Monday, November 23, 2015

An Unforgettable Farewell Celebration

On our last day of clinical in Korat, we were honored to be invited to celebrate the evening with the SUT faculty and students, as well as the community members. The celebration took place in the center of the village, and many of the patients we had seen during home visits and in the clinic were in attendance to see us off. It was the perfect ending to an unforgettable clinical experience working closely with our Thai sisters and the community. 

During the afternoon leading up to the celebration, we had the opportunity to assist our Thai sisters and the SUT faculty in preparing a meal to bring to the evening celebration. Our Thai sisters showed off their skills cleaning and shredding coconut, and we helped them to make fresh coconut milk for a panang curry dish. 

                                          Michelle and Nar shredding coconut

We all got dressed in our traditional Thai outfits in preparation for the celebration - thank you to the sophomore SUT nursing students who lent us their clothing for the event! We bonded with our Thai sisters as they braided our hair to help us get ready for the event (excluding the guys of course). After two weeks of hard work, it was very fun to see our Thai sisters get a well-deserved break and enjoy the afternoon cooking with us. While we were occupied with coconut shredding contests, hair braiding, and cooking panang, other members of the village were preparing handmade decorations and traditional Thai dishes for our community dinner.


In the evening, we walked to the center of the village together to begin the celebration. The community members had elaborately decorated the bridge and center of the village for the event. Yards of vibrant colored fabric were draped over the bridge, with hanging decorations creating the perfect centerpiece for the party. The older adults in the community lined each side of the bridge, seated in chairs. The first part of the celebration was very special, as we were honored to participate in a Baci ceremony. During a Baci ceremony a white thread of silk or cotton is tied around the wrist of the individual who is being wished well-being and good luck. The white thread symbolizes peace, harmony, good health and fortune, and community. The thread is to be worn for at least three days, and untied or allowed to fall off on its own thereafter. During our Baci ceremony, an elderly community leader (who has often been a Buddhist monk at some stage in his life) performed a blessing and tied a thread of cotton around each our wrists, one at a time.

Baci Ceremony

Following this initial blessing, we moved down the line of elders in the community who each said a personal blessing and offered well-wishes as they tied more threads around our wrists. We cannot describe how meaningful it was to us to look up into the warm, sincere faces of these older adults as they each said a blessing and wished us safe travels. It is something we will never forget. 

Making our way down the line for the Baci ceremony
After we completed the Baci ceremony, we were each presented with a traditional Thai krathong. Loi Krathong is a Thai holiday celebrated on the 12th full moon of the Thai lunar calendar and typically falls in early November. “Loi” means “to float,” while “krathong” is a small wreath-like raft constructed out of intricately folded banana leaves. The krathong typically includes flowers, candles, and incense sticks. The krathongs were all different and very beautiful.

After the candles and incense were lit and a blessing jointly recited, we were instructed to make a wish as we placed the krathongs into the river. The act of floating the krathong is symbolic of letting go of any grudges and anger, allowing one to start life anew on a better footing. 

                                              Clare during Loi Krathong Ceremony                                Community Clinic Nurse Practitioner

Dancing, led by the older adult women of the community, followed the Loi Krathong ceremony. They individually invited us to dance with them and did their best to teach us traditional Thai dance. When the music stopped, we knew it was time for us to perform the dance we had prepared for our Thai sisters’ entertainment. We took the stage and did our best to impress during our short choreographed dance. After we were finished, our Thai sisters performed a variety of songs and dance for us as well. After two weeks of hard community clinical work, they also dedicated themselves to planning and preparing these performances for our farewell. They are truly an amazing group of women and future nurses! 

Our group in traditional Thai outfits with our SUT sisters and faculty

After our group performances, we enjoyed a variety of authentic Thai dishes, including fresh noodles, prepared by the community members. After spending so much time in the community the past two weeks and seeing how much work goes into meal preparation, we cannot thank the SUT faculty, our Thai sisters, and the community members enough for the wonderful authentic Thai food!

Following dinner, the dancing continued into the evening with the older adult women outlasting all of us on the dance floor. I don’t know how they keep it up in the heat and humidity, but we all got some good exercise for sure! The presence of many village members and the sense of community throughout the evening was unbelievable. When the evening came to an end, it was especially difficult to say goodbye to our Thai sisters whom we’d grown to know and trust over the past two weeks. As we drove away, they lined the streets waving and shouting goodbye. It was an emotional yet perfect ending to our final evening among our Thai sisters and the community. 

As we travel back to Michigan, we want to say thank you again to the SUT faculty, our Thai sisters, and all of the community members who made the evening one that we will never forget. It was so meaningful for our group to be able to participate in these Thai cultural traditions with you. We cannot thank you enough for your kindness and for welcoming us into your community during our short time in Thailand.

Saying farewell to SUT before the drive back to Bangkok

-Mary Beth, Hanna, and Clare

When opportunity knocks...

There are three types of people that you encounter as a traveler: missionaries, mercenaries, and misfits. I’m not sure where nurses fall in this spectrum. For a good portion of this month I have had the honor of participating in a program that pairs advanced practice nursing students with bachelor level Thai nursing students through a collaboration between the
Sometimes travel is a leap of faith.
University of Michigan (U of M) and the Institute of Nursing at Suranaree University of Technology (SUT).
The SUT students are completing a community health course, which entails completing a through assessment of the health status and history of nearly every individual, family, and village serviced by the district clinic. They are doing a proper assessment; they are placed in a foreign community and spending nearly six weeks living and working in these communities. Additionally they have been taking on the role of medical interpreter as we conduct physical and psychosocial assessments in both clinical and home settings.
            Although we are students ourselves we have been assigned the role of expert clinician, a role that we have been prepared for. Our program has taught not only the importance of clinical assessment skills, but also the importance of considering our patients as people. We look at their needs and desires, assets and barriers to health care. We are trained not to only diagnose and treat illness, but also to promote health and help in eliminating the barriers to health. We have been gifted a skill set that transcends borders and language barriers.
Other times it is PowerPoint longing for coffee in a bag, as our Thai Sisters demonstrate.
            Our Thai brothers and sisters as well as the communities we served have welcomed us graciously. Huay Tai, a small village about 45 minutes south of Nakhon Ratchasima, (or Korat) has been our base of operations. We’ll call it Village 11, as there are 15 villages that are served by the clinic… and I usually spell and pronounce the names incorrectly, and confuse them with the province, district and each other. Village 11 is amazing. The health problems that we encountered are pretty standard, the same kinds of illnesses that you’d see in any clinic or home visit the world over, but they have just been managed a bit differently. Of course there are a couple of region specific problems that we don’t really come across in the States – dengue fever, typhoid fever, betel nut related complications, and healthy food choices in Buddhist monks, to list a few.
            The team dedicated to Village 11 consisted of three U of M NP students, whose specialties include adult/gerontology primary care, pediatrics, midwifery, occupational health, and international health (we like school, what can I say?) and seven Thai students, who are finishing their BSN degrees. Like all teams that matter it took awhile for everyone to work well together but in the end we were a solid team that worked well together in increasing our own knowledge as well as assessing and assisting our community. A community that embraced us from the beginning; I’ve lost count of the number of new grandmothers that have claimed us as their own.
I told you it was a left at the Mango tree next to the chicken, not the duck.
  A home visit in rural Thailand isn’t quite the same as a house visit in the US. In the US visits are planned well in advance (usually), have specific billing criteria, and tend to focus on a specific problem: post discharge follow up, acute care, wellness visits, medication review. Here we show up sometimes without a formal appointment. There is of course more to it than that but essentially we knock doors and people welcome us in (usually) they are open to share their stories, just like in the States people will talk if you give them freedom to do so and just like in the States you kind of have to keep them on track or a 20 minute visit lasts two hours. Our patients here give us access to there medicine, log book (each provider encounter is summarized and noted in little note book that the patient keeps with them and brings to each encounter – America I’m looking at you for this as it beats a eMAR any day), the even let us roam around their homes and look in their food (a great way to measure sodium intake). The patient’s here are open to suggestions (and just like the States knowledge doesn’t equal action). That’s the beauty of this program, the Thai students gain a bit more knowledge of assessment and the types of questions to ask from us and then they have another month to follow up with the patients.
            As our time in Thailand comes to an end I feel like I’m grieving. The community threw us a party, complete with locally sourced food.
Noodles first, we'll address that burn after lunch.
There was a mom and pop noodle factory that I assessed and have been trying to sample for the last two weeks, high risk for thermal injury but world-class noodles. We had a early celebration of Loi Krathong, the annual river festival where decorated baskets are placed in the river and wishes are made as the basket floats away. Our group was blessed by a traditional healer and received Sai Sin, or blessed string bracelets, from the village elders (we did health assessments at two different temples and I can tell you that performing a health assessment on a monk with an audience of ten or more requires a new level of cultural competence. That and monks tend to be stoic so don’t take offence if your jokes are met with silence). And there was a three-way dance off between the community, the Thai nursing students, and the U of M nursing students. While it wasn’t a contest, they watched us Whip and Nae Nae. We nailed it.
...and that is how the Thai Family Functioning Scale was validated.
            I’m sad to leave but the community is in good hands. Nursing is hard to define, just sit through one of our theory courses and you’ll understand, or actually not understand. We enter the profession for various personal reasons (we hate the ‘Why did you become a nurse?’ question) and soon realize that it’s a hard job that’s rewarding spiritually, and every once in a while financially. Nursing takes us places if we are willing to step through the doors that it opens. So yes the next time you are out in the world and trying to decide if that quirky person with the dark sense of humor is a missionary, mercenary, or a misfit… maybe they are all three because they just might be a nurse.

Adventures in Thailand

I am going to write about one of my experiences during the best clinical ever.  I had the privilege of seeing many patients in Nakhon Ratchasima, one in particular had a great impact on me.  "C", a 60 year old woman living in my assigned village.  C was recently diagnosed with stage five kidney failure.  Her physician recommended immediate dialysis however C was very reluctant.  She did not understand dialysis and was afraid.   On initial visit, the talented and dedicated Thai students and I assessed her current health status.  We found her to be doing remarkably well for a patient with advanced renal failure and not on dialysis.  C attributed her well being to the tea she drinks several times per day. This tea is made from traditional medicinal Thai herbs, a subject I plan research further in the future.
Phyllanthus amarus
Together with the Thai students, C was educated on chronic kidney disease and how important dialysis is for her health.  We explored her concerns and found she had limited knowledge about dialysis.  Additionally she was afraid about getting an infection that would cause her to die quicker than not receiving dialysis.  The Thai nursing instructors and students decided to present her case to the village elders for assistance.  Once her case was presented, it was decided that she would receive whatever assistance was necessary.  I was amazed and delighted as I watched an entire community coming together to help one of their own in need.  I guess if one member of the village is sick, they are all sick.

Renal Failure Education
The village leader arranged for C to talk with a member of the community who was already receiving dialysis.  We found ourselves there the very next day!  He described the process to her and explained he was still living a reasonably normal life.  This went a long way to assuage C’s fears, but she was still not ready to commit to treatment.   One of the Thai nursing instructors suggested we take her to the local hospital to see hemodialysis in action.  Again, the very next day we were on the dialysis unit at the district hospital.  I watched happily as one of the patients utilizing a dialysis machine assured C that this was not some horrible sentence, rather a chance at prolonging her life.  By the time we left, C had decided to proceed with hemodialysis, and a vascular surgeon consult was arranged for the following week.
Community Forum

I have been pleasantly surprised at a great number of things during my adventure here.  Wonderful food (not the same as Thai restaurants in the States!), beautiful temples, picturesque countryside views, and the most courteous and welcoming people I have ever met.  What stands out the most, for me, is the Thai peoples' ability and desire to come together and help each other when one of their community is in need.  I feel very fortunate to have been part of this experience.

Thursday, November 19, 2015

Compassion, Dedication, and Trust: The Heart of Community Nursing

Prior to arriving in Thailand, I wasn’t sure what to expect during our two-week clinical experience. I anticipated feeling a bit of initial culture shock and assumed that the language barrier would potentially interfere with my ability to connect with patients as well as our Thai nursing student colleagues. 

However, I was pleasantly proven wrong. Since day one, the Thai nursing students (our “Thai sisters”) and the SUT faculty have welcomed us and integrated us as part of their team. Our first clinical day we rode bikes into the community with our Thai sisters to perform a windshield survey and begin the process of assessing the community’s health problems and needs. Our Thai sisters were kind enough to share their bikes with us, even letting some of us ride on the back of their bikes to get to patient’s homes. While a few of us felt a bit shaky about our bike-riding skills, we felt reassured that we were in safe hands when out in the community with our sisters as they frequently looked back to check on our status or warn us of the presence of a potentially unfriendly dog. 

  Biking to home visits in the community with our Thai sisters

When making home visits, our Thai sisters assist us in introducing ourselves to the community members and help translate our health questions. They help us learn basic Thai words and phrases so that we can better connect with the patients we see in both the clinic and the home. During home visits, they gather extensive data regarding individual health risk factors and community health concerns. 


Over the following days, we got to know the patients in the community better and begin to build more trusting relationships. They seemed to appreciate our attempts at learning their complex language and our eagerness to learn about their life and health status. And when we had difficulty communicating with words, a smile and touch seemed to go a long way in making a positive connection. 


As a healthcare provider, it really is a privilege to have the opportunity to see patients in their space, and the members of the community have been very gracious to allow us to enter their homes to learn from them. We gain a glimpse into their environment as we can see how they live, manage their daily healthcare needs, and explore what barriers and health risks are present. We can perform a thorough health assessment and medication review in the home, and when concerns are identified we can recommend that the patient come to the community clinic for further evaluation. During our days in the clinic, it has been encouraging to see these familiar patients from the community follow through and come to the clinic for further care.
I have greatly appreciated that the community clinic staff has welcomed us into their setting as well. In the community clinic, we work closely with the nurse practitioners and nursing staff, as well as the SUT faculty and nursing students who assist us with translation. They have an organized system for directing patient flow, even when well over 100 patients arrive at one time for chronic disease management day. The clinic staff, community members, and SUT students and faculty work collaboratively with us to develop individualized care plans and strategies to promote each patient and family’s unique health needs. 

SUT faculty, community clinic nurse practitioner, and Jason evaluating a complex patient in the community

As our time here in Thailand comes to an end, I continue to be extremely impressed by the hard work and dedication displayed by our Thai nursing student sisters. They stay up working late into the night, sometimes past 2AM, to ensure that they have complete data and a thorough assessment of the community’s main health risks and concerns. They frequently seek our feedback and suggestions on ways they can improve and prepare for community forums and grand rounds presentations on complex patients in their communities. Our Thai sisters will spend four more weeks living in these village communities after we return to Michigan, and I look forward to hearing about their progress as they strive to succeed in making a positive impact on the health of their communities.


Wednesday, November 18, 2015

My 8 Thai Sisters

This trip is my first time traveling internationally and I am in love. 

I owe most, if not all, of my incredible cultural and clinical learning experience to 8 amazing students. On the first day of clinical I was assigned to a village along with 2 of my fellow Family Nurse Practitioner classmates from the University of Michigan and 8 Thai Bachelor of Science in Nursing students from Suranaree University of Technology. These 8 Thai students were embarking on a 6-week journey: living, learning, and providing care all in the same community. They all live together under one roof which consists of one room, one bathroom, and one kitchen. The room is approximately a 12 foot square where all 8 of them bring out blankets and pillows to sleep at nighttime and during the day bring out a table and 8 chairs to study and work on their community projects. 

Through the short time I had the pleasure of knowing and working with these students I learned quickly they are all brilliant, passionate, kind-hearted and extremely hard working. I honestly do not think "extremely hard working" is even a grand enough phrase to emphasize their strong work ethic. For example, I made it a routine to ask the girls every morning how many hours of sleep they received. On a good morning they would answer about 4-5 hours; but more often than not they would respond with 2 hours. Whatever their answer was to this question, everyday they would be prepared, smiling and ready to get to work.

Working within the village has been a great learning opportunity. The quality of community nursing care provided was remarkable. I think the greatest aspect of community nursing in Thailand is the thorough screening and education on an individual, family, and community level. In the United States access to home care and community resources are available usually only after a patient is diagnosed with a chronic disease or some sort of disability. In fact, the patient is usually the one that initiates the care through a clinic appointment or a hospital visit for a health concern. Throughout this experience, however, these 8 girls were aware of all the 200+ people within the community. They went to the houses, met with the patients, and talked with them if they had an official diagnosis or not.  They became familiar with who had diagnosed hypertension, who has had a stroke and required assistance with activities of daily living, who was an uncontrolled diabetic and needed educating about their diet and disease management, and who had a newborn and when their next vaccinations are required. 

During the community visits we made sure to provide education where needed and involve the families. On many occasions screening of the family members was completed after learning of excess stress or certain symptoms they were experiencing. This sometimes led to recommending the family members to follow up at the local clinic for high blood pressure, pain management or symptoms that required further evaluation. Many times we were able to see them later in the clinic to truly have continuity of care. I felt that during this process we were able to gain trust and build relationships with the people of the village and essentially became part of their community.

As my experience is coming to an end I would like to thank my 8 Thai sisters for their incredible patience, knowledge, and kindness. They have contributed more than they know to my Thailand experience and I am a better nurse and future family nurse practitioner because of them.