A Glimpse at Structure

27 January 2018 – 16 February 2018

Seven and a half weeks have flown by; they came in one door and went right out the other. I have finished an incredible week of exploring Bangkok and beyond, three amazing weeks at two different hospitals within the city, have moved to Chiang Mai, Thailand, a small city in the north of the country sitting at the base of the mountains. I have then spent a week there exploring and now am in my third week at the hospitals here. As I am now seven weeks (and counting) behind in an update, one post would go on for far too long to even know where to begin, so I will break things up a little. Coming to you first is my time in Bangkok traveling and starting at the Department of Surgery in Thammasat University Hospital. Having reported to you last about life moving a bit more slowly in January, I cannot say the same about now. I am so thankful to have had that time then, but to also now be on the move, daily, is truly wonderful. Having just written about moments along a Watson Year that drag and clunk versus the times that fly and sail, I can now so clearly see this playing out before me. We are sailing, full speed ahead. For each moment along this year, I try and give thanks, but especially now I feel I owe an extra word of thanks: to you, Watson, and to so many others, like you, reader, who continue to support me as I go. I have been this happy before, I know, but there is hardly a moment in each day that I cannot stop smiling. Perhaps a bit of the Thai Way is rubbing off on me, but the people I have met, the experiences I have shared with them and with myself has left me so fulfilled – both personally and with where I have hoped to see my project take me. New questions continue to arise and I love to engage in conversation with others as they come. I have been able to visibly see a change in the confidence I feel when approaching new situations and I can only sit here now with excitement to see where that takes me next.

Enjoy this read, detailing pt. 2 of my Thailand Journey and stay tuned for more follow-ups to come shortly!

Week 4: 27 January – 2 February

After a week spent planning for the road ahead, blogging to you all and finalizing all that lies before me in Thailand, I took some time to really get to know the beautiful and expansive city of Bangkok. There was no way I was able to see it all, but I had so much fun exploring all the different corners the city had to offer. To begin, I spent the day exploring the Grand Palace, which holds many royal buildings, as well as the Temple of the Emerald Buddha. I had wandered in and out of some places prior that displayed traditional Thai architecture, but nothing could compare to the intricacy and grandiosity of the Palace. The attention to detail in every piece of the temple constructed a breath-taking view from every angle. I spent some time along the river on a boat to catch in some sights and enjoy the sun and later spent a fun evening out celebrataing the birthday of my AirBnB host! Moving over early to the Friends for Asia House, I was excited to have a settled spot to live in for a few weeks, I took a day to settle and explore the nearby Weekend Market, called Chatuchuk. Having enjoyed my boat ride so much before, I went back to the river and hopped on a boat where you could get on and off any time you liked. This allowed me to stop at Wat Arun (The Temple of Dawn), Wat Pho (The Temple of the Reclining Buddha), the central Flower Market, and many other beautiful parts of the Old City of Bangkok. Wat Arun is a beautiful and famous temple within the heart of the city. Its white-tiled exterior beautifully reflects the sunlight that hits it. Every piece is symmetrical and looking at it casts one’s eyes continuously upward. Just across the way is Wat Pho home to a statue of the Buddha lying 46 meters long and 15 meters high. It is one of the highest class of royal temples in Thailand. The flower market was home to endless corridors of smiling faces and beautiful colors. People weaved flower necklaces, offerings, and bouquets. Later in the week I traveled across the city to Bangkok’s “Green Lung,” called Bang Kachao. As one of the last large green places in the city, further development of the area has largely been restricted. Renting a bicycle, I was able to explore through beautiful lofted sidewalks and roads (thankfully not falling into the marsh below). The week also included some rainy days, meeting new friends at the Volunteer House, a few nights out (annnnndd…one lost/stolen wallet (sad.)). On my last day of the week I traveled by train to Ayutthaya, the ancient capital of Thailand. First getting on the wrong train…I finally made my way and was able to rent a biculce to travel between all the ancient ruins. Mixed between temples, grand palaces, and ordination halls, these 700 year-old structures largely still stand to this day and reflect a beautiful history to the origins of this Country.

Week 5: 3 February – 9 February

I was so excited to start this week because I knew that it also meant starting my time in the hospital. The week began with a two-day orientation at the Volunteer House with the other volunteers and interns who had just arrived. There were six of us in total, four who had signed up for the medical internship and two others who would be teaching English. We worked with Aom, Manong, and May, the three Thai coordinators who work for the foundation and endlessly work behind the scenes to make our time there so great. We spent the day running through some need-to-know basics, toured a new temple and got to know each other a bit more. That first evening, I met up with Sarah Wells, who I had previously met a few weeks ago, for one more night before she headed back to the states. We cooked Shabu, where all the meat and vegetables come to you raw and you cook them together over a burner. It is a delicious and fun way to share a meal with others! With one more day of orientation, we continued where we had left off the day before, learned a few new Thai words and explored the market where it is far too easy to do some serious shopping there. Monday was Day 1 at the Hospital. The three other interns, May, and I took a bus, van, and shuttle across the city and through the campus to finally arrive at the Hospital. It was quite the trek, but allowed for a nice pause in the morning to get ready for a good day of work (and a nice nap in the evening on the way home!). I’ll hold off on the details of my time there until later when I discuss some project work, but our first week was awesome. Finding our feet beneath us on the first day, we were able to see many surgeries and get to know the hospital staff well. This really helped us during the second week as we returned and got to see and meet so many more awesome staff.

Week 6: 10 February – 16 February

As the weekend rolled around, I spent my Friday night with the volunteers in Khao San Road, a fun and hectic touristy strip within the city, and then trekked out of the city on Saturday and Sunday to Kanchanaburi to camp out in a nearby park as well as explore some waterfalls. Having had the time to do so in Chile, I was so happy to get back out, away, and in the woods again. At the campsite, everyone was so friendly, there was plenty of local food to eat, and the waterfalls were great for cooling off and swimming at their base. Beginning Week 2 at Thammasat University Hospital, we continued to see incredible surgeries. Benefiting from having walked around the surgery ward the week before, most people recognized us and often offered for us to step into their surgery room to see a procedure we had not seen before, like a C-Section, which will definitely go down as one of the coolest moments I have ever experienced! Also included in the week was a celebration of my Dad’s birthday from afar, exploring the University Valentines Day Night Market with a few resident Interns at the Hospital, the best hospital food I have ever had, and good evenings out after work at nearby food markets and out door eating spaces. One night I managed to see the Black Panther Movie, and it was amazing! (So far I’m keeping a good record on the new Marvel Movies released while I’m away – Rob and I need someone to talk to about it!) That Friday I went out with new friends to celebrate the Chinese New Year in Bangkok’s Chinatown District. Full of red, gold, plenty of fireworks, and even more people; it was fun to explore and experience that celebration!

Lastly, as the second week at Thammasat came to a close, I began to really appreciate the time I has having at the Hospital. I was up at the same time everyday, off to the same place, although still with enough unknown and new experiences to be had, and back home around the same time. I got to find a routine evening run and walk towards food, followed by a relaxing end to the week. All of these things put together, reminded me, as I have said before, how much I love structure. The structure has been nice: it gives me good direction for what I am doing each day and allows me to set my sights forward to the new activities and experiences to approach open the weekends. After so many years of school, you get quite used to the structure you had. Each new year you tweak it with new things as you leave behind old things, but your structure largely remains the same. For the most part, my Watson year has been the opposite of structure, at least in the way I have been used to it – and I think that is a good thing for me. It’s taught me to think on my feet more, to make a plan at a moments notice, and be prepared (and excited) for anything that happens, but…structure is still nice when it comes.

Picture Time!

The Temple of The Emerald Buddha, or What Phra Kaew in Bangkok

Every piece of the Temple stands littered in gold, covered in exquisite detail.

Next door, the Grand Palace mixes Western European and Thai Architecture.

On the water, the Temple and Palace together stand out amongst the rest of the city landscape.

Bangkok sometimes is called the Venice of the East. The canals and many Boat Taxis that run through them sure do make you feel like it is that way. (Check out this cool video, with low sound…unless you want to listen to a loud motor!)

Wat Arat, or the Temple of Dawn is absolutely astounding when you get up close to see the extraordinary symmetry.

Wat Arat Beauty Pt. 2

Bang Krachao, or Bangkok’s Green Lung, is a large green space in the heart of the city restricted to further development. Raised bike paths weave you through homes and neighborhoods in a quiet retreat from the bustling city.

Check out this time lapse taken by bike of some of the biking paths along the route.

Although I initially got on the wrong train to Ayutthaya, I enjoyed the views along the way

The Ancient Capital of Thailand holds much history to it, including this fallen Buddha’s head at Wat Maha That, now reclaimed by the natural world.

The Fallen Buddha’s Head and Me at Wat Maha That

Ayutthaya’s ancient and most holy temple: Wat Phra Si Sanphet. After centuries, it is amazing to see these buildings withstand the test of time.

I found the symmetry at Chai Watthanaram Temple to be the most beautiful of them all.

A weekend trip away to the Huay Maekamin Waterfall, brought me out of the city and back to some much needed nature.

The falls consisted of 7 flowing tiers that

This is just one of them, Tier 2.

The water was incredibly refreshing on a hot day!

Sunday Morning, I awoke to a beautiful sunrise over the lake below.

Sunrise Pt. 2

On my way back, I stopped at Death Railway. Much of the original lines for this railroad were built by WWII Prisoners of War

My last stop on the trip was a late lunch on the Khwae Yai River. These suspended nets were enticing for a late afternoon nap!

And now, a Project Update!

Within 2 weeks time, I got to see 27 surgeries ranging from minimally invasive cardiovascular surgeries such as Arteriovenous Fistulas and Grafts up to Open Heart, Aortic Valve Replacement Surgery. We saw what seemed to be everything in between: plastic surgery for cosmetics and injury, cancer and tumor removals, laparoscopic and open, multiple child births and even total uterine removal surgery. Having previously only seen a few minor surgeries at Vanderbilt during an undergraduate internship, it was really incredible to see as much as I did. Some simple (at times funny) observations I made for myself during this time: the OR is cold and there are many hours spent standing (don’t lock your knees!), but there is some really incredible work being done behind those closed doors. Above anything else, it seems like the Operating Room is what remains most hidden to the outside world in medicine. As patient’s we at least get a glimpse of our own treatment, and that may help us understand, in general terms, what it looks like or doesn’t for others; however, even if we find ourselves on the operating table, we are either asleep or restricted in viewing what is going on. On the inside, when you get the opportunity to see doctors, nurses, and aids working together for the patient’s benefit, you begin to see what a well orchestrated machine looks like. At Thammasat, the head surgeon, a resident, intern, and scrub nurse always surrounded the patient. By the patient’s head, a nurse or two monitor vitals and anesthesia. In other parts of the room, other techs help maintain order and medical students stand in different corners observing some and studying at other times. Doctors get to work, but never give off too serious of an aura: conversations were maintained, laughter sparks every once in a while, phones ring and nurses hold them up to the doctors ears. And then there is that one automatic sliding door. It separates the in from the out. Unbeknownst to the outside world, the tireless efforts of all involved create, at least endlessly strive to create, better lives for others.

In the time between surgeries, we often had the chance to speak with the physicians, nurses, and students about their work and the larger Thai Medical System. Through this we began to learn a little bit more about who pays what, or who doesn’t for that matter. Essentially, there are four different types of coverage. The first is what is called the “30 Baht System.” The name derives from the cost it takes to pay for one visit to the doctor, no matter what it is. Whether it is for a yearly physical or major surgery, the cost is 30 Baht for the patient. This equates roughly to one U.S Dollar. This system is provided for all Thai people, but others choose to use a different service where eligible, which often includes opting for a different hospital, such as a private one. For the most part, the 30 Baht system covers all the necessary things one may need, but there are limitations. As I learned, the limitations for this often fall more on the hospitals than the people. Under the 30 Baht System, the government will pay up to a certain amount of money. If a procedure costs more than this, then the extra cost will fall on the hospital where the patient is treated. This can make it difficult for a hospital, resulting often in reliance on donations and fundraisers. A recurring theme that echoed around different surgical practices was money. It is clearly on the mind of personnel here; specifically, how they can save money while maintaining the highest level of care they can give. An example of this was during a laparoscopic removal of a gallbladder. The doctor inserted a small bag inside the patient’s abdomen, and then later pulled out a gallbladder synched inside of it. Afterwards he pointed at the nurse across from him and said, “she designed this for the hospital. We can create hundreds of them at little to no cost, but if we were to order them externally, we could never afford it.” Innovation at its finest.

If a person is employed, then they are often covered under a social welfare system provided by the employer. Although similar to the 30 Baht Rule, the patient under the social welfare system does not pay anything. It is through this system that patients may opt for coverage at a private hospital and still revive full coverage by their employer. A third form of health insurance is the Governmental System, where any employee of the government, whether they are military or a teacher at a government school is funded and covered separately. Lastly, one can opt to be on their own with payments. This will either mean paying upfront in cash or through purchasing individual, private health insurance. What I learned through this though is that as a Thai National, there are plenty of options for coverage at little to no cost. Under the 30 Baht rule, it will likely cost more for the patient to even make it to the hospital than it will for them to receive coverage. As I continue to travel, and explore new systems of health, I am amazed at how many places have a system of health care that provides for their residents at little to no cost. It causes me to also reflect on the cost of health care back in the U.S and how often individuals face the dilemma of what they can and cannot pay for.

A few ideas that stuck with me during these two weeks of surgery were these: During our day with the plastic surgeon, he said, “Thai people don’t get cosmetic surgery in order to impress others, or look more attractive to others. They do it so that they may see themselves in a better way. I do this work because I want to help people feel better for themselves, for them to view the self as beautiful.” It’s hard to think that some people go to the point of surgery in order to improve their self image, but at the same time, to hear that this is the mission and intention behind this doctor’s work is inspiring. There is reason to it.

Birth is truly a miracle. On our day rotating with an OBGYN, we saw four different C-sections, each one producing, out of what seems like nowhere, new life, full of tears and screams, but nonetheless full of life. In my next post I speak a little further about the magnitude of life itself that continues to be revealed to me along this year. This was one of those moments without a doubt. At lunch that day after seeing the first two births, I wrote, “Some things are universal. Perhaps they are operated and performed in varying ways, like birth, but new life comes and is brought into this world everywhere. Far and wide, new life comes; that is something to celebrate.”

Another doctor shared with us that he thought there needed to be more doctors who remain in Thailand to train, rather than go elsewhere. He spoke about how often people leave, learn elsewhere, and return not knowing the standard of practice in their home. This was an interesting take for me, and I have had difficulty remedying it in my head. As I am so clearly away from home with the intention to learn while I am away, it is difficult to think that one should limit themselves to their own home in the process of learning. What I am taking from it is this: it is important to train in where you will practice, but this does not mean to not engage elsewhere. Nor does it mean that one shouldn’t explore new contexts, practices, and cultures in the process of learning, especially within medicine. Western medicine and practice has permeated all forms of health care, and in many ways this is a good thing as the world strives together for greater, more universal access and coverage. Today the world collaborates around new, innovate ideas and techniques, and we are better for it as a whole, but I also question what is lost in the process. These ideas about global practices and similarities in medicine coincided with other thoughts I have had about the intersection between health and culture – about the outcome of such an intersection, for the individual, or the community as a whole. To say that one’s culture doesn’t effect your practice would be naïve, so I am left with many thought after those two weeks in the Surgery Department. Where does culture permeate the into the Operating room? What is threatened when we homogenize a practice? In each of my interactions this year, I am shown just how much we are shaped by culture. Every action we take is a result of where we have come from. I have to believe that this too exists in the operating room. It may not be in in the specific incisions or sutures performed on the operating table, but I believe it still exists. These are ideas I am still working with and I welcome any and all ideas you may too have about the intersection of culture in practices/procedures that have become standardized worldwide, such as surgery.

When I started these two weeks at the Thammasat University Department of Surgey, I was initially a little nervous about how I may explore the context of my project in the surgical room. After all, I had originally posed the question about ambulance care, not surgery, but at the same time I was excited to explore the question of care within community through a new lens. Care most definitely does not stop once a patient leaves the ambulance, or the hospital ward. It occurs in the OR, the recovery bed, the outpatient ward, the ambulance stretcher, and the bed back home. I am thankful for my time at Thammasat and for the opportunity to see the care behind the closed doors – to see where it continues, and to be shown that it is given in every corner by health professionals of all levels.

Bryant, Frank, Jessica and I snagged a selfie outside the Faculty of Medicine on our first day in Thammasat University Hospital

On Valentines Day, a few medical students took us to the University Valentines Festival/Night Market.

Alright…long, over-due update (part one) complete! Stay tuned, a few more are coming! As I hit submit on this post, most of you are likely fast asleep, but I know at least some of you are wondering what I am doing on this day! Today is my Birthday! Yippee! Leaving home, I was a little worried about what my birthday would look like while away. Where would I be? Who would I be with? All those fears have vanished here. Today has been great and will continue to be! I woke early to go to a temple with my two close friends here, we made offerings to the monks and received a blessing for this day and the year ahead. They both do the same on their birthday and wanted me to share with them in that practice today. I’m thankful they did! I spent the morning at the hospital, dipped out a little early after lunch, got a Thai Massage, and am enjoying an iced coffee as I submit this post. Later I will go on a great run and meet up with close friends for a fun night of celebrating. You create family where you go; I am thankful for the one I’ve created here and for their willingness to welcome me into it.

Morse (right), posted this in the morning after our temple visit. Gig is in the center. They’re both so great. Khob khun Krap, my dear friends.

Cheers to a pretty incredible year, and for the one coming up. It’s sure to be just as good. Until next time,

Mark

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