Thursday, October 23, 2014

It Takes a Village...

Tonsillitis, lumbar back strain, herpes zoster, viral URI, sciatica, diabetic ulcer, contact dermatitis... all typical diagnoses in the day-to-day for us as health care professionals. The difference today is we are in the jungle,  we speak a different language, the clinic we are in is indoor - outdoor and flies love to try to invade your sterile field,  and the differentials include Dengue fever and Japanese Encephalitis.

There are many other differences including,  but not limited to:

-Children rode up to clinic on their bikes, got seen, treated,  were provided with health education and medications and sent home with no parental involvement.
-The clinic we are in  is fully funded by the Thai Ministry of Public Health and donations from the rural community it serves.
-Keeping with Thai culture, no shoes are worn in clinic or in any homes when on our home visits.
-Speaking of home visits! Students and providers ride to the homes on bicycles and see patients in their homes, on their porches, in their neighbors yard, or at the local market... wherever they are at that moment.
-Public health volunteers, members of the community who mostly have no health care degree or background, are a large,  valuable,  powerful presence in both the clinic and during  home visits. They attend student presentations on their assessment of community needs and offer feedback (for example: students this term focused on decreasing dietary sodium intake in efforts to improve hypertension), they do their own home visits on their neighbors to help with medications, cooking, and compliance,  among other things.

The sense of community is quite remarkable.  The community is so invested in the health and welfare of each individual as well as the overarching goals and needs of the community as a whole.  There is a clear trust and respect for one another as well as the Thai nursing students and us UofM graduate nurse practitioner students that have come to their community to help them achieve their goals.
It's true, in just a handful of days, we have started to become a part of this village,  each day seeing the same faces..."grandma," our favorite dancing public health volunteer,  the stoic children already taking accountability for their own and their family's health needs, the frustrating but endearing non-compliant patients. Despite our obvious physical differences and language barrier- when it boils down to it these people are our "sisters" and "brothers" as we have called them from the time we arrived. Working alongside them and taking care of them and their community has made me feel more connected to this earth and the diversity of the people living in it

"Differences are not intended to separate,  to alienate.  We are different precisely in order to realize our need for one another." D.Tutu

Among the 10+ patients I saw in morning clinic on Wednesday,  not one was upset about waiting, not one was frustrated with the language barrier, each greeted me with a warm smile and their customary respectful head bow.  We spoke a universal language to one another- the language of facial expressions  and body language elicited by therapeutic touch and charades. This experience is already helping tune us improve our nonverbal communication,  elevating physical assessment to a whole new level.

Despite all of our differences, our goals are the same: compassionate care, health promotion,  disease prevention, access to care... for everyone regardless of their social status. These appear to be universal concepts.

I'm so grateful to be on this journey.  I can't wait for tomorrow.

"We are all equal in the fact that we are all different. We are all the same in the fact that we will never be the same. We are united by the reality that all colors and cultures are distinct and individual.  We are harmonious in the reality that we are all held together on this earth by the same gravity. We don't share blood, but we share the same air that keeps us alive." -C. Joybell C.

Wednesday, October 22, 2014

Happy Thai Nurses Day!

0800 - The air is already thick to breathe, and I can feel the humidity on my skin. The first thing I see are the clusters of scooters and bicycles lined up at the base of the clinic, in no particular order. Walking up, I hear only quiet murmurs, though all of the chairs are full and people are lounging outside on the porch and filling every bench. 190 patients from the surrounding districts, all checking in for the doctor who isn't scheduled to arrive for two more hours.

0830 - Inside the clinic, community volunteers work diligently to check patients in by performing standard vital measures that you would anticipate when you visit your family provider: blood pressures, blood glucose checks, height and weight, and brief complaint or major diagnosis. The patients carry their own medical documents, bound like a small paperback book.

0900 - There are four areas for exam: one space for procedures or traumas, one room with three beds for exam, another room for the doctor, and finally an area where nurses are able to see the more stable patients who do not require full examination. We accompanied the SUT students into exam room one. As the patients started filing in, there was barely time to process the lack of privacy in conversation or exam. Time flew as we worked with the Thai students to address previous history and work up new findings, even sending a couple of patients to the hospital for further testing.

1200 - As we took a break for lunch, the clinic was still a constant buzz of activity. To consider the volume of patients with the availability of staff, resources, and space, the actual efficiency is an impressive example of health care in the rural setting. No one is turned away or left behind.

When we bowed to say goodbye after our first assessment, a mother took her daughter's hands, contracted up through her shoulders, and put them together across her daughter's chest, as if to say thank you and good bye. Her daughter, whose face had remained solemn and unresponsive throughout the exam, suddenly lit up, revealing a spectacular smile. And that was it. A somewhat chaotic assessment, the awkward uncertainty between strangers, the language barrier - turned perfect. People serving people - and to quote SUT's Naruemol, bringing the community into the university and the university into the community. Halfway around the world, we could not ask for a better example of this mission.

Tuesday, October 21, 2014

Best Clinical Ever

Today was red letter and, at times, red carpet for our group as we officially set off on our clinical adventure. After a few days of settling in and exploring it was time to get to work!

We started our day with a meeting with some of our SUT "sisters" to discuss the case presentations they have been preparing. Yet again, we found ourselves in awe of the work they had done, and then the added work of presenting in a second language. We are so lucky to have the chance to learn along side these students during our time here!

Next, it was off to the hospital where we were kindly greeted by a truly impressive group from the community including; the Chief District Officer, the hospital chief, Deputy Directors of the district health offices, and directors of both clinics! We know that at home these positions are incredibly demanding, so to have so many of them make the time to present to us was incredible. Our very own April Bigelow and SUT's Naruemol presented together on University of Michigan and SUT- April got some good laughs from our Thai students with her picture of the university covered in snow. After lunch (and much talk with our new found friends about spicy, but delicious, Thai food) it was time for a quick round at the hospital and then back on the road.

We divided in to our two clinic groups and it was off to meet our communities. The five students at Tajalung Clinic had the opportunity to walk through the surrounding area with the SUTstudents and community health volunteers. So off we went, through the rice paddy and over the creeks, to familiarize ourselves with the district and it's people, some of whom will be our patients before we head home. Everywhere we looked there was something else we'd never encountered before- tropical fruits growing, a rice mill running, and a beautiful Buddhist temple. We even stopped for a snack- fresh bananas! They're smaller but more delicious (and selfie worthy) than at home.

It has been an incredibly eye-opening day, but now it's off to bed to dream of tomorrow's adventures in global clinical immersion!

Sunday, October 19, 2014

International Connections

The higher the technology, the greater the need for human touch. 


Our first day of work: teaching physical assessment skills to Thai nursing students! We had an opportunity to go to the nursing school and meet the students we will be working with in the community.

Our first assignment was to review physical assessment with small groups of students. Some students had more experience with examination techniques than others. The trick: the Thai-English language barrier. It was amazing to see how well we were able to communicate, with the students who are stronger English-speakers helping students who were not as strong. We learned that the students are required to learn how to document in English, as well as Thai! It seems American students struggle enough with medical terminology in English, let alone learning it in a foreign language!

The students are delightful - respectful and knowledgeable. After we finished a head-to-toe examination, we spent some time chatting, learning about their interests within nursing and sharing our experience with them. My favorite part: when one student asked "do you mind, can we selfie?" A common bond between international students! They also taught us a few Thai phrases and words. We are looking forward to spending more time with them and learning more about the life of nursing students in Thailand!

Wednesday, October 15, 2014

On the Road Again

The University of Michigan School of Nursing graduate students in primary care are embarking on another global clinical immersion.  Inspired by the pictures, stories, and experience from the pilot group, the 2014 group is double in size.  Students from the Adult-Gerontology, Family, and Pediatrics programs will spend more than two full weeks providing patient care, conducting community assessments, and delivering educational programs for rural Thailand.

It is clear that global clinical experiences challenge and change clinicians, many times in ways we least expect.  In fact, it is often difficult to predict what type of experiences will be available for students.  So much is dependent on the student personalities, the global health climate, and clinical site itself.  While the unpredictability is uncomfortable at first, students begin to realize how well this type of experience prepares them to be better clinicians, both domestically and globally.

This afternoon we board a plan bound for Thailand filled with a mix of emotions.  While we may not know exactly what awaits us, our trip last year taught us that we need to always be prepared for the unexpected.  We are ready to roll and embrace all that Thailand and the global community have to offer.

Wherever you go, Go Blue!

Friday, November 15, 2013

Nursing Across the World

During our time in Thailand,we have been working hand in hand with nursing students from Suranaree University of Technology (SUT).  Not only have these girls worked so hard and taught us so much over the past weeks, but they have also been instrumental in our understanding of the differences in nursing education around the world.

For starters, we have learned that nurses in Thailand have a different scope of practice than we do in the United States.  For example, as an undergraduate prepared nurse, one can prescribe some medications, suture, and function as a midwife.  We learned that each student from SUT had currently delivered 6-7 babies as a part of their clinical time! At the clinics in which we have been working, there is no doctor on site daily.  The clinic is run by assistants, nurses, and nurse practitioners.  This different scope of practice was eye opening.

Currently, the Thai nursing students are completing their community health clinical rotation and are in the final year of their undergraduate nursing program.  This rotation requires them to immerse themselves in the community, uncover current health disparities, and create community interventions that will be beneficial to the people in the village.  While this is similar to the community health nursing class taken by all undergraduates at the University of Michigan, there are some stark differences.

The students here in Thailand must LIVE in the village they aim to serve for the entire 4 weeks of their community clinical rotation. They live in a small, two room cabin that is on the property of the health clinic. The rooms have no air conditioning and have only enough room for the students' sleeping bags.  Their program is intensive and requires them to interview 80-100 families from the community while also seeing patients in the clinic.  During home visits, students enter community members' homes, greeted with open arms, to conduct very comprehensive surveys including: demographic information, thorough health histories, and comprehensive physical exams.  After gathering community information, the data is analyzed using online systems, and a presentation with results of significant health disparities for community members is compiled.  At the open presentation, people from the community are invited to attend and the health priorities of the village members are determined in order to decide what interventions (also implemented by the students) will be most beneficial.  Furthermore, we noticed the students working 10-14 hour days seven days a week. The students opened the clinic as early as 6:00am and finished their last home visits as late as 9:00pm.

This intensity and passion put forth by the nursing students is remarkable.  The dedication that they have not only to their nursing program, but also to enhancing the well being of a community population is very clear.  Not one student complains, not one student seems disengaged.  Each student participates as an equal member and furthermore, each student makes an unbelievable effort to make us feel involved, understood, and respected. Taking some of these lessons back to our own life as we complete our Nurse Practitioner programs is integral for success.  In Thailand, we saw a willingness by the students to be their best and to put forward their best efforts.  These students understand that hard work, passion, and dedication is not just a means to an end, but a way to live life.  From these girls, we learned the importance of giving the world the best.  Heading into our last semester, and future practice, we hope to bring the continual passion to provide, with open minds, dedication, and humble hearts, to those that we serve!

Friday, November 1, 2013

The Essence of Health Care

Our group of seven from Michigan has been split between two clinics here in Nakhon Ratchasima. Our two previous posts have come from half of our group working in a more rural clinic in the village of Keetun. The other half of us have been working at the clinic in the village of Dan Kwiean. Our village is considered more urban, in part because of the vibrant pottery industry that brings in shoppers from all over the world. Although more urban by local standards, at home we would compare our village to small rural town. Our clinic serves an area of ten villages with a total population of about 1,700. We have a check in area, a dental room, two consultation rooms where we see patients, a room for IV infusions, and a small procedures/emergency area with one bed.

For the most part, the chief complaints of the patients we have seen have not differed drastically from those of patients seen at the rural clinic, or even from those of patients at home. One of our first mornings here we were able to help with a diabetes and hypertension clinic. Almost 200 patients showed up for blood pressure and blood sugar readings, education, and consultations. We have treated upper respiratory infections, a plethora of eye complaints, gastroesophageal reflux, and occupational complaints such as pulled muscles from factory work or bad burns from pottery irons. On occasion, we encounter diagnoses we rarely see in the United States though, such as leptospirosis and dengue fever.

Things that have surprised us or are different:
Patients come to the clinic with extensive bruising and wounds which require dressing changes then they jump back onto their motorcycles with only flip flops on and drive away.
The use of lots of herbs and multiple prescriptions for diagnoses we often wouldn't treat with prescriptions back home.
The consistent stoic response to pain and discomfort we see with all of our patients. Even patients with acute eye injuries, extensive dressing changes, or wound suturing display minimal physical or verbal response to pain.
Many times multiple patients are seen within the same consultation room. Patient privacy does not seem to be priority concern.
Our clinic does not treat mental health disorders, instead we refer out to a tertiary care center for psychiatric evaluation and treatment. This has meant that for acute mood disorder cases, we may be able to prescribe a day or two of Valium but won't otherwise treat a patient while they wait to get in to see a psychiatrist.
We have three dogs that call the clinic home. During the busiest part of the morning, they are not allowed in the clinic, but as the day winds down we often see them wandering in and out. These dogs also escort us around town as we walk to do our home visits and guard us from other territorial dogs in the area.
There is only one sink in the entire patient care area of the clinic, we are used to seeing a sink in every room in our clinics at home. It is the same with gloves, we have a single box of gloves out in the entire patient care area.
We notice some other vital supplies low or missing such as a full oxygen tank or defibrillator.
The willingness of patients to allow us, and the Thai nursing students, to walk right into their homes, sit on the floor, open their cupboards and refrigerators to assess their food choices, etc.
The way that generations live together in homes or compounds. We have visited homes with up to 4 generations together under one roof.

As our two weeks come to a close, however, we realize the essence of our health care mission is the same in Thailand as it is at home. We are all working toward the common goal of improving the health of our patients using a compassionate and holistic approach. It has been amazing to immerse ourselves in a different health care culture and to understand the differences, but more importantly, the similarities of our systems.