Injections and Flannel Boards

It was a busy week here with only Dr. Nilson and I running the program without any additional help this week. To top it off we both got violently ill on Wednesday evening and all day Thursday. We made it back to the training center Friday but we were nowhere near 100%. In fact on Wednesday night and most of Thursday I was so sick I could not even sit up for more than a few seconds at a time. We are both much better now and back to our busy schedule.

The Barefoot doctor’s training this week started off with more quizzes and student presentations. You can see here a few of the students presenting on arthritis and hypertension.

On Tuesday we had the students learn about and practice injections

on oranges. Once they had the technique down for intramuscular injections we had them practice on each other! We

had ordered 15 Tetanus vaccines for about 11 of our students as a booster after receiving their 1^st shot last year. That is right. About half the class had never had a tetanus shot before last year. Three of the extra shots went to students who had one tetanus shot in their life but never a booster and one was a simple booster shot for a student. They all did very well with this skill and now can

give vaccine shots back in their homeland when needed. Some of the students live near clinics that will give children vaccines if the parent brings the child into the clinic. This may involve walking for miles or even days. Other villages do not have a clinic or sometimes the “clinic” does not have vaccines or even electricity. If you do not have electricity you can not properly store the vaccine so it is not much help in this area. Our hope is that now that the students are trained in giving vaccine injections, they can work with whatever government or non-government personnel may be in the area to help get the children and adults vaccinated. Even if vaccines only come through an area once or twice a year, you can get a lot more people immunized with more people power. Additionally, the Barefoot Doctors will have the trust of the people so hopefully the villagers will take their advice on getting their children vaccinated. We have heard many stories of villagers who refused to get their child vaccinated because of fear and mistrust of the government officials giving the shots. We have heard more examples of simply not having any vaccines available in their areas.

On Wednesday I started them on a flannel board project. This involved a flannel cloth board used to stick other flannel-backed pieces to it with pictures on them. I had them break into 4 small groups to prepare the projects.

The presentations got off to a rough start and I was worried maybe this was a bad idea and going to be a total waste of time. By Friday the presentations were amazingly good! I could follow the story without the verbal translation! The groups who did the best presentation then had to give the 5-person kitchen staff their presentation on how germs are spread and how to minimize this. You can see in these pictures that in the early presentations the drawings are small and unclear, and they put all the pictures up at once and then pulled them off and pointed to them as they talked (very distracting), even though they were clearly presented. By Friday they had great

drawings and cut outs that were large, easy to see, and simple ones, and only one idea at a time was on the board so anyone can follow along. In this way, the story is clearly presented even through language barriers.

The idea of the flannel board is you can use pictures to tell a story in addition to the words you are saying. This is particularly helpful in areas with little or no education or when teaching across language barriers. So this lesson is not only to teach them but also to teach the students how to teach others. By drawing and

preparing presentations the students learn the subject even better. If they feel this technique is useful, it is lightweight, compact, cheap, and easy to take anywhere in your back pack.

I am very proud of all the Barefoot Dr students. They are doing a great job and are passionate about their work.

Until next time Sawadee Krup,

Rick Astone

Border Run

Over the weekend we made a trip to the Golden Triangle so we could cross the border and get a 2-week extension on our visas. An added bonus was getting to go to Timothy’s house on the Burma side for lunch. We had a big crew of Dr. Dave, Cyril, Bjorn, me, and Lydia one of the English teachers for the FLC Mission. Of course Timothy was guiding us around and BeePal our driver provided his van for the long drive up to the border. Moses, one of the Barefoot Dr students also came to see his 3 yr old son in the hospital. His son is fine now and back home but would appreciate your prayers. As for the rest of us we had a great adventure. We got in late and stayed the night in Mae Sai, the border town on the Thailand side.

The next morning we had to cross the border and then go to breakfast in Burma with Timothy. It was actually pretty good but the atmosphere is quite different than on the Thailand side of the border. There was a lot of yelling and running in the busy street side restaurant. This has a tendency to make one a bit on edge but we never felt threatened. Then it was off to visit a pharmacy to see what was available and the prices of meds we will be recommending for the Barefoot Dr. Students. Very interesting for all you medical types. They have a mix of Chinese, Indian, and western medicine with strange rules of what you can buy over the counter and what you have to get from a hospital. For example, you can buy antibiotics over the counter but one of the best malaria drugs available you can only get through the hospital. HIV meds are only available through the hospital but adrenalin injections you can get at the pharmacy. Of course you have to be on the look out for counterfeit medications in Burma as well, but usually the pharmacist can tell what is ok and what is not so good. The poor pharmacist got very nervous with all the questions we were asking. I thought he was going to kick us out of the store when Cyril whipped out his video camera. After we explained who we were and what we were doing the pharmacist was extremely helpful. It was a good example of the underlying tension and fear that exists in that country, and yet there are many good people living there.

Timothy’s house for lunch was a real treat. Fabulous food prepared by his wife and a good time looking at old cross bows hand made from wood and bone Timothy used for hunting in his younger days.

The Doctors got a chance to examine a few patients as well. Timothy had treated the neighbor’s boy for TB last year and he is now totally recovered, but his mother was concerned and wanted Dr. Nilson to take a look at her boy. She also was worried maybe her other boy had TB as well. Both boys are totally healthy and the family’s worries were put to rest after having a pediatric expert like Dr. Nilson examine them. One other fascinating patient at Timothy’s home presented herself with

“Moth – eaten” alopecia! The verdict is still out on that one but a very rare condition to be sure and one that needs more medical work up by a hospital.

On our way home we stopped and saw a few sites in the Golden Triangle including a small opium museum. It was very educational to us and has important implications to our work, not only medically but socially as well.

It was back to work this week. It is just Dr. Nilson and myself from here on out with a one-day exception of help from a local Dr. So pray for us to have endurance.

Thank you all and May God bless you.

Rick

Week 4 completed

We finished up week 4 on Friday and said goodbye to Dr. David Brumwell and Cyril Thomas, PA. They did a great job and were a huge help to us and this program. The students enjoyed all the hands on activities. They really seem to learn best by doing things rather than book learning. We finished up Friday teaching them how to place foley catheters on male and female manikins. This is a relatively simple technique that will allow a bladder to empty if a patient is unable to urinate on their own. Then we said our good byes and of course a lot of picture taking at the end.

As usual, the instructors both had a profound experience through teaching in this program. They were touched by the students' passion and dedication to help others. We all hope and pray they will be able to return next year to contribute again.

After that we headed straight for Burma! More on that trip later.

Help From the ER Guys!

Well it has been an exciting few days with the ER guys here. Yesterday was suture lab using pigs feet. This is always a favorite for the students. It is truly amazing how quickly they pick up hands on skills. Some would even say these students are better at learning skills then American students. Above you can see Dr. Dave demonstrating lancing an abscess after Dr. Cyril showed us how to project live images onto the big screen using the camera in his computer. This is a huge advantage in showing them all a small scale technique. Especially when you are dealing with a language barrier.

Dr. Dave and Cyril have been teaching a lot of exciting and useful subjects including what to do for a patient after a motor vehicle accident, as seen in this picture.

Yesterday after class we made a trip into town to see a local dentist for our two patients with severe teeth issues. Since we have been unable to find any dentists willing to help us teach these students we had to take them into town to get treatment. There is a very nice Christian Dentist in town that was extremely nice in helping us out with this, but he was unable to treat one of the students because of his high blood pressure. We treated this student as a class last year and had his BP well controlled. Like many patients in the USA he stopped taking his BP medicine after a few months because he was not feeling sick from his high BP and felt the medicine was making him a little weak. So we use this as a perfect example to the class of what not to do and why it is important. After spending about 4 hours belaboring this subject from every possible angle I don’t think he will stop his medicine again.

We fond some old pulled teeth in the training center from years past so we put them out for the students to see. Simply horrible teeth! I don’t think you would ever see anything like them in the USA. Just take a look.

That is all for now. We head to Burma this weekend to get our Visa’s extended for our last two weeks in Thailand.

Half way through!

Not only are the Barefoot Dr students halfway through the second year but they are also half way through the entire program! Of course that means Mid Terms! On Friday we gave them their mid term exam and we will grade them Monday. This is good to see how the students are doing but also how we are doing as teachers. If there are any class-wide trends of missed questions, then likely it is do to our teaching and not the students. We will use this information to further tailor the program to the students needs. All the teaching staff ends up learning and growing from this experience as much as the students.

We also had Dr. David Brumwell return and Cyril Thomas MS PA-C join us on Friday. They were not scheduled to teach until Monday the 14th but they were so eager to get going they started Friday. Dr. Nilson and I could surely use the extra help.

Dr. David and Dr. Cyril, as they are known by the students, are both from San Diego. They work at Kaiser Permanente Medical Center ER. Their skills will be very valuable to the students.

Dr. David’s daughter Alexis also joined us for the day on Friday just to see the program. She quickly was recruited as a practice patient as

David and Cyril taught on choking and CPR. In these pictures you can see Cyril 1^st demonstrating and then having the students go through the procedure for an unconscious choking victim, using David as patient. Also, there is a picture of David demonstrating on Alexis the jaw thrust while showing the “look, listen, and feel” of CPR. Alexis was actually a big help in allowing the patients to practice on a real person.

Cyril started out by giving them all a small gift of a T-shirt. They loved the gift as you can see by the picture.

For dinner that night Dr. David requested we return to his favorite worm serving restaurant so his daughter could enjoy the fried bamboo worms for herself. Perhaps this was intended as her reward for helping us in class. I am sure Alexis appreciated the gesture. Doesn't she look happy as she is about to eat the worms in this picture?

The Buie's last day

Thursday was the Buie’s last day teaching with us this year. It was a real blessing having them here with us and we pray they will be able to return next year. The students gathered around and prayed for the Buie’s at the end of the day as seen in this picture.

We also all learned something new today. One of the students asked us about a bean none of us had ever heard of before. The student had heard that it is poisonous, but it is popular to eat in Burma. Thanks to the newly installed internet at the training facility (thanks to Bob Bowling!) we looked it up instantly. The Djenkol Bean is poisonous and causes kidney disease when eaten Raw. However, if properly prepared by boiling it and changing the water a time or two, or by soaking it in saltwater for a few days, it takes the poison away and it is quit nutritious. Then we looked up how to treat Djenkol poisoning so the students are prepared for this very possible emergency in Burma. Here is a picture of the Djenkol Bean. More information can be found by searching it on Google. The students did add that it smells awful. I occasionally eat some strange things but I think I will just stay away from the Djenkol bean for now.

We started off yesterday with more small group presentations per Dr. Buie’s assignment the night before. They covered all sorts of abdominal pain including appendicitis, ulcers, gallstones, urinary tract infections, and ectopic pregnancy. Dr. Buie also taught on one of the more

important subject of T.B. We were surprised at the high numbers of TB the students are reporting. Of the 24 students 5 of them reported TB in their family and 22 had TB in their village.

Gayle Buie used very creative and fun ways to teach about nutrition. She used yarn to show how long the intestines were and made peanut butter and banana sandwiches to talk about food groups. This was a tasty idea and for most of the students their first peanut butter and banana sandwich.

Gayle also used a sock with a tennis ball in it to

show how food moves through the intestines. The students really enjoy and get a lot out of the hands on activities.

Sawadee Krap from Thailand,

Rick

A Good Day of Worms and Black Eggs!

I finally got a few pictures of the Audience Response System I talked about in the last blog. I think the pictures help explain what it is and how we use this technology in the teaching. You can see the question and then the bar graph of the students' answers instantly on the screen behind Dr. Nilson.

The students gave a couple more presentations today. Here is Ken Saw in one picture and a small group presenting in another.

We used poor Bob Bowling as an example to the class about how to address health and safety issues in villages. Bob is wrapping up the big dormitory construction project on the Kalnin Leadership Center property where we do the teaching. Awhile back we had the students walk around the property and find health and safety issues. As each issue was identified we also had them set up an action plan on how to correct it. They did well with issues they can address themselves like putting fish in empty bodies of water so no mosquitoes will grow. However, they have difficulty forming committees or addressing authorities. Because there are still no handrails on the steep outside steps to the newly constructed dorm, Bob was the perfect scapegoat and example. Here is a dramatic photo of the confrontation of Bob by Dr. Nilson in front of the class! It was all in good fun, of course. Bob made a call to the construction company and the rails should be up by the end of the week. We can only begin to understand what it is like in their country, but obviously they are not encouraged to address authorities with any requests like this.

This week Dr. Jim Buie and his wife Gayle are teaching the Barefoot Dr students. They have both taught Barefoot Drs in the past but not for a couple of years, so all these students are new to them. It has been great to have their experience and encouragement this week. Today we learned about WORMS! They are totally disgusting little parasites that can be a huge problem in the developing world. The Buies made good use of some gummy worm props to illustrate their points. Also quite tasty! Gayle told the students something to the effect of “The worms havealready eaten you, so you might as well eat them now!”

They also brought some useful gifts for the students including good old- fashioned thermometers. The students actually all received digital thermometers last year, but many of the batteries had already died and they have been unable to replace them. Even we could not find batteries for the student’s thermometers in our short search. It was cheaper and a better long-term solution just to get them the low-tech version.

The Buies have also been teaching and having the students practice taking vital signs. Jim has been showing them how to exam a patient and teaching on common diseases. Jim finished up with the abdominal exam on one of the students.

All the talk of worms and abdominal issues made Bjorn and I awfully hungry. So, when we got back to our hotel, we walked down the street and decided we would eat in one of the local dives on the side of the road. To our delight they had a special treat “100 yr old eggs!” Just the look of these black rotten eggs is enough to give you abdominal pain. Of course, we both had to try it (see the pictures below). Nether of us had ever had one before and actually they were not bad . . . . Not good but not bad. To top the experience off, it all took place across the street from the Thai “Office of Disease Prevention and Control.”

It was a good day!

Week two completed!

This week’s highlights.

Dr. Nilson also made a point with a tee shirt that read, “ Where you live should not decide if you live or Die!” He was emphasizing how important and doable preventative health care can be, particularly with children. The Barefoot Drs can save many more lives preventing disease than simply by treating sick patients.

It has been another busy but great week. There are a few highlights I did not get a chance to tell you all about on the Blog.

One is that we have a new toy. Bjorn ordered an Audience Response System for us to use with the students. There has been a bit of a learning curve for the students and for us but it promises to be a huge help. It is basically a radio frequency receiver that hooks to your computer with a program for collecting data. Each student gets a small hand held clicker. We project a question on the screen with multiple choice or true / false questions and the students can answer with their remote clickers. This way we know what the individual students know, not just the class collectively. We get the data instantly and can immediately show it in graphs or charts on the screen for all to see.

This brought up an interesting problem for us. The students were very confused when we would ask them a negative question like “What is not the right answer?” Evidently, most of them have not been exposed to these types of questions before. This is something we did not realize until now, and it is very important because as Westerners we talk like this often. So many times in the past when they were confused it may not have been the subject matter but the way the question was presented that was the problem.

Another highlight was on Friday when we decided they needed more practice on paperwork and how to actually take care of a patient from start to finish. They had significant difficulty with this. We had them break into small groups then take a history and exam on an actual patient (one of the students with severe abdominal pain). We then projected one of their field patient log forms on a white board and had them fill in the blanks so then we could all see and ask questions. This was great practical practice on how to see a patient and use the form. They had quite a bit of difficulty with this. It took at least two hours to go through what we thought would be a fairly simple exercise. Again, we as Westerners take too much for granted. One of the translators told me that often in Burma they are not taught critical thinking. In many classrooms you do not ask questions and you only give the right answer. You definitely do not question the teacher. We are asking them to do all of these things, but we have realized we must first teach them how to do them.

Here is Abraham (one of our translators) helping to fill out the projected log form.

In this picture Thin Bey is summing up the conclusion on the patient and what drugs to use. The patient has a 5 yr history of stomach pain and the problem is likely an ulcer. We expect him to start feeling better by Mon.

The students have been continuing with their presentations. Here is Zimi Ram presenting on the eye.

Splinting practice

Yesterday Dr. Susan McDowell showed the students how to use some splinting techniques using a “SAM” splint and Ace wrap for fractures in arms and legs. Dr. McDowell gave them all their own ace wraps among other supplies she donated to the program. The “SAM” splints are courtesy of Cyril Thomas who will be joining us in a couple of weeks.

One of the students saw an interesting orthopedic case in one of the villages. A hunter shot a wild bore but it charged him. Before the bore died he rammed into the hunter's arm, breaking his humerus (upper arm bone). Using techniques from last year the Barefoot Dr splinted the arm with bamboo and cloth for 6 weeks. When the Barefoot Dr last saw him, the hunter is recovering but he is still very stiff in his arm. These “SAM” splints will be lighter and flexible and easy to use. This new splints and Ace Wraps will make it much easier and faster to splint injuries.