Getting Schooled

If you had told me when I started this journey that I would find myself dancing the Chicken Dance and the Macarena in a classroom atop a mountain shrouded in monsoon clouds, I’m not sure I would have believed you, but that is exactly where I found myself yesterday.

I have been attempting to use any free time outside of the clinical setting to have experiences that can better inform my practice. While hiking, exploring, and trekking with elephants has had more of an indirect corollary to my understanding of the lived experiences of the patients, families, and staff I have been working with during my time here in Laos, yesterday’s adventure provided me with a much greater understanding of the Lao educational system, how many children learn and play here, and offered one explanation of why certain thought processes and cultural norms are common amongst patients, families, and staff.

Yesterday was Lao Women’s Day and many of the staff, myself included, had the day off from the hospital. As it was a weekday, I took the opportunity to visit a local school with a friend who is also a hospital volunteer. Our day volunteering as English teachers was fascinating and, in some ways, troubling.

Laos is not a literate country. Today, there are few books and it is quite common for people not to know how to read and write. Illiteracy is even more common amongst adults and for many families who I work with at the hospital, it is often that the patient or the patient and siblings are the only members of the family who can read and write. Approximately a decade ago, a publisher from Boston visited Laos and, shocked by the complete lack of books, started a not-for-profit, Lao-owned business to publish books and teach reading and writing in Lao and English to interested children and adults. The business continues to operate, selling books and holding informal conversation classes out of a storefront in the tourist area of Luang Prabang as well as operating a local school. Both my friend and I had heard about the organization and wanted to visit the school as a way to see what some children may be experiencing in the Lao educational system.

We met at the storefront and were joined by the founder who continues to teach the older children at the school as well as to be one of the shepherds of the daily tourist volunteers. My friend, the founder, another tourist volunteer, and I climbed into the back of a tuk-tuk truck and began the half-hour drive through the monsoon to the school. As we forded roads that looked like rivers, the founder told us more about the mission of the school and their philosophy. Hearing him talk, I was quite excited to visit the school. He spoke about wanting to change the educational system here in Laos from rote memorization and recitation to one that nurtured creative thought and problem-solving and increased children’s skills in literacy, English, and mathematics.  It sounded like a very noble and inspiring learning environment and, having been a preschool and kindergarten teacher prior to entering child life, I was greatly looking forward to not only seeing, but offering my time to help support the mission. As we climbed out of the tuk-tuk truck and slogged up the hill to the school, navigating flowing water and mud to begin the day, it slowly became clear that, while what the founder had shared with us was a grand vision, the school itself was a bit different from what was advertised.

The three of us met with a school employee whose job it was to accompany us throughout the day. We met with the group of oldest children first, who ranged in age from 16 to 25 years old and who live at the school, studying math, English, and receiving training to become teachers. We sat with them on the floor, were asked a series of pre-written questions in English, and then handed a stack of flashcards which became a repetitive theme for the day. The flashcards contained a random mix of pictures of regionally appropriate fruit and vegetables, random animals, and dinosaurs accompanied by an English label. We were instructed to “play a game” by laying the cards face up in front of us and asking questions about them, such as “where is the rhino?” or “what card has the color yellow?” The students would then point to or tap whichever flash card they thought I was referring to and, if correct, gain possession of that card. We were given the same flashcards and the same task with children in every classroom in the upper school, regardless of developmental level. When my fellow volunteer and I would try to mix it up as the day went on by playing games with the cards, such as a bizarre version of Go Fish or Memory, or handed out the cards to the children and had them choose from their hands in a silly, made-up game of “what goes in the soup?”, we were immediately told to stop and go back to the original task.

While the flashcards disappeared when we visited the lower school and worked with children aged 3-5 years old in three other classrooms, we were also given very repetitive assignments that lacked opportunities for creativity or open-ended play. In every classroom, we were first made to stand in a circle and ask the children to point to different parts of their bodies by asking questions like, “where is your nose?” We were then separated into groups and given a book to show to the children instead of reading, instructed to describe what the pictures were on the page. When I attempted to sing “Head, Shoulders, Knees, and Toes” with the children or ask open-ended questions about the pictures, I was immediately hushed.

There were other moments in the day that I found troubling. I was at first elated to learn that the children in both schools are given frequent music and dance movement breaks, only to learn that each music and dance movement break was incredibly choreographed. Being in a room with close to fifty children aged 6-15 years dancing the Chicken Dance, the Macarena, and another dance with which I am not familiar in nearly perfect unison as a break from their incredibly scripted, rote memorization-style lessons was a bit unsettling.

The children did have about half an hour of recess time, spent indoors due to monsoon season. This half-hour stretch of time was the only point I saw any creative, open-ended play as children bounced from classroom to classroom, skipping rope, talking, and playing and building with a set of straws and connectors, a new toy at the school. My relief at this one moment of creativity and problem solving was quickly dashed when the founder, having learned that both my friend and I are volunteering at the hospital and have knowledge of child development, dragged us over to one school-aged girl who, though perhaps with a mild intellectual disability, was gleefully engaging with the other children and building an elaborate two dimensional shape with the straws and connectors, telling us that they thought she was probably a lost cause and would never learn anything at all.

As a teacher, a child life specialist, and an individual from a Western educational system with a rather privileged educational and teaching background, I wanted to run screaming from the school. The whole experience felt incredibly wrong to me and knowing that this school is one of the foremost, expensive private schools in the area was heartbreaking. Yet, while the school may be approaching education in a way that I would not, there were positive strengths. Every child appeared well fed and happy, a sharp contrast to the rate of malnourishment in the patients and families I see at the hospital. Every child was receiving some form of education, even the child labeled a lost cause. While it may not have been a part of the curriculum, the movement away from rote memorization and recitation towards open-ended play, creativity, and problem-solving is something that is valued by the school and, hopefully, may one day be the way children are taught.

My experience at the school, though unsettling to me in my Western educational bias, did more than illustrate what patients and families may be experiencing if they are enrolled in school. It also served to explain the complete lack of open-ended play I found when I began at the hospital, the lack of choices children receive from staff and caregivers, and they way staff seem to think and process information during rounds and during discharge planning. There is a lack of creativity, abstract thought, problem-solving, future-oriented thinking, advocacy, and questioning and a task-oriented thinking pattern that I found completely overwhelming when I first arrived in Laos, but which definitely makes sense in adults if they were only given rote memorization and recitation tasks throughout their educational experience. Whether this way of thinking and doing is purely a result of the Laos educational system or a combination of education, culture, communism, and the lived experience here, I cannot say, but my brief stint as a volunteer teacher was certainly very educational.

A Hard Rain

I’ve had Bob Dylan’s “A Hard Rain’s Gonna Fall” stuck in my head this week and only partially due to the weather. Monsoon season leads to a lot of rain here in Laos and a tropical storm hitting Vietnam has made the rain in Laos even heavier. Part of me wants to choose the easy option and take a tuk-tuk to and from the hospital every time I wake up and hear the rain crashing on the roof like a waterfall. The other part of me loves the comic sense of adventure when I gamble on biking through a puddle and my peddling turns to paddling as I am suddenly up to my knees in rushing water. The constant damp squelch in my sneakers and the fact that my biking clothes are usually still quite wet when I change out of my scrubs to bike home at the end of the day can get a bit old, though the hard rain has not been what has made this week difficult.

There were many moments this week that were not easy, but yesterday and today’s events were by far the most difficult moments of a week that has felt much longer than four days. I’ve been present for multiple bereavements in multiple hospitals. The death of a child is never an easy thing, but it can be peaceful and meaningful, especially when a patient and family have time to prepare and choose what to do to make the dying process what they want it to be. When death is completely unexpected and when it happens in the most chaotic of ways, it is somehow more difficult, especially for the patient and family, but also for the staff.

I was not in the room when the patient arrested. I was next door in the emergency department, supporting a preschooler and her father during an abscess drainage. As we giggled and played a color naming game, I was acutely aware of which medical team members were suddenly running around in the background and what they were grabbing from the crash cart. It was obvious that something serious was going down.

The medical team does not usually run resuscitations in the inpatient unit. Most times, there are plenty of clinical signs that cause the medical team to relocate the patient to the emergency department where there are fewer onlookers and more room for machines and staff. The inpatient unit is one large room where there are no dividers between beds and no privacy, though a few wheeled screens exist and were used to attempt to shield the view of the main resuscitation action as much as was possible. When the patient arrested, it was not possible to move her. Unlike the babies who will be scooped and sprinted two steps into the next room, this patient was a teen and moving her, as we did later after death, required moving multiple other patient beds and a walk down and around in a corridor that simply would not have been possible while compressions were happening and while patients were in those beds.

The patient who died had appeared to be improving earlier on in the day. My coworker and I had brought her father away from the bedside so that physical and occupational therapy could sit her up and help her with passive movements while he chose activities for her from the games and art supplies. They strung beads on a necklace together that morning. At one point, a question was raised about whether some of her symptoms were attempts at attention seeking rather than the result of her yet unknown diagnosis given how astronomically better she appeared when her parents were away from the bedside. A few hours later, however, her heart stopped. Despite the best attempts of the incredible medical team, she passed away.

The patient’s family remained close by during the lengthy resuscitation attempt, sitting and crying together on the grassy slope just outside the closest door to inpatient. My coworker, the medical team, and I kept them informed about what was happening, how hard they were working to get her back, and offered support. The role of child life in this unusually public resuscitation alternated between familial support and supporting the surrounding patient beds, shepherding shellshocked patients and families who were mobile out of the department to the outdoor play and waiting area, IV poles and oxygen tanks in tow, while offering developmentally appropriate explanations of what was going on. By the time the medical team called time of death, only one mother and an infant were left in what is normally a packed room of twenty plus patients and families, unable to move given the medical equipment supporting her infant. The family, who that morning had been discussing how much their daughter was beginning to improve, were understandably distressed, screaming, weeping, and engaging in cultural responses, such as hitting themselves and the body. It was hard to watch and support, especially for the medical staff who have been caring for her during her lengthy admission and for whom this sudden cardiac arrest seemed so inexplicable.

I’ve found I am learning quite a bit about regionally specific cultural needs in association with death during my time in Laos. Given the unexpected nature of the arrest, we had not met with the family to offer any sort of legacy or bereavement interventions. My coworker is Hmong, but knows about the cultural and spiritual beliefs of Lao and Khmu families. At his understanding, we offered the family a clean change of clothes in which to dress the body as we did not have a blanket big enough to shroud her, a crucial part of the Khmu death rituals. We had little else to offer besides emotional and physical support. As we wheeled her body down and around the corridor to a more private location, I walked next to her mother, her hand on my shoulder and mine around her back. My sideways embrace took on more and more weight until her mother eventually went limp, fainting at her dead daughter’s bedside. With the help of the medical team, I lowered her to the floor and we made space for the rest of the family to gather around the two of them. It was a very intense experience.

The intensity of yesterday evening, the sound of wailing and action of the family and the team, was quite opposite the silence and stillness of today, though equally emotional. Given the taboo of bringing a dead body back to a Khmu village, the family chose to remain at the hospital until extended family could arrive and funeral rituals could take place locally before returning home without their daughter. The team of individuals who coordinate outreach care, my coworker, and I met with the family to offer support, including handprints. The family was greatly interested in handprints as some way to take some part of their daughter back with them, asking to have them made in a color as close to her skin tone as possible. Given my coworker’s own cultural beliefs around death and the need to juggle day to day clinical tasks with providing support for patients and families who witnessed the resuscitation, I delegated clinical care to him and went to the morgue alone.

While I have done handprints and footprints with many patients in many mediums, today was the first time I did this intervention in a morgue and the first time I have done it with a body that has been dead for some time. The morgue, like many buildings in Laos, is in a certain level of disrepair. I had not known it was a morgue until a few days previous, despite biking past the place to and from work each day. There are no doors in the doorways or windows on the building and it’s just a stone’s throw from the hospital, though shared by the adult provincial hospital and our children’s hospital, who, thankfully, uses it quite infrequently. In combination with the decrepit condition of the cement building, the amount of medical detritus, nightmarish stains, and the host of flies and maggots making themselves at home, it was immediately very apparent to me that I was entering a house of the dead. Armed with my umbrella to protect the prints from the monsoon, a pad of paper, paintbrush, and jar of skin-toned paint I had mixed to the family’s requested hue, I crossed the threshold into the morgue.

She was visible before I entered, the only body I could see through the doorway into the morbid landscape, completely shrouded in fleece and woven blankets and laid carefully on a woven rug on the floor. Playing cards and prepared food sat next to her on the rug, remnants of the vigil the family kept during the night and will continue to keep until her burial. Unsure of exactly what to do culturally, I bowed my head as I entered and knelt beside her, brushing off the flies and shooing away the maggots as I spoke to her softly and explained what I was there to do. Her uncles, whose turn it was to keep her company, arrived moments after me. While it made me more anxious to have an audience, I was thankful not to be alone. After a pantomimed re-explanation of how I was going to unwrap the shroud a bit to access her hands or feet and make prints for them, the uncles added their consent to the rest of the family’s and I began.

I found her left hand first. It was nestled snuggly at her side, tucked under the first layer of soft fleece. Stiff with rigor mortis, her hand clutched a handful of kip, the currency here. With the okay of the uncles, I massaged her hand to try to relax it a bit in order to get a print. Given that it was approximately 24 hours since the time of death by that point and given that the climate here is warm, I had hoped that her rigor would have eased enough, but it was not so. I replaced the bills in her hand and tucked her back in, moving instead to her feet. I kept a narration of my actions going as I would do with an alive patient, serving both to inform the uncles if they understood any of my English and to ground myself. Unwrapping her feet was easier than unwrapping her hands, a simple untucking at the correct end. Carefully brushing the paint over the sole of her right foot was also simple and, as I lifted her heavy leg and pressed the pad of paper against her foot I was struck by how similar it looked to the traditional medicine practices here and found myself beginning to relax.  The uncles, too, felt more comfortable and joined in, helping to paint and print her left foot and to clean away the paint from the cracks in her heel and between her toes. When it was done, we tucked her back in, bowed, and I returned to matte and laminate the prints for the family. As I crossed the mud pool of a  dirt road back to the hospital, I realized that for the first time in days, it had stopped raining.

When it rains here, it rains hard. Life here is hard, so is death. Yet, as I bike through puddles up to my knees and find myself kneeling in the houses of the dead, I cannot help but be continually humbled and thankful that I have been trusted enough to be granted the opportunity to do this difficult work. Some days and some weeks are harder than others, but I have learned so much about child life care, culturally competent practice, trauma-informed care, and how to educate, supervise, and empower one another as members of a multidisciplinary, multicultural, multilingual, international team. Each hard day is a challenge, a chance to learn something new. While some challenges are tragic, as this one was, I would like to think that for a moment, I was able to offer some comfort to this patient and her family, a brief respite from the monsoon of grief.

It’s Electric! (Boogie Woogie Woogie)

I have a strong memory from my childhood of a physical education teacher trying to teach my second-grade class the electric slide. In the memory, I’m standing in the middle of the gym’s hardwood floor surrounded by my seven-year-old classmates staring in bewilderment as the teacher instructs us to move our arms and legs in a distinct pattern while “It’s electric, boogie woogie woogie…” plays in the background. I’m about as coordinated and graceful now as I was then and dancing is definitely not a strength of mine. The elegance, grace, and resilience of the patients and families here in Laos, however, is a strength which continually humbles and amazes me.

Patients seeking treatment for burns have been a constant here in Laos, but, according to staff who have been here for some time, the burns that patients arrive with have changed in type and severity. There are the everpresent burns from spilled boiling water or noodle soup and that which accompanies cooking on an open flame, but, with the expansion of the electric grid and the ongoing construction of the bullet train from China, children are now arriving with severe electric burns. Whether children come into contact with electric wires because they do not have the fear of or awareness of safety concerns around electricity due to a lack of knowledge, because their caregivers do not know to educate them about the dangers of electricity, because of the lack of safety regulations surrounding electrical expansion into more rural areas, because of their natural curiosity, or by accident, more children are coming in with serious, traumatic electric burns, resulting in amputations and skin grafts. Patients with these severe electric burns experience very extended hospital stays with frequent dressing changes, pain and itching at burn and amputation sites, and, in some cases, the need to relearn basic physical skills when treatment results in, for example, amputation of a dominant limb or a change in the range of motion and ability to use both legs. From a child life perspective, my main goals with these patients have been to decrease trauma and anxiety surrounding frequent procedures and bodily changes, normalize the hospital setting, and provide opportunities for strength-based gratification which nurtures the patients’ resilience and sets them up for success when they are eventually discharged home.

Despite the life-altering nature of these severe electric burns, the patients I have had the privilege of working with thrive with a constant joyful resilience. Three school-aged children, two boys and one girl, are currently receiving inpatient treatment for electrical burns. One of them has been inpatient for approximately four months as he heals, the others are more recent arrivals. Two of the three patients have lost most or all of their dominant arms and are relearning basic skills. One of them is able to walk independently, the other two are variously dependent on crutches, wheelchairs, and the hospital tricycle for mobility based on the condition of their legs.

Given the nature of these injuries and the extensive treatment, I had suspected that these patients might be more traumatized, but the exact opposite is true. The patient who has been here for four months speeds about in his wheelchair, calling to staff members to join him in a very competitive round of Uno or to let him pluck gray or white hairs from their heads. The three of them have joined the basic English classes held for staff here as well as participating in bedside school lessons in math and reading with a developmentally appropriate level of mischievousness and reluctance. Non-dominant hand drawings and paintings cover the walls above the patients’ beds, layered mural-like with abstract colors, jungle flowers, and pictures of the red sun setting behind blue mountains, a picture every patient I have drawn with here in Laos always seems to create. Last week, we built a lap-sized foosball game out of a basket, chopsticks, a styrofoam ball, medical tape, and laminated paper people which rivals the World Cup in competitiveness within the physio-playroom, four people each lending a hand and shouting as the tiny styrofoam ball bounces back and forth around the plastic basket.

The bewilderment I recall feeling as a seven-year-old trying to learn the electric slide is often present in my interactions with these three patients, though my open-mouthed wonder is not a result of my own lack of coordination. Rather, my amazement at the joyful resilience of these three patients and their families is inspiring and contagious, prompting me and other patients, families, and staff to join in the play, laughter, and mischief they make.  The effect these three have on the unit, in the physio-playroom, and in the classroom brings such light and laughter. One might even call their exuberance electric and I am honored to ride the current.

Presume Competence: On Speaking Spanish in Typhoid Season

In previous medical settings, I have had the privilege of working with multiple patients and families with brain injuries and illnesses during their treatment and recovery processes. Until coming to Laos, however, I had never seen nor heard of typhoid encephalopathy.

Typhoid encephalopathy is a severe form of typhoid fever in which the infection spreads into the brain. Rainy season, as I have unfortunately learned, is typhoid season. Typhoid is caused by the bacteria salmonella typhi and is spread by the fecal-oral route. Initial symptoms include high fever, headache, abdominal pain, weakness, and constipation or diarrhea. Eventually, people with typhoid who do not receive treatment become delirious, lying motionless with half-open eyes in what is referred to as a typhoid state. Antibiotic treatment usually cures the bacterial infection. Many patients receive antibiotics and supportive care, such as hydration and pain relief.

Typhoid season is definitely upon us here in Laos. The majority of patients in the inpatient unit either have a confirmed diagnosis or a query for typhoid and, to the surprise of the medical staff I have spoken with about typhoid, a surprising number of the typhoid patients have typhoid encephalopathy. From the research I have done online and what I have learned in speaking to the medical staff here, I realize how little I know about typhoid encephalopathy. The patients here who suffer from this most severe form of typhoid lie completely unresponsive on their cots, seemingly unable to communicate even when their clothes and bed linen become soiled with fecal matter. Their body tone is alternatively floppy and jerky. They cannot hold their heads up, open their eyes, or sit unsupported. As they begin to recover, they move their bodies in uncontrolled jerks, often kicking the bed rails and bruising themselves. Families are often quite anxious at the suddenly unresponsive condition of their previously healthy children. Earlier this week, I witnessed a father of a preschooler with typhoid encephalopathy sitting next to his bed, taking hold of his son’s arm, raising it and watching it flop back onto the cot like a rag doll while frantically looking around the room as if to say, “does anyone else see this?”

Typhoid encephalopathy, like many things here, has seemed quite overwhelming to me. The infection and its aftermath is utterly unpredictable to me, both as I am not a medical doctor or nurse and as I have little knowledge of this illness. Some patients make a seemingly miraculous recovery. A school aged child who was discharged in order to visit a tvix neeb or shaman per his families wishes returned for follow-up a week later walking, talking, and kicking soccer balls. Others are discharged in a similar state to how they were when they were admitted, suddenly nonverbal and dependent on a nasogastric tube for nutrition in a country with a undependable electric grid where families may or may not be able to reliably puree and refrigerate their child’s food, let alone have streets they can navigate with a wheelchair or someone who can care for their child during the day while they work in their fields.

As overwhelming as typhoid encephalopathy has been to me, I have found myself repeating the words a wise professor of mine from graduate school instilled in our class on children with special health care needs: always presume competence.

Presuming competence has been a theme to my time working in Laos. Limited by my own language barrier, I often navigate social situations, market transactions, and patient and family interactions through a mix of nonverbal cues, gestures, pictures, and the handful of translated snippets I receive from coworkers. All of my child life interventions use play as the language of communication. At times, I find myself frustrated with my own inability to communicate which, though hampered by my lack of Lao language knowledge, is leagues above what is open to the patients and families I work with who are struggling with typhoid encephalopathy. I find myself wondering how I come across and whether or not, like my patients, I am presumed to be competent or incompetent based on the barriers to my communication.

I had lunch today with my landlady who also happens to be a pediatrician at the hospital. An older woman with many years of experience and a no-nonsense, unflustered, inexhaustible attitude, she reminds me in some ways of my grandmother and has taken me under her wing, worrying after me weeks ago when I was ill, looking out for me, and always asking me if I have had enough to eat. She brought me out of the hospital to a roadside stand for fried rice. Initially, I was worried about getting back to the hospital. I usually do not take the full lunch hour or spend it multitasking to maximize what I get done during the hospital day, yet the conversation we had radically reset my perspective and reawakened my approach to presuming competence.

We found seats next to a group of adolescent girls who my landlady translated were on a lunch break from scholarship testing. In Laos, there is a round of exams administered to secondary school students. Out of the approximately 800 students, 300 receive scholarship to go and study out of the country and continue schooling in places like Vietnam and Thailand. Those who do not receive scholarship remain in Laos and many do not continue schooling. I asked my landlady if she had studied in Vietnam or Thailand in order to become a pediatrician. To my surprise, she informed me that she and 9 other adolescents in her class had gone to Cuba to study medicine for 7 years after passing their scholarship exams. I asked her whether she spoke Spanish and the remainder of our conversation occurred in Spanish, a language both of us speak with near fluency.

Speaking Spanish at a roadside fried rice stand in Laos with my landlady was absolutely fascinating. Not only were her stories of Cuban medical school, culture shock, and communism incredible, but the act of speaking a language which was not a primary tongue for either of us completely leveled the playing field of competency and communication. Laughing and stumbling, we both struggled to find the right words to get our point across, slowing down our speech and pausing to help one another when stuck with an “olvido, I forget…”

I returned to the hospital with a renewed approach to communication, searching not for the right words in Lao or the right gestures to get my point across, but instead for the midpoints and commonalities, the second tongues or places where competence was not only presumed, but shared. This new approach to presuming competence made a world of difference with one patient in particular.

Many members of the interdisciplinary medical team, myself included, have been especially worried about one school aged patient with typhoid encephalopathy. Initially, though quite ill, she was able to communicate by mouthing words and had some ability to swallow. Now, though fully treated and off antibiotics, she is totally dependent on a nasogastric tube for any nutrition or hydration, is unable to swallow, incontinent, and seemingly has no control over the violent jerks and spasms that flail her limbs around on her cot. She cannot hold up her head. Any passive movement contorts her face into extremely pained expressions. Her mother, a single parent farmer with many other children, is desperate to get her home, but there are many steps to be put into place before discharge is possible.

This morning, I took her for a walk in a wheelchair around the grounds of the hospital, looking at the mountains and feeling the sunshine. Though at times her body stilled, she spent most of our walk moaning and moving in a way I interpreted as being uncomfortable or expressing a lack of desire to be engaging in a walk. Presuming competence and an attempt at communication, I cut our walk short and helped tuck her back into her cot where she was somewhat more peaceful. In the afternoon following the enlightenment of lunch hour, I returned to her bedside with my coworker. She was again making facial expressions of distress and moving her body in a seemingly uncontrolled way. I took my bubbles out of my scrub pocket and began to blow, catching them and popping them. My coworker did the same. To my amazement, this patient who before this afternoon had shown no signs of purposeful movement, lifted her left forefinger with extreme effort and determination and popped bubble after bubble which we caught on our bubble wands and held for her to pop. While my engagement with this patient had heretofore presumed competence, I had looked for competence in response to verbal communication or sensory stimulation. With the bubbles, my coworker and I had joined her in a middle ground of motion, an area where her body, though somewhat uncontrolled and disjointed, already was ready and healed enough to be present. After each successful bubble pop, her face, which for so many weeks has been a grimace of pain and frustration, opened into the most beautiful smile.

I have learned so much in my time here so far in Laos and much of it has been an exercise in humility. I look forward to more moments of insight as I move forward, presuming and searching for shared moments of competence and communication.

 

For more on Typhoid:

Mayo Clinic (2018). Typhoid Fever. Retrieved from https://www.mayoclinic.org/diseases-conditions/typhoid-fever/symptoms-causes/syc-20378661 

Love, Death, and Elephants

I spent today with elephants. Yes, you read that correctly. I spent all day wandering around the jungle with actual living, breathing, hungry pachyderms. The photo above is from the very beginning of the day during the first breakfast feeding session. Beyond being an amazing experience, on the surface level, it may seem like my day-long jungle trek has little to do with child life. In fact, so much of what I spent today doing in a 1:1 session with a 40-year-old female elephant is deeply tied to much of what I do clinically as a child life specialist, especially in an abroad setting like Laos.

I chose to go on a day-long trek with Mandalao Elephant Conservation. Mandalao is a nonprofit organization here in Luang Prabang which is endeavoring to rescue elephants from logging and riding industries and educate and empower Laos to practice elephant centered care. This focus on restoring freedom and health to elephants centers around following the elephants’ cues and meeting them where they are, essential components of child and family-centered care and child life practice. With elephants, this has a lot to do with the food they eat. According to my guide, elephants eat about 18 hours a day. At night, they will eat bitter food they find in the jungle, like leaves and shoots. In the morning, the Mandalao elephants come down to the Nam Khan river to wash away the bitter taste and because they know that the trainers will give them sweet bananas and sugar cane. Much like in child life practice, creating a predictable schedule which both meets the needs of the elephant and supports the creation of a trusting relationship between the mahout (elephant whisperers) and the elephants is critical to elephant centered care.

Advice that the mahout guide I was trekking with gave me as I was slipping on my anti-leech boots stands out as emblematic of my whole experience as a child life specialist practicing abroad: “Elephants are like people. They know when you show them fear, love, sadness, anger… Show them love and they will show you love.” Many times when I have worked with patients and families here in Laos, I have not had the ability to communicate verbally. I don’t speak Lao fluently and not every patient or family who I work with speaks Lao, as some speak exclusively Hmong, Khmu, or many of the other languages and dialects here. As in my interactions with Tu, the 40-year-old female elephant I was paired with today, I have learned a few meaningful words. With Tu, I learned simple commands, such as for come here and go. In the clinical setting, I know basic Lao greetings, words of comfort and praise, simple phrases, and medical specific questions, such as whether someone is in pain. Despite my very limited language abilities in both the clinical and jungle settings, the mahout’s words ring true, “show them love and they will show you love.” Through nonverbal interactions, such as kneeling to the child’s level, smiling, blowing bubbles, and engaging in play, it is easy to overcome a language barrier and communicate safety, forming a trusting relationship with patients, families, or, as in today, elephants.

Forming a trusting relationship and communicating despite language barriers becomes all the more crucial in critical care settings. This past week, I provided support for my first bereavement in Laos. There is a lot of cultural significance to death here and a lot of taboo surrounding dead bodies. Depending on the belief systems of the family and the village, a dead body may or may not be able to return and be cremated or buried in the village from where the family came. In many cases, when it is clear that death is the outcome, patients will be discharged to die at home so that the family is able to conduct whatever funereal rituals are appropriate for them, free from the taboo of bringing back a dead body. Discharging and transporting a patient home before death is not always possible, however, as was the case this past week.

Back in the US, there are many legacy and bereavement interventions which I have been trained to offer to patients and families based on their appropriateness and feasibility on a case by case basis. In Laos, given that the ideal is discharge and death at home, I have not had the chance to offer many. Usually, by the time my child life coworker and I receive word that someone will be discharged to die at home, the family is out the door. Any intervention offered in such a case would take away valuable transportation time. However, in some cases, making it home to die is not an option and, as in this past week, there is a space to offer legacy and bereavement interventions. Given the high humidity of monsoon season and the fragility of plaster handprints on bumpy roads, the primary bereavement intervention is painted handprints which can then be laminated for durability.

Given that the family to whom I was offering bereavement interventions did not speak Lao and I do not speak any Hmong, I was anxious about offering handprints. There was a lot happening in the room. I was not sure about the cultural significance of handprints. The patient’s parents and aunt were understandably distressed at the bedside and medical staff were working hard to try to change the course of the inevitable, though very open to our intervention. My coworker speaks Hmong and was able to translate what we were offering to the family and provide the family with a choice in participation and the color of paint. They chose a dark green which rivaled the rich foliage outside. My coworker then entered into a supportive conversation with the patient’s mother, leaving me language-less with the patient’s father, her aunt, the dying child, a pad of paper, a paintbrush, and a cup of dark green paint.

In my anxiety, the intervention is a bit of a blur, but what I do recall echoes the words of the mahout, “show them love.” I pantomimed brushing paint onto hands and feet and pressing them onto the pad of paper. The patient’s father and aunt lovingly spread the rich green paint over the palm and fingers of one of the child’s hands and the sole of one of her feet where lines and monitor wires would not be disturbed, gently but firmly pressing her hand and foot down onto the paper to make a perfect print. We set the precious paper aside and I assisted in cleaning the dark green paint from her hand and foot with warm, soapy paper towels. We didn’t use words. There were really no words to use. By the time her father and aunt and I had gently wiped away the dark green paint from between each of her little toes, my coworker and the patient’s mother had returned. My coworker said words I did not understand, the family bowed, and we exited to laminate the paper.

By the end of the elephant trek today, I would like to think Tu the elephant and I had formed a trusting relationship. She stopped often for stokes and snuggles with her trunk. When the time came to part ways, she leaned into me and I gave her a kiss on the cheek. We had not really used words to communicate all day, despite a handful of commands the mahout taught me. Instead, I had fed her and walked with her. She had watched me lug banana tree trunks to her for her lunch. She had smelled me ambling along in front, beside, or behind her all day long. By the end of the day, I would like to think that she thought of me as a safe individual, if not a friend.

When the patient passed away and the time came for the family to take her body home, I was not at the hospital, but a medical team member who was at the hospital reported to me that the laminated handprints were all that the family wanted to take with them. They communicated their thanks to the hospital for their care and support before the father carried his daughter out and the mother held the plastic coated paper tightly against her chest as they walked out into the night, heading home for funeral preparations. While I did not have a way to speak with them, I would like to think based on their actions that, despite their child’s death, the family, too, felt valued and loved.

Whether we are limited in communication due to barriers of language or barriers of species, limits in communication ability must not limit our compassion nor our empathy.  In the clinical setting, in the jungle, in our every day lives, we must show love. We must be love and, when we are, we will be loved.

On American Legacy

Today is the fourth of July or American Independence day. The fourth of July is the anniversary of the Declaration of Independence wherein America declared its separation from Britain. It’s the national holiday back home where people tend to have cookouts with friends and family, set off fireworks, and celebrate some version of American patriotism. Despite the above hilarious picture of myself, my fellow American and Canadian volunteers, and a cardboard cut out of a coconut-drinking president Obama, I have not been filled with patriotism this fourth of July. Rather, I have spent much of my time here in Laos questioning what it is to be an American and how to approach the American legacy here.

According to the Unexploded Ordnance (UXO) Program here in Laos, a quarter of the villages in Laos are contaminated with UXO. This contamination means that fertile fields are unplowable resulting in poverty and hunger. Men, women, and children are injured when they come into contact with and accidentally detonate UXO, causing grievous injuries and fatalities that radically impact families and communities. Over two million tons of ordnance was dropped on Laos between 1964 and 1973, leaving behind approximately 80 million UXO after the war. Laos is the most heavily bombed country on Earth, mostly thanks to the United States of America.

Beyond the everpresent shadow of America’s UXO legacy here, I also feel a deep shame and urgency regarding the current specter of America on the world stage. While I am on the other side of the globe and my access to news media is not spectacular, I am very much aware of what is going on in my home country, especially how the current administration is treating immigrant and refugee children and families, people of color, women, and members of the LGBTQIA community. As a mandated reporter and as an advocate, I feel both pulled to action and completely overwhelmed by what is going on in my home country as well as completely at a loss as to how to help those at home from all the way over in Laos.

It is also easy to feel overwhelmed by the endless stream of patients who arrive at the hospital struggling with malnutrition, typhoid, burns, trauma, and preventable diseases. I cannot help but question what role my own country has played in creating the conditions of poverty here or in supplanting any foundation upon which healthcare infrastructure could have been created decades ago through the legacy of war, poverty, and UXO. I am ashamed not only of the current actions of the current political administration but also of the legacy of American involvement in this part of the world. Yet, as much as I wince when I answer the question “where are you from?”, I can only hope that I am helping to forge a new identity for America, especially for America in Laos.

The Declaration of Independence States, “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness.” On this anniversary of the Declaration of Independence, I hold onto the hope that my presence here in Laos, my presence at the bedsides in the hospital, and my support from afar carries forth those unalienable rights and begins to forge a new legacy, instilling compassion and empathy through developmentally appropriate, trauma-informed child life care. Through each small action of patient care, I carry the hope that my micro-actions contribute to macro-actions, transforming not only the life, liberty, and happiness of each patient and family, but laying the framework and scaffolding the resilience of the hospital, of Laos, and of my own country.

Happy Independence Day, America. May we all be a little kinder, a little gentler, and listen to one another a little more closely.

 

More information on UXO in Laos can be found at the Lao National Unexploded Ordnance Program’s website here: https://www.uxolao.org/

Text of the Declaration of Independence can be found here:  http://www.ushistory.org/declaration/document/

On the Magic of Grandparents

A very big difference that I have encountered here is Laos is how childcare works in this culture. It is quite common among the patients and families for moms and dads not to serve as primary caregivers for their children, especially those from extremely rural areas, though often they accompany their child in the hospital setting. In particular, for rural farming families, childcare is often the domain of grandparents, as the younger, more physically able family members spend all day at the farm which can be many hours walk from home. In some cases, parents live at the farm and see their children infrequently, dropping off newborns with the grandparents following their birth and then returning to the fields to grow the food needed to earn money for the family’s survival. School here is not free, though it ranges in price from cheaper, less educational establishments to more expensive international private schools. Most schools start at the age of seven, though there are preschools and daycares in city areas. Not every family can afford to send their children to school and, given that even if they can afford it, many do not have access to preschools or daycares, the newborn through seven years of the life of a child are quite often spent in the primary care of grandparents.

The area of child life practice here where I have observed the most impact of grandparent childcare practices has been the developmental clinic, which is held for a full day each Tuesday. This clinic is where patients who have been either to inpatient or outpatient care are referred when there is a concern about their developmental progression. Often, patients who have struggled with malnutrition, had a traumatic brain injury, been premature or in the NICU come to the clinic as wells as patients who have been diagnosed with autism or for whom a diagnosis of autism is suspected, patients with cerebral palsy, down syndrome, and microcephaly, or even patients who have a gait difference, propensity for drooling, or reluctance to speak. At the clinic, the patient’s developmental level is scored using an edited version of the Denver Developmental Screening which has been changed to best represent the culture and lifestyle of people here. They also receive a medical screening with particular attention to their height, weight, and head and limb circumference to check for malnutrition or other biological etiologies for any sort of developmental delay. The family is interviewed about their home life, what their worries are about their child, and their day to day childcare situation. Following the screenings and interview, the interdisciplinary team, who consists of medical, physio, occupational therapy, and child life, speak with the family to help them come up with things to do at home to best support their child’s development as well as ways we can continue to support them and their child as is necessary and possible given how far they live from the hospital, such as scheduling occupational and physio appointments, getting x-rays of hips, spines, and limbs, prescribing medication to increase or decrease muscle tone, or recommending stretches, tummy time, and various forms of play that both build attachment and socialization as well as help the child build muscle so that they can learn to hold their head up, sit unsupported, stand and walk steadily, engage in more speech, or many other goals.

A profound example of the impact or magic of grandparents occurred this past week at the clinic. A preschool-aged boy arrived with his grandmother just before lunch, walking barefoot, hand in hand with her into the room. Given that I have only been here about a month now, I had not met him before, but the remainder of the team was quite familiar with his case and had video footage of his last visit. His diagnosis was cerebral palsy, but despite a bit of unsteadiness while walking alone, you would not have guessed that this little boy was the same child from the video footage recorded approximately 6 months previous. According to our screenings, he was now right on target for his age group, healthily well fed, and spent his days playing outside with grandma, doing his stretches, and holding her hand, walking with her and an infant sibling to the market and back. He enthralled everyone, kicking and throwing balls, building with blocks, and giggling gleefully as he rode the somewhat decrepit, blue hospital tricycle up and down the hallway at great speed and effort. The visit concluded with scheduling of a follow-up consultation for a school visit when he begins school at a preschool here in the city in the fall as well as heapings of praise and validation for grandma.

This type of magical success story is not always common. There are many tragic cases that visit the clinic, such as a pair of preschool-aged twins with an extreme form of cerebral palsy caused by untreated, severe jaundice at birth. Similar to the boy above, their primary care is their grandfather. Unlike the above magical grandmother, in this case, grandparent care, whether from lack of knowledge or old age frailty, results in leaving the twins lying on the bed all day, which has the effect of neither of them developing any muscle tone in order to support their heads and frequent aspirations. Until they visited the clinic, neither of them had seen a toy before. We sent them back to their rural village with a bag of developmentally appropriate toys, stretching exercises, the possibility of a wheelchair, and encouragement to return for OT/PT care as well as a prescription for play.

I have a certain soft spot for grandparent care. My own grandmother was a crucial member of my brother’s and my childhood, providing so much of the tender care I find myself echoing with patients and families. A pediatric APRN, she drove from her home in Iowa to Connecticut to support my parents and the three of us as we became medically stable in the NICU and transitioned home, living at first with us and then close by to care for us after school or during the day whenever and in whatever way we needed her. Her and my parent’s continued support and love helped my brothers and I to overcome our own developmental delays caused by our extreme prematurity. My other grandparents, who visited frequently, also made a great difference in our childhood, helping to fund high-quality preschool care as well as encouraging and supporting other academic pursuits.

My fondness for grandparents and their magical role in the lives of children may be a bit biased due to my own experiences, but, again and again, I am reminded of the community, village centric mentality here in Laos. Every member of a family and of the community has their role and their purpose which is suited to their physical and mental abilities. Grandparents care for the youngest children. Parents work in shops or in the fields, helped by older children. Children with neurodiversity or special needs are included and given tasks they can accomplish, such as monitoring the animals, boiling water for tea and making rice for family members who return from the fields, or, as in the case of the twins above, being a smiling, beloved member of the family. It has been fascinating to observe the differences and similarities between childcare here in Laos and back in the United States. While there are tragedies and life is unfathomably hard here in Laos, it is without a question that every member of every village is valued, loved, and cared for. As a Western nation, there is a lot we can learn from this developing country.

On Being Sick Away from Home

Now that I’m on the road to recovery, I have more space to step back and reflect on what has been a rather interesting experience these last few days. Being really quite sick away from everything I call home has given me a much deeper empathetic understanding of what the patients and families I work with may be experiencing. The hospital environment here is very different from the lives many of the patients and families I work with live back in their rural villages. Many of them have not seen fluorescent lighting, thick concrete walls, ceiling fans, or white foreigners prior to visiting the hospital, not to mention the equipment and supplies that come along with a healthcare environment. My own time as a patient in Laos was incredibly enlightening and humbling, granting me a firsthand experience not only in what the patients and families I work with may be experiencing but also what immigrant and refugee patients and families may experience when seeking medical care in their host country.

I started spiking a fever on Saturday afternoon but didn’t really feel horribly ill until later on that night. As I lay underneath my mosquito netting alternating between feeling so cold that my teeth would chatter and so hot that my bed linens and pajamas were soaked with sweat, I was paralyzed with fear, racking my brain with possible horrible diagnoses. Had I gotten malaria despite taking a prophylaxis? Was this typhoid? My fever felt as ridiculously high and my joints and muscles ached as much if not worse than when I was hospitalized for Lyme disease many years ago – was this somehow that again? Or, given the symptoms, was this dengue? I spent a fitful night trying to force myself to drink water and juice and alternate ibuprophen and tylenol, questioning what my options were. I knew going in that the healthcare infrastructure is quite poor here and that, according to the organization with which I am volunteering, if something goes very wrong and one is an adult, the best option is to fly an hour to Bangkok for treatment, but there was no way I felt well enough to get on a plane. I woke up Sunday morning feeling marginally better, but then fainted getting out of the shower. As I came to on the rather unforgiving tile floor, I felt very afraid and very, very alone.

What happened after that moment of abject misery illustrates the community-centered way of life here in Laos for which I am so grateful. I sent a text to two friends I have been working with, inquiring about whether they thought it was necessary to go into the hospital and get a blood test for dengue, malaria, and typhoid. They not only answered my text, but showed up at my door, bearing juice, bananas, and a working thermometer. The mother of one of them happened to be visiting and offered fretting condolences. They sat with me, keeping me company and keeping me hydrated. My landlady, who is a pediatrician, also stopped by, bringing me noodle soup and making me sit outside my room for fresh air, telling me that while I am here I am like family and to please tell her immediately the next time I was sick. Their presence made all the difference in this illness experience and I cannot put into words how grateful I am for their support and companionship.

After another night of soaring fevers, I took a tuk-tuk to the hospital to try and get a blood test. My supervisor met me at the door and escorted me to a nearby clinic that treats adult patients. I sat in the waiting room, struggling to fill out forms that were mostly in Lao and understand verbal instructions given to me in Lao accompanied by gesticulations, realizing that the confusion and embarrassment I felt may mirror the experience of many refugee and immigrant patients in the healthcare setting. Just because I could not communicate or understand did not diminish my urgent need for care nor was it representative of my ability to communicate in a written or oral language with which I am fluent. The utter relief I felt when conversing with the doctor who is fluent in English drove home the point of translator usage in the healthcare setting, a practice that not only makes communication and thus healthcare possible, but which also normalizes and validates the language needs of the patient. I left a few hours later with a thankfully negative dengue test result and a course of antibiotics for what amounts to an acute bacterial infection.

As I’m sitting here writing this, my landlady has stopped in to check on me and I have spent the day answering texts from friends and coworkers. In an earlier post, I spoke about the village or community-based mentality of care here and I am so thankful to say that it extends to volunteers as well. While I may be recovering far away from my support system and the comforts of home, I am certainly not alone. My experience here as a patient makes me all the more driven to offer not only compassionate care and validating normalization to the patients and families I work with in Laos, but also to work toward creating the same sort of supportive network for immigrant and refugee children and families back in the US. No one should feel afraid and alone, especially when they’re struggling with an illness, injury, or trauma. I look forward to returning to this crucial work.

On Fear, Anxiety, and Comfort Zones

If you had told me nine months ago that I would be living and working with a group of like-minded individuals to establish pediatric healthcare infrastructure in a developing country halfway around the world from my friends and family during monsoon season, I would not have believed you. While empowering people through education and access to resources to increase healthcare and psychosocial support has been a passion of mine, I would not have felt as comfortable leaving my comfort zone to this extent, even as recently as nine months ago. I function with a rather high level of anxiety and, for a lot of my life, living inside my comfort zone was the only reality I could contemplate. As someone who has only just begun the great emergence from the cocooned safety of my comfort zone, I can imagine that the cloistering nature of comfort zones can be a fatal deterrent to any dreams of similar adventures to this child life abroad journey. As an anxious newcomer to this lifestyle, I can really only speak to what has worked for me and what I am working on.

Approximately nine months ago, I began my child life internship in New York City. New York City is by no means a part of the developing world. It is no more than a 2 hour or so train ride from where I grew up. I speak the same language as a great portion of NYC residents, understand the government and financial system, and had friends and family living within walking distance of me. In comparison to Laos, it barely qualified as a step outside my comfort zone, yet, at the time, it felt like another planet. Between the grueling nature of the child life internship and a rather unfortunate living situation, I spent the majority of my time in or close to tears, both from sheer exhaustion and anxiety. I was covered in hives. I slept very little. I was, in a word, miserable. Yet, despite the struggle that was that first step outside my comfort zone, I learned so much about myself and my abilities. I do not think that I would be here in Laos if it were not for that struggle. In five broad strokes, here are a few grains of wisdom for anyone considering taking that first step or contemplating making a giant leap outside of their comfort zone.

1. It is okay to be afraid.

For me, fear is a great part of being outside my comfort zone. Recognizing that my fear does not necessarily spring from a need to avoid something dangerous and instead stems from encountering the unknown continues to be an area of growth for me and an aspect of being outside my comfort zone that I am working on during this trek. Being okay with the heart-pounding, chest-tightening sensation of fear is a process. As I have been adjusting to Laos, I have spent my free time wandering. During the first few wanderings, I kept quite close to where I was staying or to what were already becoming very familiar landmarks. Yesterday, however, I chose to cross the Nam Khan river via the bamboo bridge and return via the Old Bridge pictured above. For full disclosure, I am terrified of heights. Crossing the river on a bridge made of bamboo that is washed away each rainy season and a bridge with missing floorboards and rickety, rusty beams high above the Nam Khan was probably the most terrifying thing I can ever remember doing, but I knew I could do it and I knew that, even though I felt like it was a near-death experience, I was okay and would be okay. Relabeling fear as less of a primal defense mechanism and more of a harbinger of growth has been crucial in venturing outside of and/or expanding my comfort zone.

2. Find coping mechanisms that work for you and build on them.

As I gripped for dear life onto the rusty trusses of the Old Bridge yesterday, this kernel was something I especially called upon, but self-care and coping mechanisms are crucial to adjustment and day to day living even when you do not feel as if you are about to meet your untimely demise. For me, regulating my breathing is a necessary aspect during extremely stressful moments. While crossing the bridge, I hummed and sang familiar tunes to myself to keep myself breathing and moving. I’m sure I looked like quite a spectacle and a local gave me an interesting look after I finally made it across the footpath onto solid ground, but knowing what works for me and drawing on those coping mechanisms made all the difference in facing my fear and completing my task. Taking note of other activities or small tangible things that help you feel safe and give you a lifeline to your comfort zone can also be helpful when taking a step or a leap outside of where you feel comfortable. For me, running, hiking, and keeping active on social media with friends and family back home act as a lifeline to my comfort zone which, thankfully, are all things I can keep doing while I’m here.

3. It is okay to ask for help.

This weekend I also had my first encounter with unfriendly wildlife in Laos. After getting out of the shower, I slipped on a tank top from my suitcase only to immediately discover that it (and my entire wardrobe) was full of red biting ants. Apparently, this time of year here they will get into everything and can be attracted to anything, even the salt left on your clothes after you sweat. Panicking, I stripped naked, squashed the ones which were on me, and sprayed bug spray and citronella all over everything, leaving me standing in my room with no clothes on, bitten all over, and no clothes to wear that weren’t infested and/or drenched with chemicals besides my pajamas. Back in my comfort zone, this would have been a moment to call on my support system, but, on the other side of the world, I did not really have that option. Recognizing that, while I am separated from the familiar, well-established support network of my comfort zone, I am not alone and there are people I can turn to is essential to coping. In this instance, I found my landlady was quite helpful and acquaintances I had made at the hospital were also a great resource for a good venting session. The worst thing that can happen when you ask for help is to have someone turn you down and you won’t know all your options until you try. It is better to ask.

4. Say yes to everything once.

Keeping an open mind to the people and opportunities around you is another essential component of adventuring and adapting to life outside of your comfort zone. Saying yes to grabbing a cup of coffee or a meal with a local or a fellow traveler can be an amazing, eye-opening experience which introduces you to a whole new way of thinking and living. Saying yes is an aspect of adventuring and adapting that I am attempting to wholeheartedly embrace. So far, it has brought me meals with some amazing individuals with a wide range of perspectives as well as a trip to the Tad Sae waterfalls on the back of a motorcycle, something I would not have dreamt to have touched back in my comfort zone.

5. People are people everywhere.

Life outside your comfort zone is scary and hard, but it can be wonderful, too. Learning about and experiencing the comfort zones of other people and other cultures is a fascinating way to broaden your understanding of the world around you as well as what you consider important and what you need day to day. People are people everywhere. If you are kind and respectful to them, by and large, they will treat you the same way.

I cannot lie and say that taking steps or leaps outside your comfort zone is an experience with only positive outcomes. As I have discussed in previous posts, discomfort, frustration, and sadness should be expected, but, though I’m only just over a week into this giant leap outside my comfort zone, I can definitely state that it is worth it. While I do have my moments of fear and anxiety, I can attest that broadening the horizons of your experiences to include areas which do not fall inside your comfort zone can not only expand your understanding of the ways other people live and think, but also expand your understanding of yourself, the things that make you comfortable, and the things that bring you joy.

Things That Glow

I’ve been struck by the quality of the light here. Maybe it’s the combination of the two brown rivers that flow on either side of the peninsula and reflect the light that gives everything a golden sepia tone or perhaps it’s something else entirely, but light outside the clinical setting takes on a certain glow, especially when paper lanterns come into the picture at super touristy spots like the night market pictured above.

In the clinical setting, light has a whole different sort of magic. I brought a couple light spinners with me on my travels. For those who don’t know, a light spinner is a pretty simple electronic toy which has, as the name suggests, multiple little colored lights that spin within a plastic globe and create a tiny, rave-like light show. While I love a good light spinner, I had no idea that such a simple toy would be such a hit here in Laos.

The first patient I showed the light spinner to is a long term school aged patient who has seen much of what is on offer at the hospital as far as toys are concerned. He has a deep affection for the iPad which is shared by the entire hospital. In this instance, he was anxiously anticipating a procedure and hoping desperately for some screen time. As I do not carry the iPad and do not speak the same language as this patient, I felt a bit at a loss for how to support him, but knew that within the string bag on my back was a bunch of stress balls, bubbles, my light spinner, and a tiny travel sized Jenga. Hoping that holding up two items conveyed the possibility of a choice, I held up the light spinner and the Jenga. The patient latched onto the light spinner, at first curious about the shiny handle and globe shape and then amazed by the lights when his fingers found the on/off button. We played with the light spinner, incorporating the Jenga as blocks to be built with and knocked down by the light spinner turned rocket, turned lightening, turned wrecking ball right up until his procedure and he coped well until anesthesia took effect, holding onto the spinner as he was wheeled into the operating room, sleepy eyes on the lights, vibrating motion soothing a rhythm against his chest.

The same fascination with the light spinner has held true across developmental stages and ages from toddlers through to adolescents, though the application of the spinner varies from the above use in play to the more passive spectator effect in the younger or less mobile patients. As I continue to find my way here and acclimate to the clinical and non clinical settings, I am constantly amazed by the effects of play and the many ways it unites us, bridging cultural and linguistic barriers. Like the physical effect of the light spinner, play has the ability to bring light and joy during even the darkest, most anxious of times and I am so honored to be able to engage in play with the children and families here as they endure and rise above the illnesses and injuries which bring them to the hospital. Perhaps the glow of the rivers, of the light, and of the world here in Laos is its own sort of resilience, shining day after day through monsoons.