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.

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.

MB

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.

Unexpected Culture

Betel nut, also known as betel gum or Areca nut, is vibrant, red, tomato paste-looking substance.  It is not actually from a "beetle," and it's quite alarming when you first see an adorable 90-year-old Thai grandma with an apparent bloody mouth.  Similar to a baseball player chewing tobacco, betel nut is held in the mouth and is quite surprising if you have never seen it.

I'll never forget my very first betel nut encounter. I could not take my eyes off our patient's mouth. Her lips, gums, and even teeth were deep red and it was difficult to determine the cause. When I asked my Thai sister what the cause was she paused, glanced at her fellow Thai sisters, and giggled, "it is culture."

"Culture" is right. 

Betel gum, consists of three main ingredients: bai plu leaf (betel leaf), limestone paste (calcium hydroxide, made from baked sea shells) spread thinly on the leaf, and betel nut (areca nut) which grows in bunches similar to grapes. Often tobacco is added to the betel gum, or used afterwards as a "teeth scrub" to freshen the mouth. Depending on preferences, other spices are added as well. Everything is pounded together, usually with a wooden or brass mortar first and then put into the mouth. A bucket or basket is usually close by, for the chewer to spit in. The aroma is pleasant, a bit like menthol, and younger Thais will tell you when they smell it they think of their grandparents. 

I never encountered any discussion of betel nut in my research or preparation for my trip.  Like most cultural education, however, nothing compares to actually seeing and experiencing culture first hand.

"A nation's culture resides in the hearts and in the soul of its people."  Mahatma Gandhi

Thai Traditional Medicine

It has been an eventful trip so far! We were happy to have a free day today and be able to take a rest from long van rides and hot days in the community and the clinic. We went to the mall, which was slightly overwhelming with four levels and tons of stores. We heard about a grocery store in the mall so we hunted it down and stocked up on snacks (mainly nuts, peanut butter, chocolate, and Nutella) which we are not getting in our Asian buffets! (sigh)

In the clinic there is a Thai massage therapist that also specializes in herbs and homeopathic medicine. Her name is Sompont and she is available for all of the patients if they needed. I interviewed her with my wonderful translator, Dr. Patama, last week and learned a wealth of information regarding traditional Thai medicine.

The massage therapist shared with me 5 concepts that are key in Thai homeopathic medicine. The first is the use of herbs. Members of the community will donate herbs to be used for different therapeutic modalities. She also has a garden in the back of the clinic with some of the most commonly used herbs: ginger, lemongrass, camphor, finger root, and turmeric.

The second concept of healing that is important to Thai culture is food. Depending on your birth month there are certain foods that are considered to be of most benefit. For example, since I was born in December, my foods are lime, strawberry, oranges and fish. Guess I’ll be eating more of those!

Another important concept to Thai people is the use of massage. Unlike other types of massage, Thai massage uses fingers, elbows, knees, feet, and any body part that can be utilized to release tension. Thai massage is unique in that they use a lot of stretching techniques that are incorporated throughout the massage.

The fourth idea is the use of warm compresses. I was able to see this done because there was a patient who had fallen a couple weeks previously and she was in the clinic for her physical therapy, which included the use of a warm compress being pressed into all parts of her legs and arms and back by the massage therapist. The compress contains ginger, tamarind and patchouli and the function of the compress is to relax the muscles of the body. I was getting quite relaxed myself simply being in the room and inhaling the delicious smell of ginger!

Lastly, the use of steaming rooms is common. She had such a room in her clinic area, and it consisted of a wooded area about the size of a closet with a door that trapped the heat. There was a seat inside and beneath that she placed a boiling pot of water with the following herbs: ginger, banana, lemongrass, zingiber and balsamifera. This room is utilized by women who have just given birth. They come in 3-5 times and sit in the room for 30 minutes. Through the inhalation of the herbs in the boiling water the women undergo vasodilation and increase their blood flow. It is also believed to increase the flow of breast milk. This is a Thai tradition that goes back 1000 years!

It was very informative to be able to learn more about Thai traditional medicine and the aspects of care that are fundamental to this culture. It seems that homeopathic solutions have more of a place here in Thailand and the Asian culture in general than in western medicine. I will be excited to take this knowledge to my practice in the United States!

Gratitude At It's Finest

First day of clinic

Upon arriving in Korat, our group dove right in and began working with both the Thai nursing students and the community. While working in clinic and providing health assessments in designated villages, our group quickly realized that the "Thai way" varies greatly from that of many other cultures.  The primary aspect of the Thai culture that immediately stood out, was the level of gratitude expressed by all in the community.  

Gratitude is defined as "readiness to show appreciation for and to return kindness."  Throughout our first week in the community, I found myself astonished at the level of gratitude expressed by the residents of the villages.  The people of our community were both ready to have their health assessed and eager to learn about ways to modify their lifestyle choices.  After completing community visits with residents who own very little and struggle to provide enough food to feed their families from week to week, many villagers would offer us food, drinks, and gifts to show their appreciation.  Others offered to teach us their occupations, such as dyeing silk and making rice noodles to sell at market.  

Learning the silk dyeing process

Thai Nursing faculty- Nar learning to make rice noodles

I found myself surprised at these heart warming gestures, as in the United States this is not always common practice.  I hope to be able to embody this aspect of the "Thai way" into my daily life back home, and look forward to our second week working with the people of Thailand. 

Arms Wide Open

     In coming to Thailand, I was mentally aware that we would be faced with quite the language barrier. In preparation, I had made notecards with basic Thai phrases and rehearsed them in my spare time at work or sitting at home. Let me tell you, that pretty much got me through "hello" and "thank you." I quickly learned today, from our very patient Thai sisters, that the dialect and enunciation of Thai is a delicate and beautiful language that will take years of practice. Seeing that we only have 2 weeks here, I have never been more thankful for students willing to take on an American girl with a nasally Michigan accent. 

     Today we had the opportunity to teach a morning class of Sophomore Thai nursing students basic physical assessment. We were greeted by excited, giggly students waiting with anticipation to learn in a lecture hall. After introducing ourselves, two of our gracious counterparts volunteered to demonstrate in front of the lecture, a head to toe phyical assessment (in English). Following that, we broke up into small groups in the nursing lab of one NP student from our group and about 6-8 Thai sophomore students. In teaching a head to toe assessment with no Thai experience, and minimal English from the other side - we became quite good at charades. The students were enthralled with learning how to look, listen and feel to assess their patient - many times that being me. Wrapping up the small group session, the group insisted that we take a picture 'selfie.' Once again, I realized we were being schooled in taking selfies - or any picture in general. In attempt to thank the students, I put my hands together and performed my best 'wai,' or Thai bow, while saying "khaawp khoon kah," or thank you. A symphony of giggles errupted from my group. Slightly befuddled, I asked if I said something wrong. Immediately one of the girls came over and pushed my elbows down closer to my sides and motioned how to bow correctly without looking silly. We all erupted in laughter as I tried again, apparently failing once more - hopefully I will catch on by the end of our stay. 

     Our group in the lecture hall with the SUT sophomore nursing students.

     Following lunch, we were introduced to our Thai sisters that we would be paired with for the remaining 2 weeks. Once again, we were split up into small groups to review a more advanced head to toe assessment. These SUT students are in their senior year, and have a much broader scope of practice in Thailand than our BSN students in the U.S. They are in their community clinical rotation, and plan to spend a total of 6 weeks in the villages we will be placed in learning every detail about each family dynamic along with chronic and acute disease management. Determined and meticulous would be two words to describe the group of Thai students we are placed with. Over the next couple of weeks, I am excited to learn more about the culture, language, and individualality of each student we are placed with. They call us "phie" (older sister) and they are our "noong" (younger sister). Today we were greeted with open arms, and together we plan to live and work together to build a stronger community.

     SUT sophomore students learning basic assessment

Getting ready for orientation!

Breaking into small groups to discuss community needs

Excited to learn much more,

H.