Tough cases

Throughout my year of physical therapy work, I’ve faced a number of tough patient cases. By “tough” I refer to the fact that the economic status or cultural factors dictate the quality of care and ultimately the functional ability and quality of life of these individuals. The ones that are most heartbreaking always seem to be the patients of higher risk and less independence - children or elderly adults.

There seems to be this sentiment of learned helplessness when it comes to kids with CP (cerebral palsy) here – like “oh, he or she never started walking on his/her own, so there’s really not a lot we can do.” When I’m partnering with other local PT’s in treatment, especially in situations where it’s just for a short time period, I always feel like I have to tread carefully in my words and actions – I don’t want to offend anyone or come across as all-knowing, but at the same time want to maximize the type of care the kid is receiving.

Last month I went to check out a school for kids with disabilities, where I encountered an 8-year-old boy (we’ll call him Jose) who has CP and is in a wheelchair. The director invited me to spend a few hours working with the other PT’s in the rehab room. Generally, from my observations across a number of different facilities, care for kids with CP involves supine passive range of motion and massage. Sometimes hot packs. (Yeah, I know... The problem is, this is what they are being taught in school.) The PT wheeled Jose in and began the range of motion routine. We began to talk and he expressed a desire to be able to walk around like his friends. He has spastic diplegia it was evident to me right away that he had sufficient strength and balance for ambulation with an assistive device. When I brought this up with his PT, she said that they had never tried walking before and that the walkers provided by the school were too big for him. I suggested we give it a go at the parallel bars and the next thing I knew, to his PT’s surprise, he was ambulating with min-contact guard assist in the parallel bars. It was a beautiful moment- his entire demeanor changed, his eyes sparkled, and he had the biggest grin. We also practiced balance and coordination tasks; Jose had a great time with the games. The walking was slow going, but it was obvious that if they practiced in PT every day, he would make the gains necessary to safely ambulate with a walker on his own some day.

THIS is what drives me nuts here- this recurring theme of learned helplessness by people in rehabilitation. To me, it seems like common sense – if someone has the goal to walk, practice walking! If the assistive device isn’t perfect- seek another temporary solution and find a way to get something custom made for the home. Practice FUNCTIONAL activities! But it seems that many PT’s here are hesitant for some reason - and the patients are not often pushed to their functional capabilities. It breaks my heart, time and time again.

This is just one of many examples. And it’s not just the PT’s. The parents often share this sentiment and it’s very hard to motivate some to get involved with their child’s home exercise program. I know it’s partly cultural and partly institutional – there’s a definite need to change the education system to reflect more evidence-based practice across the board, particularly with the pediatric population. Just another observation into physical therapy practice in Peru – and one that I wish I would have worked harder to change in the last year.

On a more positive note, last week we had our first support group meeting for parents of kids with cerebral palsy. It’s been a little vision in the back of my head all year (better late than never, right!) The group has 9 members and its’ goal is to provide a self-sustaining regular source of companionship, support, education and social activities for caregivers of kids with disabilities. The clinic has offered discounted and free health services for the group, who will meet bi-monthly. Members agreed to pay a tiny amount at each meeting, with the idea of a small community micro-lending type fund that can be borrowed for medical emergencies or used for the end of the year Christmas party. The mothers are also planning to take turns in childcare so that other group members can have a free afternoon each week to run errands or have some alone time. The group will have occasional guest speakers from different health professionals, but will be led by the mothers, with the bigger focus in creating a social outlet and a grander sense of community.

These are some of the toughest, most incredible women you will ever meet. They are truly amazing. They all have several children and on top of that fight tooth and nail for the rights of their disabled child. They talked about how the community reacts whenever they go to public places, how their children are constantly rejected from the public and private schools, how they struggle to find quality medical care and specialists, and how they are barely scraping by financially. Every day is a struggle, in even the simplest of things. Imagine trying to navigate the public transit system here (Moto-taxi? Small fast-driving van with 20 other people?) while having three toddlers, one child or teenager with CP, and one giant un-collapsible wheelchair in tow. They have to resort to taking taxis – but even the taxis often reject them when they see their child and wheelchair.

Needless to say, it was an emotional meeting, but also a joyous one. It’s very frustrating how un-accepting the culture is of people with disabilities, but hopefully now these 9 women will feel less alone in their situations. I hope that when I visit next year, they’ll still be meeting and will have grown to be a great community resource here in La Esperanza.

Helping vs. Hurting

“No das pescado… enseñales a pescar” – “Don’t give the people fish… teach them how to fish” – Peruvian expression

I recently read the book “When Helping Hurts” by Steve Corbett and Brian Fikkert. Many parts of the book have paused me to reflect on volunteer work I’ve done in the past, and on my actions here in Peru in the last year.

Did you know that in 2006, Americans spent 1,600,000,000 dollars on short-term missions?! Often without the volunteers’ awareness, short and long-term mission trips can cause more harm than good in developing nations. Often we have these big expectations and want to GIVE so much - but on our own terms. From my experience, #1- you always get more than you give on a short-term trip, and #2- to be effective, you really need to get a solid understanding of the culture and the community, your role and what is considered “success.”

One important distinction is relief vs. rehabilitation vs. development. Back in college, I signed up for a trip to New Orleans for a few months post hurricane-Katrina. We spent a week gutting homes in what was then a “ghost town” of a city, for persons who were older or had health conditions that prevented them from helping with the manual labor. It was an incredible experience and when the opportunity came up the following year to go back, I jumped right on board. However, the 2nd year’s situation in New Orleans was much different- there was better infrastructure and many people had returned to the city. The work had changed from gutting homes to repair and we spent a week helping rebuild a church. While we left feeling pretty good about ourselves that second trip, I often wonder if we did more harm than good. Where were the church’s community members and why weren’t they rebuilding? Why did we provide relief when we really should have been working on rehab. and/or development?

Another difficulty facing short and long-term missions lies in our individualist (vs. collectivist) culture and the need for rapid, measurable results. Corbett and Fikkert agree that “the North American need for speed undermines the slow process needed for lasting and effective long-run development.” During grad school, I went on a weeklong “alternative spring break” trip to a small desert community in Mexico. For the last decade, students from Regis University had been going to the same community once-twice per year to help build a community center. The progress was painstakingly slow. Most of the men in the community worked 2+ jobs to make ends meet and thus were unable to continue the building once we left without the manpower of the Regis group. The year I went, day 1- we played soccer with the kids and began to plan a health fair, because we were waiting on the actual building supplies to arrive. The manual cement mixing was slow and thus in one week, all that we accomplished was laying cement and getting the roof up. As volunteers, we started out feeling a bit frustrated. I was blown away by the fact that the community was that patient- every year they saw the center grow a baby step closer to completion, but not by much. But what I learned above the patience of the people was the importance of community in the process. To the locals, the groups’ coming meant so much more than construction, health fairs, and a few physical therapy home visits – to them it was all about the feast of a goat, Catholic mass, swimming in the river, playing with the kids, various meals and celebrations together, movie night, a fantastic dance party, and soccer games – community building. It’s not about the product- it’s about the process. And say Corbett and Fikkert, “development is a lifelong process, not a 2-week product.”

The book elaborated on these concepts – development/rehab. vs. relief, processes vs. projects and products, and the importance of empowering people and ensuring local collaboration/participation. Avoid paternalism and don’t do things for people that they can do for themselves. Many lessons I’ve learned here in Peru mirror some of these notions. Another - “I was still amazed to see people in this Kenyan slum who were simultaneously so spiritually strong yet so devastatingly poor.” Though across continents, I see this day in and day out in the people of Peru, too.

So now I look back on my year here in Peru and wonder, did I do more helping or hurting? One of the underlying issues is the idea that providing continuing education is a good idea, but it’s really only putting a band-aid on the “problem.” Why didn’t I focus my energy this year on changing the curriculum of the local PT schools? Is continuing education really worth it? This is something I’ve struggled with as I’ve begun thinking in the lines of public health projects, too. How do we act at the root of the problem, vs. helping the symptoms?

When I first arrived here, I began to learn about the different types of health problems faced. Based on statistics from the WHO in 2008, the number 1,2 and 4 causes of death in Peru are non-communicable diseases. In my community, I noted the poor diet, the low physical activity/opportunities for recreation, and began to see a lot of patients affected by conditions like stroke. In my first month here, I began to envision this project targeting non-communicable disease – exercise classes, educational sessions, an incentive program teaming with the local health clinic, etc.

Right around the same time, I became connected with a number of PT’s here and became very impacted by the lack of continuing ed opportunities and the huge thirst for knowledge. This ultimately shifted my focus for the year. I often wonder how successful a different type of program would have been. I think that ultimately the most important aspect as a volunteer abroad is to listen to – what do the people need? What do they want? What are they most likely to participate in? And how can we build on the skills and strengths that already exist? Reality is, I would be up against a large number of cultural challenges in creating the first project targeting non-communicable diseases– had I jumped right in quickly without really knowing the community, I could have hit a dead end really fast.

That being said, I know that many of my actions could have been better thought through this year. I think that 2 projects – the regular continuing education classes and the planning and execution of the international event - went well and included important cultural factors and community participation. Ultimately I saw the event build relationships and networks, community togetherness, critical thinking, hands-on skills and introspection of physical therapy practice here in Peru. While it doesn’t directly target the cause, as I mentioned in a prior post, I think continuing ed is an important piece of the puzzle.

I’ve been lucky to have 3 short-term volunteer groups of healthcare providers visiting this year. I think that in general, their experiences were well-planned and really tried to get at the sustainability potential in short-term missions. The volunteers were working with community members and people on-site who already knew the ropes, which assisted in their effectiveness. Each group participated in teaching and also had activities planned to visit sites and learn more about the healthcare system here. The opportunities to develop relationships and continued collaboration with the Peru Ministry of Health, a local university that has a PT program, CMMB, etc. were all valuable outcomes of the trips and the beginning of exciting new relationships.

However – when I reflect on my other projects this year, I don’t feel they encompassed as many of the qualities suggested by the authors. Take, for example, the survey of people with disabilities. Here in Peru there are constantly people begging for money – in the streets, at the clinic, even my neighbors and people I know well. There’s a big problem here with free handouts and I don’t think Peruvians and tourists alike realize how much they are perpetuating the process by giving the beggars money. I fear that the survey hurt more than it helped by setting people up to expect free hand-outs from the project. Also, the questions were functional, yes, but some were worded negatively toward “what can’t you do? What do you lack?” vs. the approach of “What are your assets? What do you bring to the table and how can we help develop them?” Ah yes, hindsight is 20/20.

Luckily, I’m still finishing components of the plan for “Rehabilitation con Esperanza,” so I have the opportunity to right some of these mistakes and hopefully leave a well thought out model behind. In this manner I hope to ensure participation by mobilizing the skills/resources of the community and only bringing in outside resources when local resources are insufficient. Thus, the project will ultimately act off some of the authors’ helping principles – as in my favorite Peruvian expression, instead of fishing quickly to produce mass quantities, to slowly teach people how to fish.

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?

MUCHAS GRACIAS to team Perú-USA!

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!)

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
JOBST
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 (www.cmmb.org) 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!

Volunteers!

I want to give a big shout out to two friends and colleagues, Layna Shorter and Keri Vonkalinowksi, who came down here to help me out last month! Also, a big thanks to Beth Calder and Preferred Home Care for their equipment donations – much appreciated! And, thank you Cathleen Daly for organizing our work out in Chimbote and letting us crash at your house!

My volunteers were here a week helping with assistive device modifications at a school, work in the clinic and in Winchinzao, home health visits in Cambio Puente and various educational projects. We did a session with teachers talking about preventing disabilities in children and later a session with Clinica Santa Clara healthcare workers in the theme of prevention of disabilities in adults, with a focus on body mechanics and lifting techniques. It was so great to have other sets of hands, eyes and opinions in patient care and they did a fantastic job in the educational sessions too. And, we even managed to squeeze in some time for the beach, Pisco Sours and archaelogical ruins. :)

My only complaint is that they left so quickly. (I miss you guys! Come back soon!)

Assistive Device modifications..

Before...

& After!

 Clinic work...

Home health visits in Cambio Puente...

 Educational sessions...

 

Sandlots and Webpages

Lately, my work here has been a bit all over the map – the afternoons remain consistent with work at the outpatient clinic. But, I spend my mornings and weekends either doing wheelchair fittings at a school, home health visits, preparing/leading educational sessions, or working on various projects. The survey for persons with disabilities is currently on hold as we wait for funding to go through, but I’m staying plenty busy with other various projects - planning a 200-participant physical therapy continuing education conference for August (with the help of Regis University and ten US-based volunteers who are coming down!), working on a detailed plan for “Rehabilitación con Esperanza” (a community based rehabilitation project), continuing to do lectures and labs 1-3 times a month for local PT’s, and trips to Lima to talk about community-based rehabilitation and the survey. With such a variety of work tasks, I’m learning a ton and certainly not getting bored.

And, with some (a lot of) help I just created my first website! Special thanks goes out Matt Medlock for all of his hard work and patience in getting the site up and running. I hope it will grow into a good shared resource for physical therapy materials in Spanish:
www.recursosdefisioterapia.com

Other news - I just started a new job!

Welcome to my office!

 I’ve affectionately termed my new workplace “The Sandlot.” In partnering with the Hermanas Del Buen Soccorro, I’ve begun a new work assignment in the neighboring community of Winchinzao. Twice a week, myself and one Peruvian PT head out to the Sandlot to provide affordable ($1 dollar/session) physical therapy services in a “red zone” neighborhood. This area has a lot of problems with juvenile delinquency, and the plan is to develop this space into a neighborhood resource center – a home for about 16 youth, and an outpost offering services such as physical therapy, speech therapy, early infant stimulation, and psychology. Fortunately, the donations from abroad keep pouring in, so we’ve been able to outfit the small room with an exercise ball, mat, and small toys. However, with theft problems, we are forced to carry the equipment – even the pillow! - back and forth to another building each time we work. Also, I have to remember not to drink water or coffee before I go to work these days – no toilets or running water! I will never again take for granted a fully-equipped physical therapy clinic like the ones I’m accustomed to in the US. But, at the same time, one thing I love about my profession is that you don’t actually need material objects to have success in patient care – just a little creativity. ☺

Growing Pains

I’ve started to compare my feelings as a foreigner living in a new country to a constantly evolving romantic relationship. The relationship starts out pretty great – the “honeymoon” phase – where everything is new and exciting, and I can’t get enough (of the culture). A few months later, (okay- maybe more like weeks in my case) I settle more into reality and the novelties wear off a bit, and I begin to acknowledge little pet peeves – things that can be annoying, but at the same time kind of cute, endearing. I give it a few more (days? weeks? months?), and those things turn into straight up annoyances. As time goes on, it becomes a game of positives and negatives – well, these things aren’t ideal, but ________ makes it worth it. Now, we all know from my relationship track record that all of this can happen in a pretty short time span.

Fortunately for Peru, the pros still outweigh the cons. But, as I’m growing better with Spanish, and more insightful with the culture, I’m picking up on more and more health practices/beliefs that particularly drive me nuts. I haven’t made a list in awhile, so here goes- my list of Peru health-related growing pains:

- 1. Multiple injections in the butt (of a mystery solution) for any and every ailment... (sore throat? foot pain? eye infection?)

- 2. Use of antibiotics for everything (and prescribed for 1-2 days. Got into an argument with doctor the other day about whether antibiotic resistance is a proven phenomenon or not)

- 3. Insistence that you are sick because a) there was a change in the climate or b) you had ice cream/drank something cold

- 4. Belief that if your joint makes an audible noise, it is dangerous and means you have severe arthritis or a fracture

- 5. Osteoporosis diagnosis (so common here!), and patient is not educated to take calcium, let alone anything else for it

- 6. Similarly, my sister (who was down here for a few weeks volunteering in a Trujillo hospital and clinic) informed me about the problem with general practitioners and advocating avoidance of milk– often the doctors tell parents to avoid giving their kids milk when they have a minor illness. Now, nobody seems to ever drink milk and cheese is scarcely consumed (see #5)

- 7. Insistence of creams/lotions for musculoskeletal injuries

- 8. Belief that a cold shower or the use of ice is bad for injuries

- 9. Wrapping areas that hurt (with a scarf, sock, cloth etc.) – not to help with swelling, but to keep it warm at all times

- 10. Belief that if you bundle up at the gym or when you go running, you will burn more calories (similarly, cranking up the heat for gym exercises classes! I think the only place I’ve found an actual heater in Perú has been at the gym)

- 11. Belief that a back brace is necessary for any physical activity (running, spinning class), regardless of whether the person has a history of back pain

- 12. Lack of patient education, or very improper patient education / diagnosis

- 13. General dependence on MD, external locus of control and desire to medicate/ take a pill for everything (Doctors here even sell little bags of a powder called “stress medicine!”)

Also, depending on where you are in Peru, you may observe some other very unique practices related to health. I recently had a patient in a more rural area tell me that she rubs human urine all over her body to help with her low back pain (and swears by it!) I’ve also learned that Peruvians will sometimes rub a (live) guinea pig all over their body when they are ill, and then they kill it and cut it in half. The organ in the guinea pig with damage corresponds to the origin of their own health problem.

With the exception of urine and guinea pigs, in noting these cultural tendencies, it seems that in general some of these beliefs and medical practices can be compared to how the US was – 50 years ago. It sounds like many people in my parents’ generation grew up with some of the same common practices. It’s frustrating to observe some of these practices, but also important to be respectful of the cultural differences, as difficult as it may be. Though this list of “cons” seems daunting – don’t worry, my positive experiences and joys of being part of the Peruvian culture are overflowing, and (contrary to my usual relationship patterns) we won’t be breaking up soon – at least until October.

Inpatient Care

Peruvian art - hospital depiction

My sister recently reminded me that I’ve never written about my experiences in the hospitals here. The truth is, I’m not sure how to correctly portray inpatient care without sounding completely negative. Thus, my disclaimer: This post is not intended to point fingers or look down on the culture, but rather I hope that by talking about some challenges we can move forward with change in some of these areas in the future. Here goes...

I worked in one hospital in Perú for about 3 months, right when I first arrived. In all reality, the hospitals here are not as scary as I expected. While they are crowded (generally 6 patients and their families per room), they are less crowded and seem a bit more sanitary than the hospitals I observed in Africa. However, they’re a far stretch from anything I’ve seen in the US. No high-low beds, TV’s, meals, “pain buttons,” assistive devices, DVT prophylaxis, clean sheets, or support bars for bed mobility here! Gloves, soap, blood pressure cuffs and toilet paper are generally non-existent. The patient charts are very difficult to read/navigate. There’s little patient modesty/privacy. I won’t even go into the smells or sanitation issues. They are very strict about visitors- I’ll never forget one day when a 3-year-old girl with a wrist fracture screamed and cried for her mom (who, like everyone else, was banned from coming in the hospital)– for the entire shift, poor thing.

The patients’ family is expected to pay for everything in advance. (They usually aren’t even admitted to the emergency department without waiting in line to pay first!) If they can’t afford, for example, the pain medications or the surgery, then the patient just has to tough it out. I’ve seen a lot of x-rays of horribly displaced fractures that are treated with conservative management, when they really should have surgery. I’ve also seen some scary looking external fixations and a lot of issues with contractures, bed positioning and a general lack of patient education following surgery. That’s right - no bed mobility, let alone gait training or assistive device fitting!

Another challenge is interdisciplinary communication (or lack thereof). Here in Perú there seem to be power issues between the doctors and other professionals, and some do not seem to respect those who have “lower” roles. Nurses are commonly shunned out of the room during rounds, and I’ve never seen a doctor communicate with a nurse before, aside from scribbling notes in a chart.

Peruvian art 2 - hospital depiction

My profession of physical therapy also appears to lack respect from some of the doctors. One surgeon told me that they are afraid for “the PT’s to come in and screw up their work.” In fact, I was supposedly the first PT to ever work with post-surgical patients at that particular hospital. Sometimes PT’s from the outpatient clinic are called in to other parts of the hospital for respiratory therapy, but they do not normally work with patients in the surgical units. It seems elitist that the doctors included me but not other PT’s in the surgical ward. While it’s true that the local PT’s have less years of schooling than those from the US (3-5 years after finishing high school at age 16), many are good clinicians. On the other hand, the majority of treatments I’ve observed applied within PT here are modalities (ultrasound, TENS, magneto-therapy, infra-red, hot packs, whirlpool therapy, etc.) so I see both sides.

Despite the incredibly vast needs evident in the 40 or so patients residing in the surgical ward, they selected 3 or 4 per shift that they thought would benefit from PT. When I tried to tactfully point out the numerous benefits and cost-effectiveness of physical therapy pre and post surgery, I was told, “Well, some people claim that’s the case, but I won’t believe it until they conduct a study about that here in Perú. In fact, we need a study here in my hospital first.” However, the difficult part with my argument is that one of the roots of the problem is in the education the PT’s receive here – first we must ask, would they be prepared sufficiently from their education to provide inpatient care?

There’s certainly a huge fear of early mobility – doctors also told patients to remain in bed one-two months once they leave the hospital, regardless of the case and surgery involved. You would think with the high DVT rate (not to mention the many other complications following immobilization and bed rest!) they would change their patient advice. Many of these culture-embedded challenges are large and controversial to tackle in one year’s time! I’ve certainly learned that in working abroad, you have to pick your battles, and in my year here inpatient care is unfortunately not one of them.

The PT work is difficult, especially without access to assistive devices, blood pressure monitors, and pain medications. Also, a big problem with many of the patients who are waiting for surgery is nosocomial infection- pneumonia is quite common. I’ve also been in the Tuberculosis ward once, and let’s just say, it’s not my favorite part of the hospital. Though my time working inpatient care was short, I had some pretty eye-opening experiences. I saw many examples of treatment that would have been lawsuit material in the US. One of my patients had a toe amputation secondary to diabetes, and because someone in the hospital wrapped his limb so tightly after the surgery, they had to go back in a few days later and remove nearly all of his foot from the tissue death.

Peruvian art 3 - hospital depiction

The amounts of injuries caused from trauma were overwhelming. It was certainly not an upbeat place – I had several patients with spinal cord injuries – one was a young mother, at 18, spinal cord severed at T5 and incredibly heart-breaking to work with. With economic hardships, no health insurance and a lack of affordable physical therapy services – I often wonder what’s become of certain patients – where are they now? What is their quality of life like?

I was lucky to have the opportunity to watch some surgeries during my time with inpatient care. In one case, the patient suffered multiple fractures from a car accident and the operation repaired a shattered femur. The surgery itself was similar to what I’ve experienced in the US, but it was less sterile and a little slower, namely because the facility does not have a real-time x-ray machine. They had to bring in this giant x-ray machine, wait to get it all set up, remove everyone from the room, take the x-ray, remove the machine, wait for the image, discover it had movement artifacts, and then re-do the whole process before they could continue! All in all, about an hour of the time on hold to get the x-ray results before they could continue on with the surgery!

I learned a lot during my short time in inpatient care and have many more stories. Some of what I saw makes me cringe at the thought of ever having to be admitted to a hospital here. However, I also interacted with many great, hard-working doctors and nurses who were dedicated to serving their patients with the best care possible, given the limited resources.

My sister recently spent a few weeks volunteering at a different Trujillo hospital in labor and delivery. She has some great insight into a completely different side of the Peruvian hospitals (and also a lot stronger of a stomach than I do)! You can read about her adventures here:  http://travelrunlivelove.blogspot.com/2011/05/tears-of-joy-and-tears-of-sadness.html

Peruvian art 4 - hospital depiction (is that baby reading a book?!)

More Thank You's!

I’m feeling extremely blessed to have so much support down here from contacts in the US. I want to thank an extremely generous anonymous donor for sending down equipment to properly fit the children of Colegio Sagrada Familia in their wheelchairs. This donor sent a variety of seats, cushions, trunk/head supports etc. so that we could make the kids more comfortable. This type of equipment is only occasionally available in Lima (and it’s not cheap!) so if it weren’t for the donations, the kids would remain in miserable postures with only pillows attempting to support them for the majority of their waking hours each day.

Before...

and After!

I felt like Santa Claus as I took each kid out of the classroom for the fitting! It was a lot of fun working with my Peruvian colleagues to select the proper set-up for each individual. It was even more incredible to see the results – the kids were visibly more comfortable, relaxed and full of joy with their new additions – and more able to interact and access their environment. It’s amazing what a few small changes can do to improve one’s quality of life. One of the kids, pictured, frequents the clinic regularly, and I’ve already seen vast improvements in his head control, trunk control and spasticity since we performed the wheelchair modifications. We even have some equipment left over which we plan to use in a new project in the neighboring community of Winchinzao over these next few months.

So, MUCHAS GRACIAS to my anonymous donor! (Also, thanks Mom and Dad for hand-carrying the equipment down to Peru and getting it through customs!)

Sembrando Infancia

This weekend I took a “field trip” out to work with one of CMMB’s more rural projects. Sembrando Infancia works to provide resources for mothers and children within about 300 families in an area called Cambio Puente, just outside of Chimbote (about 2 hours from Trujillo). An impoverished area, Cambio Puente has dirt/sand roads, no running water, and no electricity in many cases. Here, an outhouse is considered a luxury. Geographical distance and financial constraints are large barriers to receiving healthcare in this community. Thus, Sembrando Infancia goes to them. Every few months they conduct a “campaña” within the community, offering free visits with doctors, nurses and other health professionals. They move the location of the campaña each time in order to reach out to more residents.

They also offer regular health education – this time, they had a talk on how to prevent the tropical disease Dengue. Symptoms of Dengue include a fever, head/body aches, and a rash – and the disease can be life-threatening. Dengue is a disease transmitted through mosquitos – with no vaccine available, prevention measures are crucial.

Sembrando Infancia also attacks issues such as hygiene and sanitation – teaching important skills such as hand-washing and safe drinking water practices. For example, they taught residents of Cambio Puente the SODIS system, a method of water purification via ultraviolet rays, which involves hanging clear plastic bottles in the sun. They weigh the children and address issues related to malnutrition. In the last few months they’ve also performed large-scale screenings and treatment for problems such as intestinal parasites and anemia. My friend and fellow CMMB volunteer Cathleen Daly is spending a year working hard with this project and you can read about her work in her blog: http://cathleeninperu.blogspot.com/. (Cathleen, I hope I did you all justice with this short description!)

I had a great experience working with the team for the campaña. We set up a bed and some reed mats on the dirt entry-way of a residents’ home, where I conducted physical therapy assessments for the day. Most of my patients were children, and I saw everything from mild to severe hypotonia, cerebral palsy, hydrocephaly, torticollis, and clubfoot. All of the children were underweight and most had a history of labor complications. My observations continued to note the trend that here in Perú, developmental delays in motor milestones, particularly walking and crawling, are very common.

It was difficult to perform my assessments knowing that these families would not receive much follow-up, and of course a big part of the day revolved around education and practicing home exercises. A big challenge I’ve noticed here is that the families are very hesitant to do home exercises with their children – sometimes it’s the fact that there’s simply little time with job demands and trying to find the next meal. Other times, the cultural attitude seems to be very much a contentedness with dependence on receiving outside care. These parents/caregivers simply think that they don’t have what it takes to do it on their own, even when they are fully capable and we start with very basic exercises. Illiteracy is another complicating factor, but next time I plan on bringing some home exercise handouts that have pictures.

The campaña ended with a child-mom dance party, and each kid went home with bags of a nutrient-rich milk-and-oat beverage. All in all, this physical therapy experience was a great one, and the kids were adorable and a lot of fun to work with. I really enjoyed learning about the strategies and inner workings of a successful public health program.

I head back to Cambio Puente in May for their next campaña – where I hope to also do some home visits of the families I worked with this past weekend. I would say that the health disparities here certainly mirror what I’ve seen closer to “the city” in my own neighborhood of La Esperanza, but I had a great time getting out to “el campo” to learn about a new community and the incredible efforts of its’ leaders to empower the residents with health resources.