Past, Present and Future

To say today was another eventful day would be an understatement. I think we all expected to be changed after coming to Thailand but we continue to be surprised in the ways that it has already begun to shape us. For some, today brought about a new appreciation of acute care, others, a painful new experience, and for us all, a new perspective on ourselves and each other. Today was, above all, a poignant reminder of the fragile nature of life and why we became nurses.

But let's start at the beginning. We began our day touring the Ban Prasat archeological site in the Korat Basin. We toured the museum and excavation site, viewing the delicate remains of an ancient civilization. I was in awe of the relics, bangles and pottery and such, so well preserved over 3,000 years. We were able to see a burial site, the deceased were buried with belongings they might want in the next life, they believed in life after death. Their remains told us so much about who they were and how they lived. I was struck by the similarities between the present day culture in the villages we have been working and the prehistoric people. The use of spirit homes, which look like miniature temples, where the spirits of the deceased may live so they do not cause havoc, is a beautiful tradition that has been carried on for centuries. The style of homes in the villages were also very reminiscent of the early civilization. Coming from such a young country, it was an eye-opening experience to see exactly what it means to have a deep and rich cultural history that has persevered for thousands of years.

Next we traveled to the Phimai Historical Park where we walked the grounds of Prasat Hin Phimai, a beautiful one thousand year old Khmer temple. Our tour guides shared the temple's history with us, however we most enjoyed the numerous photo opportunities among the spectacular scenery. We were able to take our "U of M" photo wearing our university garb.  This was followed by a trolley tour around the city, provided by a local businessman and his son. We toured another more modern temple, a magical feeling 350 year old banyan forest, and the hotel owned by the businessman. After a delicious lunch we headed off to our next destination.

Shortly after loading on to the vans we came across the scene of a motor vehicle accident that had taken place minutes before our arrival. Our vans pulled off the road and we unloaded, rushing to see what we could do. Our ER nurses sprung into action, assessing the scene for safety. We rushed to the side of a motionless victim, compiling what few supplies we had on us. My ER and ICU classmates began quickly and calmly working to assess the scene and plan the next steps. It was quickly determined that the person was alive, but had suffered enormous traumatic injuries, being thrown from a motorcycle without a helmet. It is in these moments that we as nurses feel lost, when we know there is nothing we can do although our hearts scream for action. The only comfort for us is knowing, that as this person passed, it was in a cloak of prayers and in the hands of those who cared, a final human right to which all should be afforded, although not always received. As we walked away from the scene once police arrived, we were thanked and offered prayers from the onlookers, a reminder that sometimes it is simply presence that is appreciated more than action and result.

We became stronger as a group by this shared experience. Our classmates who were on the front line of action were surprised by the ease with which they communicated and worked together, despite never having worked together before. Those of us, myself included, unfamiliar with this kind of trauma learned from our peers those essential first steps to consider when approaching a scene. We discussed how this experience, and really the entire past week, has revealed each of our individual strengths, to ourselves and each other, be it calmness under pressure, communication, assessment skills, teaching, patience, or flexibility and understanding when confronted with a new and unfamiliar culture.

The accident has lingered in our minds, our hearts a little heavier, our minds never far from the memory. However, as all nurses know, we must keep moving, we must keep our thoughts positive and persevere.

"There are uses to adversity, and they don't reveal themselves until tested. Whether it's serious illness, financial hardship, or the simple constraint of parents who speak limited English, difficulty can tap unexpected strengths." Sonia Sotomayor

Community: The Birthplace of Connection

“I know there is strength in the differences between us. I know there is comfort where we overlap.” 
― Ani DiFranco

This past Friday was the last day of class for our some of our Thai sisters that had been living in the Tajalung community for four weeks. For their last day, the students hosted Community Rounds, where the Thai and Michigan students, professors ("Ajahn" in Thai), and key community leaders traveled from house to house via van and bicycles to discuss the current status of each family's health and plans for follow-up.

In the span of the day we visited multiple community elders (called "grandmas" and "grandpas" with endearment by students and community members alike) with chronic diseases such as diabetes, high blood pressure, and high cholesterol. Throughout the day we helped create plans of care that involved creative use of available resources to promote positive health change. We witnessed a home-made "parallel bar" system that promotes physical activity, balance, and improves circulation to the feet.

Another patient reported to use that she lost 10 pounds in one month by reducing portion size and sugar intake and using a weighted hula-hoop for exercise 300 times per day (we got to trial the hula hoop and now have a fun new way to promote weight loss in our US patients!).

The Thai students used creativity to improve medication compliance for an illiterate patient by attaching symbols and pictures to medication labels. We acted as key agents for creatively coordinating access to healthcare resources by arranging transportation to and from clinic appointments, identifying ways for patients to seek health authorities through use of neighbors or family networks, and using community health volunteers to check-in on patients for blood pressure or blood sugar monitoring as well as to help ensure correct adherence to medication regimes.

While planning for health care in US homes may look different from what we see in our rural Thai community, there is a lasting sense of total partnership, trust, respect, and appreciation for the Thai students and healthcare team by the community members. Elders became very emotional when saying goodbye to their students (called look-nak-suk-sa) that had checked in on them, taught them about diet and medications, and lived as members of their community for the past four weeks. I can only hope that the love and respect earned by the community can be translated by us as future NPs in our US communities. I know that I have been personally inspired to carry that Thai spirit of creativity and connection in my future practice as a nurse practitioner in the US or wherever life's journey may take me.

Beyond The Comfort Zone

"Creativity involves breaking out of established patterns in order to look at things in a different way." Edward de Bono

After a full three days of clinic that got us quickly acquainted to the ins-and-outs of the Thai way of life, we were ready for some debriefing!  Procedures in clinic, diagnoses, and interesting home visit stories were experienced by all and needed to be shared! So we decided to do our debriefing over an American staple...pizza!  This was a nice change from the market cart food that we have all become accustomed to eating.  Although quite different in taste then what we are used to back home, it was a welcomed treat.

Sausage Pizza

Diagnoses we've covered in clinic and out at home visits so far have included A LOT of uncontrolled hypertension, many ulcers, cuts, abrasions, and bites that all require daily dressing changes, upper respiratory infections, dyslipidemia, allergies, rashes, previously undiagnosed diabetes, fungal infections, and parasites.  While these seem like common diagnoses, just like in America, treatment is often complicated by lack of resources, access to care, and/or patient compliance.

At times things are challenging simply because our approach to care would be different in the US.  For example, dressing changes have used only alcohol, saline, betadine, gauze, tape, and kerlix. At home, some of these wounds would comprise more involved wound care (eg: more frequent dressing changes, wound vacs, prescription ointments, etc).  It has been quite impressive, in fact, to see the creativity of the providers in managing complex patients.

A syringe barrel used as an external fixator

Like some clinics in the US, we also have limited medications that are readily available in clinic for treatment. At times there may be a medication or treatment option available, but no nurse or prescriber available to administer a treatment or medication.  This is evidence that resources, access, and scope of practice impact patient care across borders.  At home we may have many more options depending on patient's insurance and clinic locale. This clinical experience been an eye opening and challenging one for all of us, especially for those of us who have not had the opportunity to work in an underserved clinic in the US.  The skills we have learned from using what is readily available will help us all greatly in our future practice and is a good reminder that a little creativity can go a long way!

Thursday we had a rare day off from clinic because of a national holiday!  We took the opportunity to sleep in (though most of us were up by 6 or 7 AM) and spent the morning catching up on laundry, work-outs, and getting in touch with family. We were excited to explore more of Korat, by visiting the local zoo.  We traveled by "open air" taxi, which was a new experience for everyone.  We definitely didn't mind the wind blowing in our hair, given that it was incredibly hot and humid despite the partly cloudy sky.  Unlike in the States, animals in Thailand are allowed to be in much more open habitats that are much closer to guests, which allowed for us to not only get a close up look, but also to feed most animals. Some group favorites were the hippos and monkeys that seemed to love having an audience.

Tomorrow we will be back at our villages to wrap up the week. Our free time this weekend was filled with adventures, so stay tuned!

Katrina feeds a pigmy hippo

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.

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.

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!

International Connections

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

Sa-wat-dee-kah!

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!

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!