand. Our early morning flight brings us to Bhutan’s emerald-green Paro Valley (7,500 feet), where shrines dot the landscape and graceful willow trees grow along the edge of the Paro River as it winds through fields and farmlands. On arrival, we are met for a transfer to Thimphu (7,600′), a wooded farming valley up until 1961, when it became Bhutan’s official national capital. The massive Tashicho Dzong, about 700 years old, is the main building in town. It was carefully revamped in the 1960s by the late King Jigme Dorji Wangchuk, the main architect of modern Bhutan,to house the royal and main government offices. This is also the summer residence of the Je Khempo, Bhutan’s chief abbot.

In the afternoon we explore Thimphu’s and free time in the town. Overnight at the Hotel …LD

DAY 2
THIMPHU / TANGO MONASTERY
A 40-minute hike through a beautiful forest of oaks brings us up to Tango Monastery, a monastic school and retreat built in 1688. We will visit the main temple and also linger in Tango’s inner courtyard, beautifully painted in bright colors, with lovely views stretching across the Thimphu Valley. We drive back to Thimphu and have lunch in the local restaurant. Later we head to Sangay Gang, where there is a sanctuary for the cattle-sized animal called the takin, the national animal of Bhutan. These rare Himalayan creatures resemble miniature American bison, standing about five feet high with large heads and front quarters. We also visit Changgangkha Lhakhang, an ancient monastic retreat set on a ridge above Thimphu. Overnight at the Hotel…BLD
Approximate Hiking Time: About 3 hours

DAY 3
THIMPHU / COUNTRYSIDE HIKE / PUNAKHA
A scenic drive through a lushly forested landscape and we climb the Dochula pass, where we hike through a mixed forest of spruce, rhododendron, hemlock, oak, pine and juniper and reach up to Lungchuzekha Monastery, surrounded by prayer flags. On a clear day, we enjoy good views of the mountains of the Bhutan Himalaya. We hike down the same way to Dochula pass (10,200) whose summit is festooned with fluttering prayer flags and more than 100 chortens (stupas) dedicated to Bhutan’s continued peace and happiness. We will have late lunch at the restaurant in the pas. After lunch, we board our vehicles and descend to Lobesa village for a half-hour walk through the cultivated fields to Chimi Lhakhang, a monastery and fertility temple. The temple, flanked by nearly 100 tall prayer flags, sits atop a picturesque hill and has long been a pilgrimage site for childless couples. After visiting the temple, we drive to the hotel…BLD
Approximate Hiking Time: About 3-4 hours

DAY 4
PUNAKHA VALLEY
From the village of Nezigang, we hike up through cultivated fields and small hamlets to visit the Khamsum Yuley Namgay Chorten, a shrine built recently by the royal family. The shrine is an elaborate structure with a rainbow of Guru Rimpoche images and superb views of the Punakha Valley. After lunch, we visit the 17th century Punakha Dzong (fortress), Bhutan’s former winter capital, built in 1637 at the confluence of the Mo Chu and Po Chu (the “Mother” and “Father” rivers). The winter capital was established in this location in part because Punakha is a warm valley with a relatively low altitude of 4,100 feet, allowing for the production of two rice crops each year, along with oranges, mangos, and bananas. The Punakha Dzong is an architectural wonder and seat of the head abbot of Bhutan. It has survived six fires, two glacial lake bursts, and an earthquake. This labyrinthine dzong has played a pivotal role in Bhutan’s history and has the official name of Druk Pungthang Decchen Phodrang, which translates as “the palace of great happiness.” Overnight at the hotel …BLD
Approximate Hiking Time: About 3 hours

DAY 5
PUNAKHA / TRONGSA
We drive to the Trongsa crossing over Pele La Pass (11,000′). We will have lunch some where after crossing pass. We continue our journey to Trongsa, the ancestral home of Bhutan’s royal family. We visit the important historical Trongsa Dzong where the Penlop (govenor) in the early 1900s consolidated political control over Bhutan to become the country’s king. Overnight at Hotel…BLD

DAY 6
TRONGSA / BUMTHANG
In the morning, we visit the Ta-Dzong Museum, which focuses on the history of the monarchs of Bhutan, with many rare artifacts on display and then drive to Bumthang, crossing Yotongla pass (11,140′) and entering Chumey valley. A 10kms feeder road goes up to the Tharpaling Monastery (2800m) from Gyetsa village in Chumey valley , but it may be impracticable in summer due to rain and so walk is often necessary. The Tharpaling Monastery was found by Lonchen Ramjam (1308-1363) during his exile from Tibetan. He was the abbot of the Samye , one of Tibet’s most important monastery and first Buddhist monastery built in the Himalaya. This place was used as place of meditation. After visiting this important monastery, we continue to hike to Kiki La and . Overnight at hotel….BLD
Approximate Hiking Time 4 hours.

DAY 7
BUMTHANG
Nowhere else in Bhutan are there as many temples and monasteries as in Bumthang, and it is also one of the most picturesque regions of the country, with sweeping agricultural valleys dotted with small villages, and forested mountainsides sheltering centuries-old monastic complexes and religious retreats. Today’s hike brings us along the Chamkhar River and through meadows and pine forests to the village of Thangbi, where we visit its gompa (if the caretaker is present). Thangbi was founded in the late 1500s by the 4th Shamar Rimpoche, a patriarch of Tibet’s Karma Kargyüpa sect. After crossing a suspension bridge, we reach Nga Lhakhang (Swan Land), and after visiting the village we drive back to Jakar. In the afternoon we visit two important monasteries: Jambay and Kurje. Jambay was originally built by Tibet’s King Songtsen Gampo in the 7th century as one of the 108 temples used to subdue the demoness lying across the Tibetan Plateau; this temple is said to pin down her left knee. Kurje is a complex of three temples and one of the most sacred pilgrimage sites in Bhutan. Overnight at Lodge…BLD
Approximate Hiking Time: About 3 hours / Driving Time: 45 minutes

DAY 8
BUMTHANG
In the morning we witness the village Festival, held in the courtyard of a village temple. This age-old festival, established in the 16th century, features costumed monastic dancers and clowns, and is an excellent chance for locals to get together and socialize. In the afternoon, free time and in the evening we have a chance to sample araa, the local wine, as well as butter tea, and watch a demonstration of how the local buckwheat noodles (puta) are made at a traditional farmhouse. Overnight at Lodge…BLD

DAY 9
BUMTHANG / PARO (Domestic flight)
A morning flight brings us to Paro. In the afternoon we visit the fascinating National Museum of Bhutan, housed in the Ta Dzong, with its collection of ancient artifacts, weapons, and silver teaware. We also visit nearby Paro Dzong, an imposing fortress originally built by Shabdrung Ngawang Namgyel. Situated along the river with a beautiful covered bridge, it is the administrative seat of the Paro district, and also houses a state monastic community. Overnight at the Hotel… BLD

DAY 10
PARO / KILA NUNNERY
In the morning we drive to Chele La pass to view the mountains and from there hike down to the Kila nunnery monastery, one of the few nunnery monastery in the country. We drive down to Dzongdra Kha monastery,built on the edge of the cliff. Overnight at hotel…BLD
Approximate Hiking Time : 3 hours.

DAY 11
TAKTSANG MONASTERY
Today we hike up through pine forests festooned with Spanish moss to reach the striking monastic retreat of Taktsang, the “Tiger’s Nest,” built into a sheer cliff face about 2,700 feet above the Paro Valley. This is the most famous temple in Bhutan and one of the venerated pilgrim sites of the Himalayan world. We enjoy our lunch en route at a teahouse midway with fantastic views of the monastery. Overnight at Hotel…BLD
Approximate Hiking Time: 3-4 hours

DAY 12
DEPART
After breakfast, transfer to Paro Airport for homeward-bound flights via Bangkok. Flights typically arrive in Bangkok between 1:00 pm and 5:30 pm…B

Please Note: Actual festival dates and activities are always subject to change (even once the trip has begun). The itinerary and/or dates may be altered to adjust to the final festival schedule. Sometimes, viewing a festival may not be possible if dates are changed at the last-minute and beyond the control of agents.

Recommended Gear and Clothing List

You should pack for Bhutan as you would for a trek in which you will be staying in mountain lodges but not camping. Informal trekking clothes that are easy to wash and dry are definitely all you need. Stylish travel cloths are not necessary. You will be going through Bangkok on your way to Bhutan and if you bring tropical clothing or city clothes for Bangkok, then you should try and leave them in your Bangkok hotel and not take them on the seminar.

The weather should be dry when we are in Bhutan but if the monsoon season lasts into the end of September, we may have rain. Please bring a light weight rain jacket or poncho. Trekking poles are a good idea for some of the day hikes and on our last hike to the Tiger’s Nest monastery.

Clothes and Equipment
Luggage; one large soft sided duffle or roller bag. The soft sided luggage is easier to pack in the vehicles. Druk Air (flight from Bangkok to Paro) allows for one carry-on bag and your checked bag to weigh no more than 20kgs (44 pounds).
Day Back pack for carrying water, cameras and jackets.
Light weight to medium weight hiking boots.
Trail running shoes or sturdy walking shoes with good traction soles.
Teva style sandals. (optional)
One warm, windproof mountain jacket for early mornings and evenings.
One lighter weight fleece or wool under jacket or vest.
One rainproof shell or poncho.
One cap or wide brim sun hat.
Warm trekking socks.
Sun screen SPF 30 or 50 and lip balm with sun screen.
Small folding umbrella. Optional
Sunglasses
Digital camera with extra batteries, instruction manual and extra memory cards
Binoculars, small light weight (Optional)
(Nikon 8×21 binoculars are excellent and cost less than $50 online)
Pocket knife

Informal, comfortable travel/trekking style micro-fiber pants and shirts (3 changes)
Comfortable underwear, synthetic if possible which is easy to wash and dry.
Walking shorts. (optional)
Comfortable and warm sleep wear.
Head lamp or flash light.
Paperback reading material. (optional)
Extra pair of reading glasses. (optional)
Insulated, light weight coffee/tea mug. (optional)
Foam ear plugs.

There will be laundry services available at many of our lodges.

Important Note: In order for us to be as respectful as possible to the culture and traditions, when visiting Dzongs/Temples/Monasteries, please do not wear sleeveless shirts, shorts, or sandals. Thank you!

Medicines and Medical Related Supplies
Antibiotics for traveler’s diarrhea (obtained from your physician)
Iodine tablets
Pepto-Bismol tablets
Imodium tablets
Tylenol or similar pain medication
Personal medications
Band Aids and/or mole skin
Alcohol hand wipes
Soft soap in pocket size bottle (Camp Suds work well)
Duct tape, small role or end of roll.

Visas and Passports

U.S. citizens are required to have a passport that is valid for 6 months after your travel dates begin.

Bio Bio Expeditions will be sending you a copy of your e-ticket receipt out of Bangkok and a copy of your Visas a few weeks prior to departure. Be sure to arrive at least two hours early to the Druk Air desk and check-in with your Passport, Visa and e-ticket information.

Flights and Airports

You are responsible for booking all international flights to Bangkok. We will arrange for the flights from Bangkok to Paro, Bumthang to Paro and Paro to Bangkok. Once ticket price is confirmed, we will update your invoice for these flights which typically cost between $900-$1,100, per person. One travel agent we often use to book our international flights is:

Sandesh
Himalayan Travels
1-800-223-1813

Bhutan time is GMT +6 hours (+14 hrs PST)

One of the ways that Bhutan controls tourism and protects its culture and traditions is to only allow tourists to travel in Bhutan with a registered Bhutanese tour company and only this company is allowed to obtain tourist visas for travelers and to buy the roundtrip Druk Air tickets from Bangkok to Bhutan. This means that after you have registered for the trip, we will contact you and have our people in Bhutan buy your international and domestic tickets on Druk Air and obtain a tourist visa for you. If you are a US citizen, you do not need a visa for Thailand.

You will be responsible to obtain your own roundtrip ticket to Bangkok from your home city. You will need to arrive the day prior to day one of the trip, because the flight to Paro will be very early on the first day. We advise spending the night prior to the trip at the Novotel airport hotel (http://www.novotelairportbkk.com/), which provides complimentary airport transfers. On the return, you will arrive Paro around 4 PM on the last day of the trip. Please allow plenty of time between your flights (minimum 3 hours).

Money Matters
Currency

Bhutan’s currency is the Ngultrum (Nu.) It is at par with the Indian rupee which is accepted as legal tender in the country. Note: INR (Indian Rupees) denominations of 500 and 1000 are not accepted in Bhutan.

On stops and occasionally in villages, you may wish to buy a cold coke or a treat. If you plan on doing some retail therapy in Bhutan, there are a lot of markets with plenty of opportunities to purchase Bhutanese handicrafts, which make great souvenirs. Remember that credit cards are not possible to use in Bhutan in most places so think in advance how much money you’ll need and bring it in cash.

ATMs

ATMs are located within all main towns throughout Bhutan, where money can be withdrawn using a Visa or MasterCard. Be aware of counterfeit currency and avoid being followed to and from an ATM machine! Go in pairs!

Credit Cards

Credit cards are not possible to use in Bhutan in most places, so think in advance how much money you will need and bring it in cash.

Personal Checks

Personal checks are not accepted in shops or at your hotels. It’s a good idea, however, to bring a few for possible emergencies.

Travelers Cheques

Travel checks are less desirable as fewer and fewer places will change them, and you may end up in long bank lines. You will need to show your passport to cash your checks at the bank.

Tipping

Tipping is, of course, entirely voluntary and how much you give depends on how you feel about the service you have received. Typically, you should designate 10-15% of the land cost of the trip for tips. For example, a $4000 trip would mean $400 in tips.

Other smaller tips might be for airport luggage carriers, hotel staff and drivers. This is where $1 bills or single soles come in handy. The norm at restaurants is approximately 5-15%.

Travel Practicalities
Trip Insurance

Bio Bio Expeditions recommends that you purchase a travel protection plan to help protect you and your travel investment against the unexpected. For your convenience, we offer travel protection through Travelex Insurance Services. For more information on the available plans or to enroll, click here or contact Travelex Insurance Services at 800-228-9792 and reference location number 05-8655. Travelex Insurance Services, Inc CA Agency License #0D10209. Travel Insurance is underwritten by, Berkshire Hathaway Specialty Insurance Company, NAIC #22276. 55Y

Immunizations

Although there are no immunizations required to travel to Bhutan, it is usually recommended that typhoid and diphtheria-tetanus protection be current. Hepatitis A, taken just before departure, is also recommended. In general, we advise that you consult your physician regarding recommended immunizations and other health precautions. Bio Bio Expeditions does not take responsibility for which medications or inoculations you and your physician deem necessary for your safe participation on the expedition in Bhutan.

For further information, call the CDC’s International Traveler’s Hotline:

Phone: 1-888-232-4636
Online: www.cdc.gov

The CDC’s fax bulletin includes additional information about preventing illness while traveling. Follow the directory instructions for obtaining information about your travel region. Be ready to provide your fax number after you’ve made your directory selection.

Water

Although it requires a little extra caution when drinking fluids in Bhutan, it is essential to stay well hydrated. We advise that you not drink any of the tap water in Bhutan; this includes no ice in your drink. Bottled water is fine to drink and can be ordered at most restaurants and found in local grocery stores. When ordering sodas, it is best to request them without ice, as the ice is usually made from tap water. Additionally, be sure to brush your teeth with bottled water.

Food

The major precaution regarding food pertains to raw, unpeeled fruits and vegetables (including lettuce) – avoid them unless you are dining in a high-end restaurant! If you can’t peel it, don’t eat it as it has probably been washed in tap water, or not washed at all, and that can make you sick. The high altitude also affects one’s digestive system so it is recommended to eat in moderation and avoid rich, thick foods (such as mayonnaise). However, don’t be afraid to try new foods and dishes – just be cautious. We want you to experience the many new flavors and local cuisine, but there are some things to consider when making food choices, especially where you are eating. The more high-end restaurants are fairly safe bets for trying new things. Street food should generally be avoided. This brings us to our next topic…

Digestive Worries

Traveling to Bhutan is going to have a notable impact on your body. Despite the many precautions we all take to stay healthy, occasionally one may experience diarrhea. The major problem associated with diarrhea is fluid loss leading to severe dehydration, so it is important to maintain plentiful fluid intake. Avoid milk and avoid caffeine, as it will only further dehydrate you. The best drinks are weak tea, mineral water, and caffeine-free soft drinks. Ideally it is best to let diarrhea run its course, however you may want to bring over-the-counter diarrhea medication to minimize your potential discomfort. The bottom line (no pun intended) is to drink plenty of fluids and get lots of rest! Lastly, we encourage that you, and all our staff, practice impeccable hand hygiene – you can’t wash your hands enough! Sanitizer gels are great when hand washing with soap and water is not available.

Prescriptions

If you currently take prescription medications, be sure to have a plentiful supply and also the doctor’s written prescription in case you need a refill. It is best to carry medications in your carry-on bag in case of lost luggage. Also, if you wear prescription glasses or contacts, we advise that you bring along a spare set.

Voltage

In Bhutan, most of the hotels have 3 pin plugs. The voltage is 220 – 240V, Primary Socket type (3 pins). If you are carrying 110-120V electronics, you will need to bring a plug adapter and converter.

Safety Concerns

There is relatively little crime in Bhutan. Petty crime, such as pick-pocketing and purse snatching, is occasionally reported. Reasonable precautions should be taken when visiting the town and, in particular, when going out at night.

When traveling in cities, always keep your wits about you and be aware of your surroundings. When with other people, watch out for each other. Large crowds are prime locations for pick-pocketing to occur. Keep your money in a money belt or hidden pouch around your neck and under your shirt. When purchasing items, do not pull out lots of money. We advise that you leave all valuable jewelry, including watches, at home. Thieves often work in pairs or groups – one tries to distract you (e.g.: by squirting food or paint on your clothing) and in the ensuing confusion, another one makes off with your belongings.
Jet Lag Precautions

When you cross several time zones to reach your destination, you often lose many hours of regular sleep. On arrival, your body then must suddenly adjust to new sleeping and eating patterns. The result is jet lag. Its symptoms are fatigue – often compounded by insomnia and restlessness – irritability, and vague disorientation. You cannot totally avoid jet lag’ but you can minimize it. Here’s how:

• Start your trip well rested. Try to begin a gradual transition to your new time zone before you leave
• Switch to your destination time zone when you get on the plane. Attempt to sleep and eat according to the new schedule
• Try to sleep on overnight flights
• Avoid heavy eating and drinking caffeine or alcoholic beverages right before and during your flight
• Drink plenty of water and or fruit juice while flying. You should buy a large bottle of water at a kiosk right before boarding – once you have cleared inside security and are “inside”
• After arrival, avoid the temptation to nap, unless you didn’t sleep at all on the plane
• Don’t push yourself to see a lot on your first day
• Try to stay awake your first day until after dinner

Altitude Sickness

The altitude can cause some physical reaction in almost anyone. Most people experience shortness of breath, headaches, and some dehydration. We recommend taking it easy your first day and avoiding alcohol and tobacco. If you feel sick, be sure to rest, breathe deeply, drink lots of fluids (bottled water), and perhaps take a mild pain killer for headaches. True altitude sickness is rare, but if the symptoms become severe, please let a Bio Bio Expeditions representative know. The front desk of the hotel often has spare oxygen bottles if needed.

How well your individual body adapts to the thinner air depends a good deal on innate factors that you have no control over. That being said, people in top shape often acclimate better because they expend less energy hiking, leaving their bodies ready for the task of acclimatization. Proper hydration has also been proven to be essential in this task. There is no substitute for being in top shape and staying hydrated!

Many altitude physicians recommend bringing the following medications for prevention and or treatment of altitude related problems.

• Diamox- e.g. 125 mg, twice a day. Beginning 24 hours before ascent to a sleeping elevation of 8,000-10,000 feet and continuing through duration of climb. Please discuss with your physician.

Hygiene and First Aid

It’s extremely important that group members follow the simple rules we have to prevent people getting sick on these trips. All drinking water is either boiled or treated with iodine. Any fruit that does not get peeled should be peeled first (i.e. Apples). Any time anyone is handling food they need to wash their hands with Dettol soap and treated water. And always wash your hands after going to the toilet.

We carry a comprehensive first aid kit that has evolved out of 25 years running expeditions in the Himalayas. All the guides are trained in first aid; they are either holders of advanced first aid or EMTs. We need to know from all expedition members if they have any medical conditions that we should know about, eg: severe allergies or if you are diabetic. Its better that we know about these conditions before the trip rather than being surprised later.

If you have any broken skin, infection is always a risk so look after even the tiniest cuts.

Women are advised to bring any feminine hygiene products that may be needed with you on the trip.

It is extremely important that you remember at all times to re-hydrate yourself. On an average day you are recommended to drink around 3 liters of water. While in Bhutan, we recommend that you remember to drink AT LEAST this much and if possible, more.