Myanmar, Sept 2018 – March 2019

CUH Nurses Volunteer in Yangon – Week 1

8th October 2018

By Stuart Tuckwood & Livi Rees

Welcome to Yangon  

On Saturday evening Livi and myself touched down in Yangon, Myanmar, to begin a six month placement in the intensive care units at Yangon General Hospital. Both us have travelled far from our normal place of work, Addenbrooke’s Hospital in Cambridge, where we work for the NHS in critical care. In our day to day roles Livi is an ITU nurse based in the neuro critical-care unit and I work as a specialist nurse in the Rapid Response Team across the hospital.

We were very soon aware of how exciting and beautiful place Yangon would be to work in, as we were driven through the traffic whilst the sunset painted the clouds red across the rivers and delta outside the city. For the moment we are based in downtown Yangon, a crowded and bustling grid close to the river at the south of Yangon. Everything around is colourful and bright, the shopfronts, marketstalls and clothes of the crowds on the street which often include wandering monks. The heat and humidity are intense. Whilst struggling to recover from the fatigue of the journey we hit the streets to explore the city. We slogged through the midday heat to see some of the city’s famous sites including the Sule Pagoda, a golden Buddhist temple in the middle of a busy roundabout, and the city’s independence monument in Maha Bandoola Park.

In the evening we continued getting to grips with the local cuisine, trying hot and sour fried bean curd and steamed fish in lemon. Monday morning and a doctor from Yangon General was kind enough to collect us and take us to the intensive care units where we will be based. Yangon General Hospital is a grand, Victorian style red brick building occupying several blocks in downtown Yangon. The Intensive Care Units comprises several rooms in the centre with 20 beds for the sickest patients who require the closest attention. Some are admitted following trauma such as road accidents, whilst others are sick because of diseases and conditions which we are less accustomed to treating, such as tetanus or snake bites.

We were welcomed onto the unit on the first day by several of the intensive care consultants and the nurse in charge of the unit, who greeted us warmly and showed us around. The clinicians working on the units are evidently highly skilled, knowledgeable and enthusiastic, this much is obvious very quickly, whilst they may not have many of the resources we do in the NHS in the UK. We spent several hours with the doctors and nurses on their units, familiarising ourselves with the care given and observing their practice.

Later, in the afternoon we stopped to pick up local phones for use whilst over here. Acclimatising to life in a new country and culture can be difficult, adjusting to a different working environment in healthcare tougher still. Working out where and how we can be of most use will undoubtedly be challenging, though I feel there are many positive signs from our first days here. The strong partnerships and relationships built up between clinicians in Yangon and Cambridge mean there is a lot of goodwill and enthusiasm to build upon and we’re very hopeful we will be able to do that.

Stuart Tuckwood

One week on from our arrival in Yangon the city is already starting to feel like home, helped by our move into the flat that will house us for the remainder of our stay. We are becoming more familiar with the downtown area of the city, and are beginning to navigate by the various restaurants and pagodas we have visited so far and of course by our central landmark, the Yangon General Hospital.

We have spent this week in the hospital observing the work of the nurses and doctors on the unit, attending ward rounds and making notes about potential ideas for projects we could implement during our time here. This week around a quarter of the patients on the intensive care unit have been trauma patients. Interestingly the classification of trauma patients here also includes snake bites and tetanus patients, and we are keen to learn more from the team here about the management of these conditions we are unlikely to see in the UK.

The remainder of the patients on the ICU this week have presented with conditions similar to those we see in our intensive care population in the UK such as [Stuart’s bed in our flat] respiratory failure, sepsis and post cardiac arrest. Another large part of our week has been meeting with other volunteers working on projects in Yangon, and with useful contacts within the hospital and the University of Medicine here.

On Thursday I was invited to visit the Neuro Intensive Care at Yangon General Hospital, which was particularly interesting for me as this is my specialty in the UK. The Neuro ICU consists of four beds for ventilated patients and two for level 2 patients, with a similar set up to the general ICU in terms of families taking responsibility for the patient’s personal care. The head consultant who was taking us around showed me their folder of guidelines, page one being the Addenbrooke’s Hospital Neuro Critical Care Unit’s protocol for the management of intracranial pressure, which made me feel very proud and a tiny bit homesick for my unit!

This week we also enrolled for a course of Burmese language classes and had our first class on Thursday. Although the grammar of the language is relatively simple, our biggest hurdle will doubtlessly be the pronunciation as there are four tones in the language and a plethora of words where a subtle change in tone or enunciation can result in wildly different meanings. No wonder our efforts so far to read aloud from the phrasebook have been met with confusion and amusement! The greatest motivating factor however is the reaction when you do say something right, I have never travelled to any country where such a small amount of the language can go such a long way.

So far our impressions of Yangon have been extremely positive. We have been warmly welcomed by the staff in the hospital and the other volunteers we have met have all been very friendly. Next week we are hoping to meet some more important figures within Yangon General Hospital and present our first ideas for projects to implement in the ICU.


Myanmar has no national ambulance service, but ambulances are a common sight on the streets around the hospital, often stuck in the traffic with sirens blazing making a slow journey towards the hospital

Little shrines line many of the streets of Yangon, this one has been here for so long it has become part of nature itself.

A view of the Swegadon Pagoda peeking through the trees, taken from the bridge in People’s Park

A beautiful Myanmar sunset in the Swegadon complex

The Swegadon is surrounded by smaller temples and shrines, and has several bodhi trees, which are sacred in Buddhism as they are said to be the type Buddha was sat under when he achieved enlightenment

Delicious steamed fish with lemon
Lights and decorations are starting to go up in Yangon in preparation for the Thadingyut or Festival of Lights at the end of October, which is a time to give thanks to parents and teachers as well as asking those you have wronged during the year for forgiveness.

Week 2

16th October 2018

By Livi Rees

We have now been in Yangon for two weeks, and are feeling thoroughly settled into life out here. We have decorated our flat with photos from home and posters with Burmese vocab we need to learn for our lessons, and have been making friends both inside and outside the hospital.

This week we have continued our observation of the working practices on the unit and have been collecting some more detailed information about the trauma patients. In particular we have been looking at their route of admission into hospital and the length of time between traumatic event and definitive treatment, which seems to vary a great deal which is very interesting.

On Friday we delivered our first training session to the nurses on the ICU which was very well received. We covered the acute care of spinal cord injured patients, and Stuart was a very good sport letting the team log roll him many many times! We were joined in our teaching by a volunteer from Glasgow called Julie Doverty, she is an anaesthetist who is in Yangon for three months working with anaesthetic trainees in theatres. We are keen to promote the idea of multidisciplinary working in the ICU so are very excited about working with her in the coming months.

We had been concerned about the language barrier when teaching, but in this session we felt the level of comprehension was quite good as the nurses were very engaged and asked lots of questions, and it was very encouraging to see colleagues translating for one another if they had a higher level of English.

It has been another busy week meeting lots of people connected to the ICU and socialising with other volunteers in the city. We went to a classical music concert organised by the Goethe institute on Friday night, and on Saturday we went to see a football game (Myanmar vs Bolivia) at the stadium in the East of the city.

Week 3

22nd October 2018

By Stuart Tuckwood

The People of Myanmar

Of the various impressions made on me over the first three weeks of our work in Yangon, the strongest and most vivid have been those made by the people we have encountered.

If it wasn’t already abundantly clear from the exuberant welcome we received from the staff in the hotel we checked into, or the various attempted conversations with excited locals, living amongst the people of Yangon, and Myanmar, was always going to be interesting.

Though we’ve not been here long, it’s obvious that life for the people here is changing at a fast pace. From what we’ve learned, new technologies, like smart phones and the internet, are now much more widespread and available than they were even a short time ago. Western style shopping malls are being thrown up all around the city, where only a few years ago there were almost none in a city of 5 or 6 million people. The streets and long roads leading away from downtown Yangon are packed full of new cars and thousands and thousands of white Toyota taxis where previously bicycles and carts dominated.

Downtown Yangon is an exhilarating mix of the old and new. Sitting outside air conditioned cafes with Americanos and free WiFi are stallholders perched on the pavement selling street foods or other seemingly bizarre items, like tiny live birds from a cage. You can wander around a glamorous mall packed with designer brands and bump into a group of monks in their saffron robes.

Despite attempts to catch up, local healthcare is acknowledged by many of the clinicians we have met to be still some way behind. It’s easy to be dismayed by the inequity between the rapid developments in the private sphere and the seemingly slower progress in the public. Obviously, however, health systems and their improvement are dependent on a myriad number of factors, including cultural and social, that are not easily overcome in a short space of time.

It does make you wonder though, how the clinicians, medical or nursing, that we have met so far, view the changes they have seen so far, and us, the newcomers from so far away. One of the senior nurses on the intensive care unit where we are based has been there for over 25 years. Witnessing the developments in any health system over that time period would be interesting, yet alone one which was isolated for such a long time that is now beginning to open up.

And I keep thinking about the patients we are seeing. Many have been through incredibly traumatic experiences. It’s well known that coming through a critical illness, requiring an admission to intensive care, can, for many, lead to problems with stress, cognition and language. This happens even in highly developed health systems, where there are initiatives to reduce the psychological burden of intensive care treatment and often organisations or professionals to support people through these experiences.

Weeks 4, 5 & 6

12th November 2018

By Livi Rees

Hi readers! Apologies for the lack of entries as the last few weekends have been very busy and I have been having problems with the keyboard on my computer which has made writing a long entry impossible. I have managed to borrow a computer for today so will try to catch you up as best I can!

The last few weeks have been slightly disjointed, first with the Thadinyut festival at the end of October where we had a few days off, then with a weekend trip to Bangkok to renew our visas. The expiry of our visas coincided with my birthday so we celebrated with some Thai massage and by eating some of the western foods that are harder to find in Yangon. We stayed in one of the more touristy areas of Bangkok which was a bit of a culture shock after having been in Yangon for a month, and we were glad to come back to our little flat despite an invasion of ants which had seems to have occurred during our time away! Unfortunately the battle with the ants is still ongoing, and has this has quickly become a dominant topic of conversation in our household, much to the amusement of the guests we have had visiting recently.

The week before last, Caroline – one of our physiotherapist colleagues from NCCU at Addenbrookes – came out to Yangon and stayed with us for a few days as she was delivering a training course to physiotherapists from YGH and other local hospitals. The physio team that are part of the partnership between Cambridge Global Health Partnerships and YGH come out several times a year and have set up a practice development team amongst the physios here who they are supporting to work towards sustainable improvements in the practice of physiotherapy in Yangon. Caroline asked Stuart and myself to help out on the training course last week, and we delivered a couple of talks as well as running breakout sessions covering more practical skills like patient assessment and tracheostomy suctioning.

After the training course Stuart accompanied Caroline up to Mandalay for a few days on a scoping exercise as the plan going forward is to set up a practice development team there too, creating two hubs to allow the dissemination of good practice across Myanmar. While Stuart was away, Jackie – another colleague from NCCU – arrived to help us with our project ahead of the arrival of the rest of the team that have just arrived from Cambridge this weekend. There has been an influx of people this week as we will be the Delivering Trauma Intensive Care (DelTICa) course that the Cambridge-Yangon Trauma Intervention Partnership has run for the past few years. Jackie is a nurse as well and came out to Yangon last year as part of the DelTICa course, so has been giving us valuable feedback on our ideas for projects going forward, as well as coming into the ICU with me every day and helping us with our Friday teaching last week.

On Friday we ran a session on ECG interpretation and touched on the management of cardiac arrest rhythms. The nurses’ knowledge of ECGs is very good, and we spent some of the session picking rhythm strips from Stuart’s ALS book and working through rhythm recognition and the changes that have taken place in the heart that would contribute to such arrhythmias. The nurses are very keen for us to do some training with them on life support, so we are planning this for future sessions. We have been able to source a CPR mannequin from another department in the hospital so we can do some practical sessions as well.

I will leave you with some photos from the last few weeks!


On the full moon day of the Thadingyut festival we went on Thida’s (the lead nurse of ICU) recommendation to the Shwegadon Pagoda as it is the main religious centre of Yangon. It was very atmospheric, full to the brim of worshippers and as the sun set the pagoda was lit up by hundreds of oil lamps

Group photo of Caroline, ourselves and the delegates from the physiotherapy course we helped teach on

A view of the Grand Palace in Bangkok, the residence of the Thai Royal family and the site of one of the most important depictions of Buddha in Thailand

Close up of some of the protector deities supporting the extremely ornate facade of Wat Arun, a temple situated close to the river in Bangkok. We took a boat down the length of the river to reach here, a lovely way to explore the

The physios from the course kindly presented us with gifts of traditional dress to thank us for our role on their teaching

Following the physiotherapy course we have been working with some of the physios in ICU, here they are showing me how they perform passive range of movement exercises to stretch muscles, an important technique for preventing complications in bed bound patients

Going through some arrhythmias from Stuart’s ALS book with the nurses, we tried to alternate practicing rhythm recognition with discussions about the pathophysiological processes underlying these arrhythmias

Weeks 7-12


19th December 2018

By Arabela Paduraru

A Journey to Myanmar

I don’t know what was in my head when I said to Stuart that ill write for the blog. It’s proving a real challenge converting overwhelming emotions into words.. but here it goes.

Let me start by introducing myself and how I got to meet Stuart and Livi, two amazing nurses that spread time, knowledge and passion in the beautiful Yangon.

My name is Arabela Paduraru, and I work as an operating department practitioner in Addenbrookes Hospital. In November I had the privilege of going on a scoping visit to the Specialist hospital in Yangon, to understand how their liver transplantation system works with the vision of creating a new partnership initiative and facilitating a future transplant conference.

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Deltica team having local dinner in Yangon

I arrived in Yangon, together with a few members of the DelTICa (Delivering Trauma Intensive Care) team and the director of CGHP (Cambridge Global Health Partnerships). The course director was already waiting for us and shortly upon our arrival at the hotel, I had the pleasure of meeting Stuart, Livi and Jackie, good friends not just colleagues. Their relationship sparks ideas constantly. After we all had a delicious dinner, we soon got involved into the course and its logistics. Although I had a very good pre-brief, nothing could have explained to me the intensity of the week that was to follow.

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The first two days were getting to know the way of the land, so to say. I met the Myanmar team that were part of the course, got the opportunity to attend a THET (Tropical Health Education Trust) meeting which helped me get a better understanding of the broader picture and got to know about the other CYTIP projects.

Whilst things were changing constantly, as meetings were being scheduled which required the attendance of different members of the team, everything found it’s place. The Myanmar faculty team was being supported in preparation for the delivery of the course.

The DelTIca team is a very well-oiled clock. Not just by the professionalism, knowledge and skill they share or their passion and commitment to the delivery of the course and cause but through their ability to work as a team, creating an environment which brings out the full potential in each member, from the morning coffee to the night time tea.

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Simulating spinal cord injury positioning with course participants

Although we had time for ourselves, most of it was spent, by choice, discussing the course, overcoming the challenges encountered on the way and constantly searching for ways to improve.

As I said before, it was a very intense week. If in our day to day life we sometimes leave things to do for the next day, here, we did not have that option. As there were only a few days available, we took advantage of every minute. Every night we had dinner together, discovering though Livi and Stuart, some secret gems hidden in the heart of Yangon and tasting the wonderful burmese cuisine.

Some might not have approved and thought us crazy but some of us got up early morning one day and whilst enjoying the sunrise over Yangon, some went rowing, others went running. Mens sana in corpore sano, as the latin saying goes. Not only the view was beautiful but yet another proof of good teamworking and empowering leadership.

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Weeks 13-18


30th January 2019

By Stuart Tuckwood

It’s cooler now in Yangon, not quite near as cold as I’m told Cambridge or Scotland is, but much more pleasant than when we arrived in September. It’s down to a shivery 34 degrees Celsius during the day, cold enough for the locals to be wearing coats and occasionally fluffy hats.

The frequent deluges that punctuated much of our early time here have passed. Having never owned an umbrella previously I had finally given in and bought one after 40 minutes stranded under a tin roof during a particularly heavy downpour. I believe since then it has rained once so it’s clearly a very lucky one.

A mysterious fruit has appeared hanging from the branches of the dense trees surrounding our apartment block. As of yet we’ve been unable to identify it but whatever it is, it clearly is very valuable to the people of Yangon.

A week or two ago I was standing by our back window, in only a pair of boxer shorts because of the heat, making a cup of coffee, when I realised there was a wisened old man about three feet away from me, suspended at an alarming height in a tree, in the midst of a hunt for this fruit. Given how often we’ve seen patients in the hospital admitted following ‘falls from height’ this gave me real concern. I was worried that any noise from me would startle him into losing what seemed to be a very precarious grip on a high branch.

Seconds later he looked around and made eye contact with me, as if he’d sensed I was watching him. We nodded at eachother and he genuinely didn’t seem that surprised to see a westerner in his underwear watching him. As I watched he unslung a long thin pole with a twisted piece of wire on the end that had been on his back and used it to hook one of the fruit from a distant branch, like you might hook a duck at an arcade.

It was extremely impressive and you’ll be glad to hear he made it down safely. Later that day two teenage boys scaled the tree and again noticed me watching, please believe this was just a coincidence as I don’t tend to spend most of my days staring vacantly out of the window. I didn’t have the heart, or the language, to tell them that a pensioner had already stripped the tree of the valuable fruit.

We’ve continued to be very busy with our project here, working on a few different fronts with one eye on how to sustain our progress once we’ve left. We’re almost about to finish a period of research and data collection that we hope will yield interesting information on the work of the intensive care unit in Yangon General and the management of trauma patients.

We’re running weekly teaching sessions where we discuss aspects of trauma and nursing care and work with the nurses on improvements we have tried to introduce on the ICU. 

Currently we are in the midst of auditing the performance of a care bundle we have implemented together with the nursing team to assess how well it is being carried out. This aims to improve the practice of the nurses and the doctors relating to how they handle invasive lines on the intensive care unit, hoping to reduce the incidence of line associated infections and spread of infectious organisms.

Conducting quality improvement initiatives in healthcare can be challenging in any area and is fraught with difficulties in resource challenged settings. Given the burden on the local healthcare staff we’re realistic about the progress that is achievable in short timeframes but we are really encouraged by the enthusiasm the local staff have shown towards quality improvement. But that’s a topic for another day!

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Presenting Myanmar nurse with certificates on completion of simulation training

We have also begun running weekly sessions of life support simulation training for the ICU nurses and nursing masters students. The culture of learning here is often focused on didactic, lecture based teaching and there is little ongoing professional development and training for nurses. The ICU nurses we have been working with have been enthusiastic about the bedside practical learning we have done together and so we decided to run a simulation course for them on life support.

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Myanmar nurses performing life support simulation training

So far the feedback has been overwhelmingly positive and there has been a noticeable improvement in the life support skills of the nurses taking part. 

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CGHP Nurse volunteer Livi Rees, Mannequin ‘Jethro’, UK anaesthetist volunteer Julie Doverty
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UK IGH Volunteer Dr Beth Moos and Myanmar nurses doing basic airway training

I’ve spoken before on this blog about the amazing people we’ve encountered in Yangon and it still continues to fascinate me. Whilst I was sitting outside the hospital shortly after arriving a little old man sat down next to me. He took my arm, held it against his own and started laughing very loudly and saying ‘so white!’. 

When I walked into a fast food outlet in a shopping centre earlier to procure food for my ever-hungry colleague the eight Burmese staff behind the counter regaled me with a welcoming song in perfect unison. I felt very special until the next customer walked in and they repeated the feat.

It was my birthday last week and Livi had kindly brought a cake to the ICU and invited some of our colleagues and friends working here with us to join and have some. Whilst some of the physiotherapists I was working with were treating a patient, I asked them infront of the patient’s family to join us for some cake. This patient has been in the ICU for a while and we’ve talked to her family several times as they speak fairly good English. The next day as I was in the room, the patient’s daughter touched my arm and said, ‘enjoy the last year of your twenties!’.

At other times it can be a somewhat terrifying place. There is a Buddhist festival of lights in a place called Taunggyi in Myanmar where brightly lit hot air balloons are sent skywards over huge masses of people in the evenings. They are laden with an average of 60kgs of fireworks which are set off over the crowds as they fly. So possibly not the strictest health and safety standards.

On New Year’s Eve we went for dinner and then some drinks at a rooftop bar. They ushered in the New Year by sending out some of the barmen to fire fireworks off the roof from handheld poles, fortunately just the one landed near the bar and showered us with bright sparks.

Whilst coming home one day I began to feel something was a bit wrong with the taxi I was in. It took me a little while to suss out that the footbrake was obviously not working very well at all and that the driver was coping by just using the handbrake every time we needed to stop in traffic. I’m not hugely fussed by taxis providing heated seats or free bottled water but I do tend to be expect the car to have functioning brakes.Paragraph

I’d be happy to write and complain about the heat here also but I suspect I will get little sympathy from anyone in Britain given it’s sub-zero in Cambridge currently. In fact I doubt anyone will have read on this far after my initial joke about the weather. Thanks for reading


Conclusion

19th April 2019

By Livi Rees

Hi everyone! This is a slightly different blog post for our last one, as Stuart and I have both been back in the UK for just over two weeks now. Rather than reflecting on the trip I thought I’d write about coming home and how that’s been so far. Returning from a long trip away is often challenging, especially when you have been immersed in a culture so different to your own, and so we were expecting a bit of a shock when we first arrived. I was particularly dreading the shock of the cold – especially once I heard that Cambridge would be a shocking 30 degrees colder than Yangon the week we got back! But this was soon made up for by the thought of seeing our loved ones, and breathing in the comparatively pollution-free air of the UK.

When I first got back I stood outside my house for a few minutes before going in, noticing how visually different the buildings and pavements are to central Yangon, but what struck me most was how eerily quiet it is here. It amazed me that I’d never noticed it before, but my street is almost silent! Gone is the constant hum of traffic, the roar of the trains going behind our flat, the laughter of the children playing in our alley and the calls of the street vendors as they tout their wares.

This initial shock was softened by many warm welcomes home from friends and family, and by the rediscovery of some home comforts. There is nothing quite like that first night in your own bed after some time away, and more so if you’ve been sleeping on a hospital bed for six months! One of my top priorities on my return was a trip to the supermarket to buy all the food I had missed, and I came home with six different types of cheese and a smile on my face!

Both Stuart and myself have restarted our jobs at Addenbrooke’s this week now. Returning to work was a similarly surreal experience, looking at familiar things through fresh eyes and becoming aware of things I may never have noticed before. Assisting in the insertion of a tracheostomy earlier this week I was really hit by how privileged we are in this country to have so many devices and protocols that are designed with the sole purpose of reducing risk in procedures such as this, making the environment safer both for patients to receive treatment and for us to practice as healthcare professionals.

Going forwards Stuart and I will be giving a few talks about our experiences, and soon we are hoping to start the process of organising another trip to Yangon for two new volunteers in the future. The last six months have been a truly formative experience, we have both learnt a huge amount and met some wonderful people. Our next task will be to embrace the changes that have taken place within ourselves, and to bring that learning into our practice in the UK to develop further as healthcare professionals.