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.

Monday, October 28, 2013

Life Lessons from the Clinic

As our first week in the clinics came to an end, we began to feel more comfortable working with the patients and students in Thailand. We have all gained significant life experiences from working in the rural villages and greatly appreciate all that we have learned in such a short period of time.

As a group, we have collectively noticed an influx of patients who present with multiple different symptoms that all can be traced back to the massive amount of flooding that has occurred in the area. During home visits, we have noticed roughly 6-12 inches of stagnant water under and around some houses. There are many areas where the water level has climbed too high for motor vehicles to safely cross, and even some spots where there are "mini-rapids" where there is even an undertow. We have all encountered children who complain of stomach aches and pains, nausea and vomiting, and other vague symptoms that result from playing/swimming in the contaminated water. Other illness (eg: types of diarrhea and skin disorders, fever) that we rarely see in the United States have presented through some of our patients in the clinic, once again due to the flood waters. These unfamiliar illnesses have been interesting cases for us to work with since we rarely encounter them at home.

Unfortunately, with flooding waters comes the potential for dangerous situations. During the middle of a busy clinic morning, we saw a man driving a motorcycle flying into the clinic. Startled, we made our way toward him and noticed that he was carrying a child over his shoulders, and shouting for help in Thai. We could tell immediately that this was an emergent situation and the child was in dire need of our help. We had learned that child was playing in the flood water and was pulled under and drowned. A group of villagers saw the tragic event happen, and joined together, linked arms to form a line, and starting walking through the rapids to find the missing child.

In a room full of chaos, we, as nurses, did what we do best by immediately reacting to the scene and jumping in head first to help in any way possible. We knew that time was of the essence, and being exposed to similar situations through work and past clinical experiences back home in the states, we were prepared with knowledge and skill to help save a life. Working as a team with members of the clinic, we were able to transport the child through the jungle to meet the ambulance (in a truck shared by the community), and transfer him to the appropriate level of care at the local tertiary care hospital.

The experience was nothing short of traumatic, yet as in all situations, there is something to be learned. When we take a step back and reflect on the situation, a major difference presents with the lack of resources and equipment that were available at our rural clinical site. Inadequate oxygen supply, lack of airway equipment, and no ambulance present for transportation (our clinic only has a single ambulance that was already in use) are a few of the key elements noticed to be missing from the scene in a time of need. We were happy to be informed the next day that the patient made it safely to the hospital and received appropriate care.

We were invited to participate in the discussions with the clinic, local staff and faculty, and community about the event. We reviewed the case and the situation with the clinic and our hosts.  Several things complicated the situation.  Primarily, the clinic was underprepared for an emergent situation.  In retrospect, there is now discussion to have double or triple supplies at the clinic for potential emergencies or other natural disasters.  Next, the clinic is in the process of relocating, further complicating things by supplies being in both locations.  We were able to identify some key resources that should be present in the clinic at all times, as well as discuss with health officers useful resources to have for potential use at the clinic.

Although this was a sad and challenging situation, it alerted us to the reality of the hardships of healthcare in rural and poverty-stricken areas. It reminds us of how we sometimes take for granted that we typically have the necessary resources to provide appropriate and comprehensive care back home. Finally, although this was a difficult situation, it was impressive to see how the community jumped into action and worked together.  While they may not have what we consider to be "necessary" supplies, they have a close knit community network that provides support without being asked.  It is now clear why they refer to each other as grandmother/grandfather/sister/brother.  They are truly family and linked in a way that so much more than the word "community" implies.

Thursday, October 24, 2013

The Michigan Difference in Thailand

Not only have we made a significant difference in the weight of our suitcases due to the vast number of scarves bought at the silk shop, we have also started to reflect on the effect of our presence here in Thailand.

Playing peek-a-boo with a small child through the window, relieving the pain from a stye in an eye, and putting a smile on the "Smoothie Man's" face, who anticipates our daily arrival, we sport our Michigan Maize and Blue colors with pride in Thailand.

While small effects are great, we are even more excited at the cultural intra-professionalism occurring. Not only have we learned all the Thai student's names we are working with and them ours, the students are now asking various questions and having us confirm their assessment skills.  The language barrier is still one of the greatest barriers encountered, but through charades and an incredible effort from the students, understanding of chief complaint and history is obtained.  Working together, we are able to collaborate with those in the clinic to devise a plan for patients.

Evidence of the full circle of healthcare and the importance of Community Health Nursing is evident in our adventures. This week, we did a home visit, a home that did not resemble anything we have experienced as a place of dwelling before. The patient had not sought healthcare services in an extended period of time, yet had several things that were of concern. Education was provided at the time about coming to the clinic to receive a referral to see a physician about these ailments, yet we all left feeling questionable about the reality of this plan.

As we walked into the clinic today, we were met with a familiar figure. The patient from the home visit came to the clinic today to receive our full assessment and referral! If we had never ventured to that home, a place of discomfort for most clinicians as it is outside of the normal clinic routine, it is uncertain if or when the patient would have sought healthcare.  Now we are aware of and involved in the steps that have been taken toward follow up.

All of these small gestures, interactions, and learning experiences have allowed each one us to grow in a significant way. We are proud and fortunate that the people we meet positively impact our lives, and that we in turn do the same. Through our strong educational foundation and tradition of excellence instilled at Michigan, we are doing our small part to make a difference in this corner of the world. Go Blue.

Tuesday, October 22, 2013

Leave Your Shoes at the Front Door JCAHO

Dressed in navy scrubs and ready to change the world we travel in vans through flooded lands to our small village of 300 people.  Take off your shoes and step over the stray dog at the door because you are in the Tajalung Clinic.  No HIPAA here.  Patient histories are taken within earshot of the lobby and no Purell to be found.  But do not get the impression that the health care here is substandard. The 4th year nursing students from SUT have already personally delivered 3-5 babies and are so dedicated to their learning that they live at the clinic for 4 weeks.  The villagers will cook and bring them food in appreciation of the services they provide while there.  Not only do we see the patients that come to the clinic for a range of services from illness to antenatal care, we also visit patients in their homes.

Today's home visit is one that has opened our eyes to the luxuries we have in America, but also the undeniable need for community health nursing.  Our patient had not been seen in the clinic in 2 years and had several chronic conditions. Had we not traveedl to this home who knows when care would have been sought out by this individual. It is through these experiences we are learning just how important we are to the community and how big of an impact we can really have.

Sunday, October 20, 2013

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

After some amazing first experiences with Thai Culture in Bangkok, the clinical group traveled by van (largest van we have ever been in) to Nakhon Ratchasima (or as we like to call it, NR for short). Thailand recently had some large rain falls- which led to significant flooding along the preferred route of travel to NR, leading us to take an alternate route. We traveled through lush green areas and winding mountain roads that had breathtaking views of the jungle. Our travel time was stretched when we came across heavy traffic- everyone had taken the "back roads" to avoid the huge floods, and we soon saw that the backup was related to a semi truck that had flipped over on the wet hilly roads and left its cargo laying across the entire stretch.

Along the way, we stopped at a very authentic Thai restaurant for lunch. The views were once again beautiful and surreal. Our Thai clinical leader, Nar (a graduate from the University of Michigan- GO BLUE) ordered us lunch and helped us gain more insight to Thai culture and cuisine. We ate a variety of new foods- including a full fried fish with head and eyes still intact.

SUT (Suranaree University of Technology) became our new home away from home for the next two weeks. After settling into our rooms and getting tour of the campus, we prepared for our first clinical experience with the Nursing Students at SUT. Meeting the students was a wonderful experience. The students and faculty were extremely welcoming and interesting in learning about us and our purpose for travel. Each UofM student was assigned a group of 4th year SUT nursing students to teach and review clinical health assessment. This was a fun and educational experience for both sides, leaving everyone with new ideas about clinical health and wellness. We were also able to connect with the students on a personal level and develop friendships, leading to multiple new Facebook friend requests.

The rest of our day in NR was spent exploring our new surroundings. We traveled to the city center and explored the NR mall (which could give mall of America a run for its money). Everyone in the group took the time to stop for an hour-long ($6.00!!!!) Thai massage that stretched our bodies in ways that we didn't know were possible.

Our day ended with a group trip to the local market. Upon arriving, we were met with a vibrant atmosphere- full of food vendors and small shops. We all explored the area and enjoyed authentic thai cuisine as we sat outside and watched the SUT nightlife at full pace. Tomorrow we all begin our first clinical experiences at the community health care sites. We are all eager to jump in and help those in need by providing primary care through the SUT Nursing motto- the higher the technology, the greater the need for human touch.

Friday, October 18, 2013

Jumping In

Wednesday we set off on the long trip from DTW to BKK for the first global clinical experience in the adult/gero and family nurse practitioner programs at the University of Michigan.  Five graduate students. Two faculty. Twenty four hours of travel time. Piece of cake.

Our trip started with a bang. After about five hours on the plane, a women seated a few rows behind the students became difficult to arouse, had a pulse of only 39, and was diaphoretic.  The students switched into nurse practitioner mode and got their first glimpse of a true global clinical experience. They had to work with family members and flight attendants to act as translators, had to adjust their treatment plan based on the patient's cultural preferences, and had limited resources to gather data and provide treatments.

Ultimately we will end up in Nakhon Ratchasima working with students and faculty from Suranaree University of Technology. In this pilot experience we will pair a University of Michigan nurse practitioner student with a student from SUT. We will work in dyads to provide health care and community assessments in a smaller town outside of the university.

Today we whet our appetite for Thai food and culture. On four hours of sleep we jumped in and explored the city by public transit and took a cooking class. Tomorrow we load into vans to make the three hour trip north to move into our new "home" for the next two weeks.

We are excited to immerse ourselves in Thai culture and learn as much as we can about the people, healthcare, and ourselves!