One Year. One Physical Therapist in Trujillo, Peru.

Combining passions of global public health with travel and cultural immersion... With the help of the Catholic Medical Mission Board, I was afforded the opportunity to live outside of Trujillo, Peru for one year's time (2010-2011). Check out old posts about my experiences as a PT working in hospitals, a school, an outpatient clinic, doing research/community based rehabilitation, and a little teaching too. And my experiences with an entire calendar year of holidays, cultural customs and new culinary experiences!

I make it back about once a year with university students/CMMB projects, so I will periodically provide updates :)

Tuesday, August 30, 2011


Today I savored one of my favorite Peruvian foods, yet again... CEVICHE! Now that my days left in Perú are numbered, I have even more of an excuse to splurge on my favorite local culinary dishes. :) (Not that I needed one.)

Ceviche de Pescado:
White fish marinated in lime juice
Aji (spicy pepper sauce)
Cebolla (sweet red onion)
Choclo (big corn kernels)
Yuca (cassava - starchy tuberous root)
Camote (sweet potato)

Yes, the fish is technically raw, but it's cooked a little from the lime juice. Peruvians swear it's a great hangover cure. I think it's great for any day - and best accompanied by a big pitcher of chicha morada (juice made from purple corn). If you ever visit Perú, you MUST try this dish - (and on the northern coast! It's not as good in Lima!) 


Wednesday, August 24, 2011

A first of (hopefully!) many

Centro de Eventos Los Corregidores - Trujillo
August 13-14th, 2011, one of my big work projects here in Peru finally came to life! CMMB and Regis University hosted the “Primera Conferencia Internacional de Actualización en Terapia Física” – the first annual international physical therapy conference held in Trujillo, Perú, created to develop a sustainable collaborative relationship between the US and northern Peru in the field of physical therapy. Secondary aims were to provide quality, affordable continuing education including access to evidence-based updates and criteria in patient management, and to strengthen the unity and leadership within PT’s in northern Perú.
Presenters from the knee group
Morning lecture session
If you haven’t seen prior posts - I began planning the event back in December 2010. Nancy Mulligan, faculty at Regis University, was on board immediately and was extremely instrumental in organizing a group of students and Kristin Carpenter (affiliate faculty) to come down and help with the event. She also helped spread the word, and Alec Kay (Anchorage, Alaska) and Ommar Ortuvia (Houston, Texas) committed to volunteering as presenters. We felt it was important to have a team of both Peruvians and Americans involved, so we sought out local leaders Ana Herrera (Lima, Peru), Pedro Rojas (Trujillo, Peru) and Pedro Romero (Lima, Peru), to present as well. The event just kept gaining momentum – and before I knew it, I had people calling around the clock from cities near and far to find out how to sign up!
With Dr. Leon (Ministry of Health) and Dra. Llanten (CMMB)
Participants from Chiclayo, about 3 hours north of Trujillo
No matter how much you plan ahead here in Peru, there are always last minute changes and frustrations. I was lucky to have a whole bunch of volunteers involved and great support from CMMB, or event planning would have been a lot more stressful! We certainly experience a few little momentary “setbacks,” such as…

- 1 week before the event, our restaurant/bar lined up for the reception of 200+ people tried to back out, even though we’d already paid the deposit. We received an invoice for event costs from the event center that was different than our calculations. Claudia’s luggage was lost, which had a number of different materials for the event. We had problems with a speaker of one organization who needed a new official letter in order to come from Lima. Customs in Lima almost confiscated the entire 4 bags of conference equipment donations.
- A few days before the event, the custom-made event bags for participants were still not in Trujillo - 1 week after they said they would arrive.
- The day before the event, I received a call that one of our Lima presenters had missed her flight! And one hospital that was supposed to lend us a large quantity of treatment tables for labs suddenly was suddenly unwilling to give them to us, despite a written contract. One of our other presenters was MIA and didn’t show for the welcome dinner.
- During the event, our person to give the opening remarks did not show. The presenter who missed her flight made it, but late, so we had to shift some things around. There was one chaotic coffee break mix-up, where one group was accidently let out at the wrong time. One day, the MC’s didn’t show – so I spoke for them.

ETC ETC! But- “asi es la vida” here in Peru. (And of course these types of things happen anywhere.) 

Afternoon lab session
Presenters of the cervical spine group
All in all, the setbacks were minor and the success was huge. We had nearly 200 participants who were split into two groups- neck pain and knee arthritis – two of the most common outpatient conditions seen here. We included “labs” both days to practice techniques, a rare opportunity for Peruvians. The labs were a bit chaotic, and the lectures were a bit heavy with material- but from an organizational perspective, we learned a lot and got some great feedback on how to change the event in future years. 

Presenters and Regis students teaching labs
Participants received DVD’s with powerpoints and videos of lab techniques, and their bag (came just in time!) complete with therapy equipment. The event included different breaks for networking opportunities, a cocktail and appetizer reception Saturday night, and a catered lunch Sunday with a dynamic discussion led by Peruvian PT’s from my focus group. We discussed some of the challenges facing rehab. providers – with a high caseload and short time with each patient, how can we incorporate more exam components into a new patient session? How can we as PT’s be more involved in the prevention aspect of healthcare? And how can grow more unified and organize ourselves as a community of PT’s in northern Peru? We came away with a list of 125 people who are interested in creating a national organization of PT’s, aids and students, similar to the something like the APTA in the U.S., who also voiced interest to work together to improve opportunities for persons with disabilities.
Enjoying the reception Saturday night
No cocktail night complete without a spine manipulation! (I swear, this was not staged!)
Saturday we invited leaders of local academic institutions to a lunch discussion over potential teamwork with CMMB and Regis University in a community based rehabilitation project. I’ll elaborate on this project later, but it was a very positive conversation and I plan to do everything I can to strengthen this relationship between now and when I leave.
Networking lunch on Sunday
One of the big challenges of the event was that it included 18-year-old students in their first semester of studies, all the way to 50+ year olds who have been practicing in the field for decades. Thus, within the participants we had a wide range of skill sets and experiences. A big emphasis in the event was the practice of basic exam skills. We also had to tread carefully in treatment with the teaching of manual skills over such a short time frame. From my experiences, I can affirm that Peruvians tend to focus almost entirely on modalities in physical therapy treatment, so we tried to address this delicate topic throughout the event by saying “Hey, since you have such limited time with each patient, how about this exercise or manual technique over the machine – more bang for your buck.” At the same time, the whole idea was to share knowledge and ideas – a two-way process – and I hope that we were able to do this without coming off as all-knowing or superior in the presentation of materials. 

more lab practice time
The event design and organization certainly had many flaws, and realistically 1 two-day course cannot change clinical practice drastically. It may be putting a “band-aid” on an evidence-based knowledge gap that is rooted in flaws in the curriculum of the local academic programs – but I like to think it’s more like one of those awesome “liquid” band-aids – the ones that fill in the cracks to create a clear, breathable seal. I know it’s not the complete solution to changing practice patterns in Peru, but I believe that it’s an important piece of the puzzle on many different levels. 

Coffee break during event
As I jumped back and forth between auditoriums to observe groups throughout the weekend, and through many conversations during the event, I was really touched by the very positive responses across the board. People came up to me in tears to thank the team of volunteers. I saw glimpses of hope and sustainability – changes in comfort levels with hands-on skills, changes in critical thinking skills, and changes in social networks. I overheard discussions on how the PT’s plan to teach their peers and co-workers what they learned at the event. I think that the event was an important tool – be it a baby step - in changing clinical practice- but I believe that it also managed to bring more unity within the PT community. And I have high hopes that it is the beginning of a strong collaborative relationship between the US and Peru.
Presenters, translators and event focus group
After the event, I had a couple of nights of 10+ hours of sleep and got back in the rhythm of nice, long, relaxing evenings in with my host family. I couldn’t believe how physically and mentally exhausted I was! However, despite 10 months of work, complete with challenges and periodic frustrations, it was all completely worth it. So, after a 48-hour recovery period, I couldn’t help myself - I started looking at the evaluation forms and – call me crazy – planning for next year. ☺ Any PT’s out there interested in coming down for the Segunda Conferencia Internacional de Actualización en Terapia Física - August 2012?

Saturday, August 20, 2011

A change of pace

I’ve just finished a whirlwind couple of weeks with a group of volunteers from the US. Regis University sent down 6 students and 1 affiliate faculty as part of a service-learning type trip working in conjunction with some of CMMB’s projects. We started planning it all back in – whew, December I think?! So it was great to finally have the group down here and put them to work. And work hard – they did!

Sunday evening myself and another CMMB volunteer met the group in Lima. On Monday we toured the hospital ESSALUD – Almenara facility with Lic. Ana Herrera. Ana has been one of my biggest mentors during my time here in Peru. During her career, she has transformed– literally from scratch – an underfunded outpatient clinic into a great resource of evidence-based PT practice for Peruvians. She is one of the few Peruvian PT’s I’ve met who focuses on manual therapy and exercises over electrotherapeutic modalities. Creativity is one of her great strengths, as is evident from a number of home-made therapy exercise devices. Ana is constantly seeking out literature on her own in order to stay up on the latest treatment techniques. She gave the group a tour of her facility and an introduction to a number of challenges inherent in the current healthcare system.
From there we headed to INR – Instituto Nacional de Rehabilitación – which is known as Peru’s one-of-a-kind model for quality rehabilitation services. INR has applied a community based rehab program in their community near Lima. Things I like – a team approach within different medical specialties, state of the art equipment and lots of space for PT services, workshops for job training, and an onsite center where people with disabilities have been trained to make prosthetic devices.
However, I’ve gotten to know the center and staff through visits and various meetings in Lima, and I do see some weaknesses with their approach. For one, they’re not very open to sharing – ideas, resources, documentation, etc. They insist that they must “validate” every form or resource that they create – a process that takes on average 2 years. For example, they wanted to “validate” and then implement an infant developmental milestone chart with the ministry of health. Instead of turning to charts that already exist, they created their own, and then spent 2 years “preparing it.” Now it’s supposedly “implemented” in all of the ministry of health facilities- though I have yet to see the same chart in any of the health facilities I frequent. Not the best use of time and resources. Another weakness is that their system is not very replicable for Peru – they train outsiders to refer people to their facility in Lima – but what Peruvian can really afford the trip to Lima and all the associated costs? There’s certainly a huge problem in Peru with most of the healthcare resources centered in the capital, Lima. I find all of this very interesting since I’m currently working on my own community based rehab project plan – but, I digress…

After lunch Monday we spent the afternoon with Dr. Luis Leon, the executive director of integrated healthcare for Peru Ministry of Health. Dr. Leon has been a huge supporter of CMMB’s work in Peru and I’ve been lucky to spend a lot of time in meetings with him throughout my year here. We skyped in Nancy Mulligan, professor at Regis University, who put the students’ trip together. The group learned about the current healthcare system in Peru and the disability statistics, and the goal of universal healthcare by 2015. Dr. Leon proposed a sustainable relationship with Regis in the form of academic support. Specifically, he asked Regis to create protocols/a review of the current best evidence across ten different common pathologies here in Peru! An exciting opportunity – more on this later.
That evening we headed by bus to Trujillo, and Tuesday morning we toured Colegio Santo Toribio, a school for kids with disabilities in a poor community near Trujillo. The school follows the Montessori approach and focuses on empowering kids with independence and functional skills for activities of daily living with the ultimate goal of integration within the community, job skills and employment. In addition to academics, they provide physical therapy, meals, skill workshops/training including a bakery business, carpentry, and jewelry making. The school has a several-year wait list and a very compassionate, talented staff.
From there we visited a part of La Esperanza called Nuevo Jerusalen, where the living conditions and sanitation are poor and people face daily challenges with things like crime, lack of water, and no access to healthcare.
In the afternoon the group (ahem… mainly Kristin!) ☺ led staff of Clinica Madre de Cristo through an exercise class! We had some technical difficulties with the video equipment, so we ended up winging it and doing a cardio circuit followed by stretching and abdominal stabilization exercises. The Regis group stayed at the convent attached to the clinic and the nuns invited everyone to a delicious welcome dinner that night.
Wednesday we headed up to Puesto de Salud Bellavista, where we split into groups to do physical therapy initial assessments with a group of older adults. We offered to see 20 people… which, not surprisingly, turned into 43 people signed up and waiting in line! I think the students were a bit overwhelmed between the language barrier, facility, time constraints, and other cultural factors, though it was a good learning experience for all. The hardest part for me was seeing a number of heartbreaking, complicated cases and feeling a bit helpless, seeing as how these people would not likely have any follow-up care due to financial constraints. One can’t help but compare the situation here to the US and how much different their quality of lives could be if they were on another side of the world.
That afternoon we toured Hospital ESSALUD Albrecht with one of my colleagues. We were able to see the emergency room, post-surgical, and maternal health parts of the hospital. We toured the outpatient PT part of the hospital, which in this case was in a 3-story home near the hospital! It was quite the contrast from what we saw in Lima, and the students observed first-hand the strong reliance on massage, ultrasound and other modalities for PT treatment here.

Thursday we headed to a community called Cambio Puente, outside of Chimbote, about 3 hours from Trujillo. CMMB has a public health project there targeting mothers and children under the age of 5. Partnering with the Sembrando Infancia team, we went out in groups doing home health visits. It was an eye-opening experience, as many of the homes have dirt floors and no bathrooms, water, or electricity. The students were deeply moved after seeing patients who were neglected or not provided with resources to reach their full functional capacity.

Friday we finished up some preparations for the continuing ed conference and then went to another CMMB-sponsored event – a Community Based Rehabilitation congress. The event included a number of presentations, and at the end a discussion on how to move forward together as a team between the different non-profits and leaders of the Ministry of Health present. For me, the discussion was a bit frustrating – as there was a lot of talk but no concrete changes or big action plans. This is one of my big pet peeves with Peru – everything appears so formal on the outside, but where is the progress? Peruvians almost never say “no” initially to something – so many things end up falling through. I hope that this group of leaders will show more initiative and that it won’t be empty promises. Nonetheless, it was a positive event and a week packed with activities for the Regis group!
The students shifted into hands-on teaching roles for the weekend, in the 1ra Conferencia Internacional de Actualizacion en Terapia Fisica. [I’ll save comments from the International PT Conference (Sat-Sun) for my next post.] After the conference, we had a couple days to relax and surf in the beach town of Huanchaco

I had a great time sharing Peruvian communities and culture with the group (not to mention wining and dining them at all of my favorite restaurants!) We were lucky to have an extremely energetic, dynamic group of students who were open and flexible, asked great questions, and didn’t complain - even after 16-hour work days! All in all, the trip was a huge success and I’m excited about the potential for a sustainable relationship between Regis, CMMB, the Peru Ministry of Health and other local academic institutions.  

Special thanks goes out to: Kristin Carpenter who came down with the students, Nancy Mulligan for all of her invaluable planning, Hermanas del Buen Soccorro for offering lodging and transportation, and Cathleen Daly & Claudia Llanten who helped with the group activities.

Now I’m having some serious group withdrawals – I keep looking for our bus (and drivers…), gazing around instinctively like a mother hen to make sure we haven’t lost anyone, cracking jokes in English over my shoulder to strangers, and fantasizing about what dessert we will have next.
Thanks Regis students for coming down - MUCHAS GRACIAS a Megan Daly, Jenna Neff, Laurel Proulx (Lor-ell..Proo!), Megan Kelly, Erin Carpenter, and John Zapanta! (And, Gracias.. A..Dios!)

Thursday, August 4, 2011

An International Event is Born!

This story begins some time ago… about ten months ago, to be exact. In my first few weeks here in Peru, one of the doctors at the clinic I work at invited me out to see a hospital in Chocope, a small town about an hour from Trujillo. In a few hours, despite my broken Spanish, I got to know a great group of PT’s in Hospital Chocope – I was able to observe how they practiced, share ideas and patient treatments, and teach some basic manual therapy principles and techniques. As I was leaving, the PT’s asked me if I’d be willing to teach a course on scoliosis in a few weeks for a small group of 5 people. Next thing I knew, the day of the course arrived – and there was standing room only! I stared out like a deer in the headlights at the 40+ crowd of PT’s who had shown up for the lecture!

I was amazed at the interest in continuing education. I was getting requests from all angles to teach, despite the language barrier. I soon discovered that PT’s in the north of Peru have very few continuing education opportunities, and employers don’t have any sort of requirements. Furthermore, work in a variety of settings was showing me that the foundational education received by PT’s/aids here was very basic and focused on modalities and passive treatment. I decided to teach a course of varying themes once-twice a month in different local hospitals.

Since the first lecture back in October, it’s been much of a snowball effect. I’ve taught 13 different classes in a variety of themes and locations– some of which had labs. I’ll never forget a lecture I did on postural analysis where 125 people showed up! It was intimidating at first but I found it was a lot less nerve-wracking to speak in front of people in Spanish – I was so busy trying to say everything correctly that I “forgot” to be nervous! I also found that by March I could teach the classes without reading off any notes, which was encouraging.

Practicing techniques in one of the physical therapy courses
The prep time was often overwhelming, as on top of work in the clinic, hospital and school each day, in my free time I was constantly creating, translating or practicing a different powerpoint. But the rewards were abundant – over time I was able to network with several hundred physical therapists/students and I’ve learned so much about culture in the process, and made some great friends. After a few months (maybe even less time!) I felt that I was being called to plan a bigger event. Fresh out of PT school, I’m certainly no expert in my field.  I connected with some faculty at Regis University and some PT’s I know and the next thing I knew – We’ve had an international event in the works!

Before Peru, the biggest event I’ve ever planned was my friend Loren’s bachelorette party held all over town in my parents motor-home in Anchorage, Alaska. (Which was a hit, by the way!) Needless to say, event planning for 200 participants was a first for me. Event planning in South America is a whole additional dimension. I’ve spent the last 8 months or so in a sort of “conference haze.” It’s been challenging to communicate mainly via email. The to-do lists are endless. In Peru, forget the double-check – you seriously need to quadruple-check everything. The other day I had a phone conversation with a colleague confirming – for the third time in a month- that my group of volunteers could tour her facility when they are here. At the end of the call, she said, “okay, we’ll be in touch, I’ll confirm the visit later.” There’s also been a lot of “red tape” to get through – official approval from so and so, official letters and stamps, etc.

Luckily, I’ve had the help of Claudia Llanten who is CMMB’s program director for Peru – without her this all would not be possible. I also started meeting regularly with “focus groups” of PT’s in Trujillo and Lima back in January to get a good feel for exactly what Peruvians are looking for in an event like this. I did a survey to gather which conditions are most commonly seen by PT’s in Trujillo, and determined that neck pain and knee arthritis are most frequent on the list – thus our themes for the 2-day conference.

I’m really excited for the event. The 200 spots are nearly paid and full, which I think it pretty great considering we’re in Peru and everything here is last-minute. We’ve rented out three auditoriums in a nice event center in town. We are covering everything from exam (non-existent here) to evidence-based treatment and will also include “labs” in the afternoons to practice skills with actual patients. In efforts to mesh CMMB’s public health work within the event, we’ll also have some guest lectures in the theme of disability, visitors from the Ministry of Health, and a dynamic lunch in small groups. We’re planning another lunch with the academic institutions here to talk about sustainability between Peru and the US/Regis University. We’ll have a reception Saturday night with music and cocktails –something social to bring the PT’s together. We’ll have catering for breaks and a patio of vendors/businesses for participants to explore. We’re giving each participant an embroidered bag complete with conference info. and a DVD of material, plus small rehab equipment that is not normally available here – goniometers, theraband, reflex hammers, tape measure, etc!

I’d like to recognize our extremely generous donors of equipment and/or money:
Dr. Michael Mulligan Memorial Fund
Ola Grimsby Institute
Aureus Medical Group
Beth Calder
David Paz & family
Providence PT (Denver, CO): Michele Wesley, Cynthia Molloy, Jessica Winkel, Angie Mueller, Laura Krum
Dennis O’Connell
Chuck Riddle and Rehab Authority (Boise, ID)
Rehab Care
Physiotherapy Associates – Colorado
(Apologies if I missed anyone – some of the packages were un-marked so let me know if you are missing from the list!)

And, of course, everyone at Catholic Medical Mission Board ( who have been
an incredible source of moral and financial support from the start.

Also, my physical therapist volunteers who have donated their time and savings to make the event happen:
Alec Kay – Anchorage, Alaska
Ommar Ortuvia – Houston, Texas
Michelle Madron – Houston, Texas
Kristin Carpenter – Boulder, Colorado
Ana Herrera – Lima, Peru
Pedro Rojas – Trujillo, Peru
Pedro Romero – Lima, Peru

And I’m extremely grateful for the bright group of Regis students who are coming down for an “alternative experience” trip to support us:
John Zapanta, Megan Kelly, Jenna Neff, Megan Daly, Erin Carpenter, Laurel Proulx

In addition, a HUGE thanks to Nancy Mulligan at Regis for all of her countless hours in helping organize the group and event.

Laslty, our official event sponsors - Regis University, Perú Ministry of Health, Colegio Tecnólogo Médico Consejo Regional V, Universidad ALAS Peruanas, CMMB and Las Hermanas Del Buen Soccorro who are offering the students lodging and meals.

As I write this, I’m about to get on a bus to head to Lima where I’ll soon meet the Regis group. Our next week will be a whirlwind of visits to hospitals, schools, clinics, rural areas, the Peru Ministry of Health, etc. In addition to tours, we’re planning a screening fair for older adults, an exercise class, home health visits, and of course some down time to explore the great tourist sites around Trujillo. At the end of the week, we all unite together to begin the conference. I've learned so much from this entire process and though it's been a mountain of work it's also pushed me out of my comfort zone in so many good ways. Thanks again to all who have supported this goal from near and far. I can hardly believe the event is finally here!