Tuesday, November 29, 2016


Traveling-it leaves you speechless, then turns you into a storyteller. Ibn Battuta

The reentry process is never easy.  Anyone who has traveled will talk of playing catch up with sleep, with current events, with friends and family, and with work/school.  At first it can seem overwhelming.  But being in a foreign country for a period of time offers a sense of protection, a buffer, that cannot be fully appreciated until one is home.  Upon return, it is easy to notice the NOISE.  We are no longer protected from the ever-present chatter as we hear and understand the words and interactions around us.

Less tangible, however, is the impact the experience has had on our personal values, our outlook, our sense of self. Henry Miller said "One's destination is never a place, but a new way of seeing things." The Thai culture and people are full of values that not only had an influence on our time there, but will continue to influence our lives and interactions as we move forward.






As we adjust to the eastern time zone and our domestic responsibilities, we can share our experience with the climate, the food, and the clinical experience.  Even more, though, we will become storytellers: the perseverance, the support of the community and nation, the overwhelming kindness of our hosts and communities.  We will notice subtle changes in our approach to patients, to families, and to life.

A huge heart-felt thank you to SUT, our communities, and our Thai faculty and hosts.  Your hard work and time is so appreciated.  Until next time, Thailand!!

A journey is best measured in friends, rather than miles.
--Tim Cahill

The Eyes of a Foreigner

       Travel, among all things is truly something that excites the soul. Quite honestly, the natural discovery of both tangible and intangible ways of life has a keen ability to satiate otherwise famished visions and perceptions.

       Prior to setting out, normalcy and taboos of the Thai culture, villages, and clinics were explained to us. Information such as the death of King Bhumibol, shoe removal prior to entering rooms, and cultural cuisine expectations were each addressed. Despite this knowledge, nothing could have prepared us for what we experienced by actually being present in the country. 

       With respect to the death of King Bhumibol, never has a  more powerful sorrow been felt. The ENTIRE country was mourning the death of King Bhumibol Adulyadej who reigned from June 1946 to October of 2016. Signs, posters, pictures, and banners of him were posted and acknowledged throughout the country. Every home we visited had a beautiful, grandiose shrine of this honorable man surrounded by other significant figures including other family members and because most people are Buddhist, Buddha. When we visited The Grand Palace, everyone was wearing black. Little black ribbons were provided for the attachment to our scrubs as we worked through the villages and clinics so we could also show our respect for the King. 

Something about living through such an entirely, highly regarded respect one has for another human being is simply beautiful. As this resonates, because it continues to, I will always be conscientious of the admirable qualities, achievements, or abilities one possesses, being sure to honor these characteristics with subduing respect. 

       In addition to respect, consideration for others was also consistent throughout the community without fail. A core part of our experience in Thailand involved partnering with our Thai sisters from SUT, and performing home visits throughout the village.  Before beginning this experience, this was the single most stressful idea to me!  Having had community health clinical experiences in the US as an undergraduate student, I expected that there would be resistance and lack of enthusiasm by the villagers to having a group of students enter their homes, and that they may perceive the discussion of their health as an invasion of privacy.  I was so wrong!  Starting from the first home we visited, I felt welcomed and appreciated, despite speaking a different language than everyone around me.  

(Making home visits by bicycle in the village)
       The villagers were overwhelmingly enthusiastic about seeing us; they welcomed us into their homes and stores, were engaged in conversation with our group, and would ensure our comfort, whether that meant offering us water and fruit, or offering us all a place to sit.  Many village residents were overwhelmingly excited to show us their yards and homes, and their friendliness and kindness permeated every interaction.  Many people even made an effort to talk with me in English when they could, and used their gestures to express hospitality and gratitude when we couldn't communicate with each other verbally.  While life in a Thai village is incredibly different from life in an American suburb, there were lessons I learned about being respectful toward others, providing comfort toward those who enter my home, and being fully present in every moment.

       Lets talk food! The Thai diet is much different from the familiar westernized cuisine consumed in America. It consists of broth based soups, various types deliciously prepared curry atop rice with fried eggs, grilled meats, seafood, fish sauce and spicy chilies. Dishes are served family style as opposed to in courses and mixes of spicy, mild, and sweet foods are served together as to neutralize the palate. Native herbs and spices such as the kaffir lime, Thai basil, lemongrass, and dried red chilies produce mouth-watering flavor combinations. Also, the Thai way consists of eating only when hungry and avoids placing emphasis on "3 meals a day" or "small meals every 2-3 hours." This contributes to fostering a being present in the moment type of dining experience. In addition, the cuisine lacks the added fats, oils, sugars, and caloric sweeteners that goes into the preparation of westernized foods-- and also, cheese! Remarkably, cardiovascular disease is much less prevalent in Thailand than it is here suggesting diet really does play a strong role in disease.

(Various vegetables and herbs we gathered at a market prior to learning how to prepare a 5 course meal at Silom Thai Cooking School!)
       Lastly, as mentioned in a previous blog post, the work ethic of the Thai people is quite impressive. We witnessed a sweating, diligent, hard-working gentleman turning a pottery bowl. Later, we learned the amount of money earned for completing such a cumbersome, repetitive task for a consecutive 8 hours! An amount that through foreign eyes could be viewed as potentially inhumane. This has made me appreciate things I may sometimes take for granted. 

"Certainly, travel is more than the seeing of sights; it is a change that goes on, deep and permanent, in the ideas of living" -Mary Ritter Beard

With Love, 
Julia and Lizzi

Wednesday, November 23, 2016

Thailand through a Pediatric Lens

Two out of ten of us on the trip are Pediatric Nurse Practitioner students. Similar to the United States, the majority of the people that seek healthcare in Thailand are the elderly. This created a bit of a challenge for the two of us, as our population was a bit harder to find. Luckily, we also had some unique benefits that made our experience different than anyone else’s. For example, we were both very fluid with our clinic placements. We followed the children, and if they went to one clinic but not the other, we would, too. This was very special to us because we got to see the differences between each clinic, and all of the care that each encompassed.

In Thailand, they set aside certain days to perform developmental assessments and vaccines for the children. The first day assessment day in which we participated was for babies up to 9 months old and was held at the Dan Kwian clinic. The patients were assigned a number upon arrival and used this to transition from different rooms to accommodate registration and measurement, developmental assessments, and vaccines. During the second week that we were there, we got to repeat the process with toddlers, ages 9-24 months. We were very impressed by the organization of the process. All of the toys were separated into cloth bags, and were labeled with the age group with whom they belonged. For example, in the 2 month-old bag, you can find a rattle, in order to test the baby’s gross motor movement. Each child was accompanied by a booklet that contained details about growth, vaccines, variations of normal, any health conditions, and medications given. The booklet always came to the clinic with the child, whether for a sick or well visit, and everything was easily recorded and congruent.

There were many familiar elements of this assessment day- the developmental screenings were done using milestones we have learned in our programs, the growth is charted to ensure adequate nutrition and screen for possible metabolic concerns, and many of the vaccinations we also administer in the United States (one exception is a three dose series of the Japanese Encephalitis vaccine). Adjusting to technique and supplies differences was initially challenging, but we had the support of the nurse practitioners in the clinic to guide our learning. We were extremely impressed by the strength the children demonstrated when getting vaccinations- tears and screams were rare.

Schools were frequently used to provide assessments and support pediatric patients in the community. Kids of all grades were familiar with the 10-point evaluation used to screen for signs of abuse, skin concerns, dental caries, lice, conjunctivitis and other ophthalmologic issues, musculoskeletal and bone deformities, and deviations from normal gait. Vision screening and growth measurements were also included in each assessment day separate from the 10-point evaluation, and a heart and lung assessment was added by the SUT students. During one school visit, two dentists and a dental student were present to assess the oral cavity for caries, administer an injection of local anesthetic, and remove diseased baby teeth. This was a remarkable process to witness, both for its efficiency and for the incredible bravery each child demonstrated. We were again able to see the strength of this population.

In the community, we were able to participate in the assessment of a jaundice newborn who had just returned home from a 24-hour hospital stay under bilirubin lights. The baby was three days old when we met him and he could not have been more adorable! We asked about the number of wet diapers, sleep, and postpartum depression and found that both mom and baby were doing really well. The multigenerational household standard was clearly beneficial from the standpoint of childcare, as this newborn had multiple caregivers and mom was able to rest and recover.

We were so grateful to have had this cultural experience. We saw many differences as well as many similarities in pediatric health care delivery between Thailand and the United States. There were many things to be learned from the Thai population and their methods of healthcare delivery, and we will take some of these lessons home with us to be implemented in our careers.

Friday, November 18, 2016

Primary Care in the School Setting

School assessment and health education in Thailand is quite similar but also different in interesting ways than how it occurs in the United States.  It was really fun to be able to teach the kids little songs and dances to remember proper hand-washing and teeth-brushing, as I’m sure many people remember these fun songs from their childhood.  I was impressed that the Thai preschoolers learned a lot of the songs in English!  It was also impressive to see that the kids were learning another language at such a young age.  Some interesting differences arose in the process of the physical assessments.  For example, EVERY child in the school came out of class and sat patiently while they waited to see the nurse. During the health screening, the University of Michigan and Thai students were able to do a number of assessments on each child: skin, teeth, hair, heart and lungs, and scoliosis checks.  Many of us have limited experience working with children, so it was very helpful to get the opportunity to do SO MANY child assessments in a row.  We were able to evaluate many normal assessments as well as identify potential health issues, such as dental caries.  Although this appears to be a more common problem in Thailand than in the United States, free fluoride and dental work are provided to children at the community health promotion hospital.  This is an interesting difference from the United States as many people cannot afford dental insurance and forgo treatment of dental issues.  When we compared the assessments of dental hygiene in younger children versus the older children, it was clear that the kids here are participating in the dental care that they need as they age.    

With the help of our Thai brothers and sisters, we were able to identify a severe heart murmur in a 15-year-old student. More history revealed that it was a new murmur, and while the student reported feeling well, his heart rate was significantly elevated. Our Thai colleagues were able to identify the abnormal finding and, with our help in history taking, elicit more details. It was a first time for us to hear a murmur this pronounced and palpate a thrill, but it was a valuable learning experience for all of us, Thai students included. We were also able to educate and reassure the student while ensuring that he would follow up with the local hospital the next morning, although in the US this probably would have bought him an E.D. visit. Since the health promotion hospital works very closely with the school, we learned a couple of days later that he was admitted to the larger hospital and would be having surgery the next day. The school health assessment was invaluable in identifying and coordinating treatment for this young man, particularly because he was not symptomatic. We were impressed by the collaboration within the community, the Michigan students and the SUT students to follow up with his care.

At the end of the day, we were able to observe a small Loi Krathong ceremony put on by the school children. This festival thanks the river for providing life to the fields and forests and asks for forgiveness for the polluting ways of the humans. Beautiful handmade boats, made of banana leaves, flowers, and candles, were placed into the river by the students. It was a perfect end to a unique and insightful couple of days.  This entire day was a great reminder of the valuable experience that we have gained thus far while in Thailand, gaining knowledge about another culture while also furthering our skills as future nurse practitioners.

Thursday, November 17, 2016

The Siamese Fireback and the Bees

During our first week in Don Kwian, two of us accompanied our Thai sisters to a primary/secondary school in a nearby village. The purpose of our visit was to assess the community health needs of the children, of which many were identified. At the end of the meeting, we were asked to collaborate with our Thai sisters to develop a sex education program for the secondary school students, to be taught four days later. In Thailand, comprehensive sex education is expected in schools, and we were elated to be included in such a unique opportunity!

(Two of our Thai sisters holding a banner they created for the day.)

When collaborating, we were astounded at how dedicated the Thai students were to this assignment. They quickly produced an intricately detailed schedule for the sex education session, and created high-quality, engaging posters on contraception, puberty, and sexually transmitted infections. Not only are these young women phenomenal students, they take an incredible amount of pride in the education they receive. They exert gratitude and respect for others at all times, even when they are exhausted from sleep deprivation, immersing themselves in a new community for six weeks, and working diligently together through all hours of the day and night.

(Julia introducing the sex education presentation with our Thai sisters, Eve and Ped. Notice Gel rocking out on the drums!)

Moreover, our Thai sisters seem to work magically well together. They fall into an intricate rhythm of enthusiasm, warmth, and supporting each others' strengths. This fostered an open, accepting environment for teaching and learning about such a potentially sensitive topic. Their work was well-organized and thorough, and they were dedicated to using multiple teaching modalities to effectively communicate with the adolescents.

On the day of the presentation, our Thai sisters impressed us all with their ability to garner and maintain the interest of skeptical, reserved adolescent students. From the ages of 12-17, children present unique challenges to teaching that force educators to devise creative solutions. The topic of sexual education is not exempt from this and is arguably an even more difficult subject to teach due to the potential for awkwardness or discomfort.

(One of the fantastic posters our Thai sisters produced!)

Nonetheless, our Thai sisters excelled in teaching sexual education and "bringing it all together" by playing a game with the secondary school students. After being seated in a circle, a balled up piece of paper was passed among the students in a quick fashion a la hot potato-- a game our Thai sisters called "cabbage." Music and dance accompanied the object being passed, provided live by our Thai sisters, and a stop to the music meant whomever holding the ball at that moment would be brought into the middle of the circle. After entering the middle of the circle, a layer was removed from the ball of paper like an onion shedding skin, and the piece of paper contained a scenario. The scenarios reinforced and applied knowledge taught in the sexual education lecture, challenging the secondary school students to synthesize and practice with new information. Audience members cheered and chuckled as the student in the middle navigated the scenario. The sheer ingenuity of this game cannot be overstated, and everyone involved seemed to enjoy the game tremendously!

Creativity in the classroom is decreasing as teachers and parents are more reliant upon technology to educate students. However, technology is often exclusionary and alienates the human element of learning. In this sexual education lesson, our Thai sisters inspired us to implement innovative thinking when teaching. As healthcare providers, much of our teaching occurs in the office setting. This activity demonstrates that opportunities for teaching extend far beyond clinic hours. Most importantly, constructing clever ways to communicate health information is tremendously beneficial for learners and teachers.

The dedication and compassion towards community health exerted by our Thai sisters was tremendously inspiring.
As future Nurse Practitioners, we will incorporate and apply all we have learned throughout this experience as we strive to provide a platform for open communication, acceptance, and comprehensive education.

With love Aubree, Cassie, Jordan, Julia, Lizzi, Misha

Tuesday, November 15, 2016

Happy World Diabetes Day...from Thailand

Today we celebrated World Diabetes Day from an international location, Nakhon Ratchasima, Thailand. While we didn’t spend the day treating diabetes specifically, I was able to reflect on the diabetic population in Thailand as well as at home. 

We are quickly learning how differently this disease is managed around the world. While it seems Europe and the US are using cutting edge technologies for management, rural Thailand seems to have a different approach. In fact, regular insulin is still used for management. 

Similar to America, type 2 diabetes is the most prevalent type in Thailand. However, I will always have the type 1 population in the forefront of my interests, and closest to my heart. I am so fortunate to celebrate this day from such an exotic location across the world while learning about different approaches to care.

Wishing my colleagues and friends a happy Diabetes Day! I encourage everyone to learn something new about this disease process today!!

Saturday, November 12, 2016

Patient Centered Care: Crossing Borders

One of the distinctive events of our clinical immersion is that we have the opportunity to tour our community, on foot and bike, and meet patients in their home.  During this process, we came across a very sweet family, who had just finished bathing their elderly mother.  As we approached the home we observed flies swarming around her feet that were covered by a blanket. When we removed the blanket we noticed that her left second toe was discolored and appeared to be ready to fall off.

With  interpretation by the Thai students and professor who were with us, we worked to do a thorough evaluation of the patient. She stated that the toe was once painful but she now had limited sensation and no pain. When asked why she did not seek care for this issue, she replied that she thought it would cause more pain.  The family stated that they had taken their mother to a health care provider, but were unsatisfied with the treatment plan offered.  These feelings have continued to impact the way that the patient and family utilize health care services. 

During the home visit we, along with our Thai brothers and sisters, developed a plan that included the priorities and values of the patient and family.  We were able to work with the clinic and the community to provide transportation to this patient who had limited mobility.  Once she arrived at the clinic, we were able to not only complete the dressing change without pain to the patient, but we were also able to teach the family how to help care for the wound while at home. Our Thai sisters also used an innovative method to catch bugs as an additional method to keep the wound clean. 

As providers, our priority was not only to provide a painless dressing change, but to also develop a plan that was acceptable to the family and patient.  Regardless of culture or country, patients and family members seem to be more invested, have more trust, and are more willing to participate in their health care if providers are able to communicate and demonstrate that they value the opinions, values, and needs of the patient and caregivers.  

Upon reflection of this experience, we were able to recognize some similarities and differences with wound care in the United States.  We appreciated the fact that the process of dressing changes was different; there is a greater appreciation and conservation of dressing supplies without compromising the need of the patient.  In the US, we tend to be less thoughtful with our supplies or resources. Unfortunately, we have observed instances in the US and abroad in which people are prescribed treatment plans that do not fit in to their lives or their belief system and therefore fail.  We have witnessed fear and lack of trust in our health system act as barriers to care.  While these are very complex issues and lack a simple solution, working to be inclusive with your patient's needs, priorities, and values is an excellent start to decreasing these barriers and improving overall care and patient outcomes. 

Thursday, November 10, 2016

Thailand: Relearning fundamentals

Today marks one week since my initial arrival in Seoul, South Korea, but with every day that passes I continue to re-learn behaviors that have been ingrained since toddlerhood. From the moment I arrived in southeast Asia, it was immediately clear that this way of life is much different.

America is loud!

After deplaning in Seoul, I entered an airport environment that was distinctly different from any United States airport I have encountered. The airport looked the same externally and internally, and the weary travelers didn't look much different than those of America. But it sounded so drastically different that it demanded my attention even in a jet-lagged state. It was silent!

Hundreds of people were lined up to board the train to transport travelers from one end of the Incheon airport to another, but nearly everyone was silent.

Not to mention the bathroom that had a small soap dispenser attached to the wall with instructions to clean the seat before sitting, and the array of mysterious Korean labeled buttons attached to the toilet seat (which I later learned to be a bidet).

Which brings us to our next topic...

Don't sit on the toilet!

In Thailand, I don't have to worry about enigmatic Korean buttons on the toilet, because many toilets are simple 12" tall rectangular pieces of porcelain better known as "squatty potties".

While city and well-developed areas in Thailand usually have access to western toilets, most developing or rural areas of Thailand rely on the more traditional toilet. There is no handle to flush, either. The small spicket on the right (photo above) is used to fill a basin with water. Pouring the basin down the potty is what flushes the waste.

Don't put toilet paper in the toilet!

If you ever want to feel confused at the most primitive level, try re-learning how to use the toilet. Due to the dated and struggling water treatment system that Thailand utilizes, toilet paper cannot be flushed. This includes both western and traditional toilets, although I have been told that large new developments, like swanky hotels, can handle toilet paper being flushed. There is usually a sign by the toilet warning you to not flush toilet paper. This is all assuming you remembered to bring toilet paper with you - notice the absence of a toilet paper dispenser in the bathroom?

Adventurous eaters welcome

Ok, enough toilet talk. If you are someone that finds the thought of exotic dishes like chicken heart, coagulated blood, or langsat enticing, you will enjoy Thai cuisine very much! The crucial re-learning process of eating in Thailand has revolved around two things. 

First, try a small bite, and be ready for some spice. Many of the flavors are brand new to American palates, and spice is used liberally in Thailand as the essence of flavor. Second, get used to using a spoon. Rather than forks, Thais traditionally use a spoon with raised edges (seen in photo above). If forks are provided, they are traditionally used to scoop food onto the spoon.


Last but not least, smiling is the foundation of socializing in Thailand. Natives have smiled at me and my American colleagues with every encounter, and they always start with saying hello in the native tongue; an enthusiastic sa-wat-dee-ka! This is a stark contrast to how strangers are greeted back home in America. 

Yes, we are visitors here, and that could be responsible for some of the friendly welcoming. Nonetheless, I constantly observe natives greeting each other in the exact same way - a warm smile and a happy hello. Thai people are kind, welcoming and selfless. We have traveled from bustling Bangkok, to small urban cities, to rural villages. Everywhere we go, the warm embrace of friends and strangers remains constant. It's a very special feeling to feel welcome everywhere you go.

The Thai culture is simply beautiful, and we are truly privileged to be here.

Monday, November 7, 2016

Culture & Tradition 101

The University of Michigan School of Nursing has returned to Korat and Suranaree University of Technology (SUT) for another global clinical immersion.  Our first days have been filled with opportunities to experience culture and tradition. While the students were learning about Thailand and Thai history in the community, the faculty had the opportunity to participate in graduation ceremonies on campus.

Discussing Michigan and B1G football with SUT Rector and Dean of Nursing

SUT graduated over 2500 students from several different programs.  This year the students received their certificates from the Crown Princess who was present on behalf of King Bhumibol.  As a cultural outsider, it was amazing to be able to witness the respect, tradition, and honor that was palpable across campus.  Similar to a graduation in US, the faculty and students wore gowns that represented their levels of education and programs, they marched into the auditorium, and students were presented with diplomas and awards. In contrast, the families were seated outside of the building during the ceremony and there was no clapping at any time (out of respect for King Bhumibol).

Despite there being thousands of students who's names were read, the ceremony was quiet and respectful. As the students moved across the stage to receive their certificates, it was like watching a performance where students bowed and stepped as if they innately knew a graceful dance of tradition.

Tribute to King Bhumibol
It was such an honor to be included in the graduation.  We love our time at SUT and our Thai colleagues and students.  The last few days have provided a glimpse into Thai culture and tradition and is a reminder that students gain so much more than patient contact hours.  Intangibles such as tradition, honor, respect, and value have the potential to impact our students not only in the short term during the clinical immersion, but can also carry over into clinical practice far after graduation.

We are our culture and tradition; if there is no culture or tradition we are no one. 
--Tamerlan Kuzgov