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?!)

Luxuries

I’ve never quite experienced the exclusivity of my own culture until I got down here. I was surprised to find that when I tried to access Pandora.com way back in November I received this message: “We are deeply, deeply sorry to say that due to licensing constraints, we can no longer allow access to Pandora for listeners located outside of the U.S.” While I wallowed over not being able to use one of my favorite websites for year, I headed to abc.com, hoping to catch an episode of a guilty pleasure mind-relaxing TV show in English to make me feel better. And, sure enough, BAM! “You appear to be outside the United States or its territories. Due to international rights agreements, we only offer this video to viewers located within the United States and its territories.” Wow. Now I know what it’s like to be on the other side… and on the other side of something so trivial.

Certainly Peruvians lack many “luxuries” that we have in the US. The one that always moves me is how difficult it is to get a Visa – even to travel to a neighboring country. I’ve only met one Peruvian in 7 months of living here who’s ever been outside of Peru. Essentially, they don’t travel. More powerful is the fact that the majority never even get to go near Machu Picchu, because tourism has driven up the prices to the point that locals only dream of ever going. When I make remarks about having my host family visit me someday in Alaska, they laugh and always say, “Maybe in another life.” I’ve been planning weekend excursions every chance I get here – but most Trujillans rarely even travel as far as Chiclayo, a three hour journey. I pretty much always feel like a spoiled, wealthy American (though my bank account by US standards would beg to differ!)

I had an interesting conversation the other day with my host family about home appliances. I’m pretty sure they deemed me crazy right away, as during first month here they were quite startled by the nightly “alien ship landing” (me using my electric toothbrush!) This time I tried to explain dishwashers, something they still tease me about now whenever I do the dishes. We also talked about how most homes in the US have things like microwaves, washers and dryers…and tools of vanity like hair dryers/ straighteners, curling irons, etc. At the end of the conversation, my host sister looked at me incredulously and asked, “But… what do you DO?”

My only answer for her was, “Work.” How do you explain what life’s like on the other side of the pond without coming off as completely self-centered and spoiled rotten? How to explain things like routines of daily gym sessions, swimming 4 hours a day for a team, or how often I used to eat out? Drying my hair every day (well, in reality - every day that I showered. Hmm, more like every other…), using microwaves, toaster ovens, or (my personal favorite), the quesadilla maker? Moreover, how to explain the concept of a work-a-holic within the context of a completely different culture? I’m definitely not saying that Americans work harder – nor longer hours - by any means, but it’s clear that our culture is certainly more individualistic and outcome-based in many ways.

Unemployment is a big problem here, any most families are supported by a single-person income (if any). But in the clinic, when I ask my patients if they are working, virtually every person will answer yes – “Of course, I work in my home.” Peruvian women are incredibly hard-working and you’ll never hear them complain! Here, the average Peruvian woman surely works 80+ hour weeks… up before dawn to go to the market and prepare breakfast, then back to the market and spending all morning preparing lunch (the biggest meal of the day), then cleaning and hand-washing clothes in the afternoon before preparing dinner. Never mind raising the children and taking care of the elderly. (Which, by the way, is also a big deal here. The elderly are almost never sent to a nursing home – family members will drop everything to be their live-in caregivers.)

So, whether it be Pandora or ovens, dishwashers or Visas, (or in many cases – sinks, toilets, running water, electricity, etc.) our cultural “luxuries” are certainly very different. Though sometimes I really miss having a washing machine, I think that if anything a change in daily luxuries has (hopefully!) made me a bit more patient and tolerant – and one step closer to identifying with these strong, amazing hard-working Peruvians I admire so much!

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!)

A Culinary Update

An update on one of my favorite topics, comida!

I’ve added a new food to my list, and please don’t judge me. It’s Alpaca. Down in southern Peru, Alpaca meat is a very popular dish. I was a bit skeptical but my mom ordered it three times and I was impressed with each different rendition! Mmm, mmm! Too bad they don’t sell it up here in northern Perú.

However, the ceviche up here is much better than in the south. I am definitely hooked on the ceviche made from pescado - fish (though I cannot attest to the kind made with mariscos - shellfish). Here they serve ceviche adorned with hard corn kernels, and sides of sweet potato and choclo (giant sweet corn). It is pretty amazing, and Peruvians claim it’s the perfect cure for the rasaca (hang-over)!

In southern Peru they sell choclo con queso- an ear of corn with a side chunk of white cheese – also at the top of my list.

I’ve become braver with the street foods. The hamburguesas here are terrifying - yet delicious at the same time. They usually consist of a hamburger patty (thin, strange looking unidentified meat), strips of pink hot dog, a fried egg, lettuce, tomato, onion, mustard, ketchup, aji, mayonnaise, and French fries all in between two buns!

Picarones remain one of my favorite desserts – a sweet sticky deep-fried sweet potato goodness, especially amazing after an afternoon of surfing! (Or just on the walk home from work).

I finally tried raspadillas – crushed ice with different natural fruit syrups poured atop. Great summer drink, but I still remain impartial to my marcianos – fruit and milk frozen and sold in a small plastic bag.

I remain very terca – stubborn – in regards to the patitas - fried chicken feet. They say it works wonders for preventing hair loss, but I just can’t bring myself to do it! (But- the bright pink hot dogs are growing on me).

However, my usual meals tend to be pretty simple –a typical lunch meal of white rice, beets, carrots, and potatoes – served with chicken. I thought I'd be sick of white rice by now, but I think my body is adapting - If I go more than a day without it, I get intense cravings for plain white rice!

And of course, no meal is complete without some type of aji – a (spicy) liquid concentrate of some type of pepper. As a whole, I'm continuing to discover lots of foods I love - it will certainly be hard to leave the Peruvian food (not to mention Peruvian people) at the end of my time here.
Buen provecho!

Dia del Trabajador

Happy “worker’s day!!” Apparently, today is another federal holiday. I am loving all of these days of celebration. I thought Dia de la Mujer (women's day) was pretty great, but this one takes the cake! I've got to wonder what Peruvians would think of some of our American party days - Superbowl Sunday? 4th of July?

The festivities started yesterday morning with beer and parties, and carried on through the night. Mid-day today they had a small break for a nap, but resumed festivities this afternoon and are still going as I speak. (I can attest to this by the neighbors’ music level, though I decided to sit this one out and try to have a productive work weekend.)

Whenever this holiday falls on a Sunday, people are upset that they don’t actually get a day off work, so it seems they unofficially elect the following Monday off as well! (But- by unofficial- I mean that many businesses and all of the schools are closed Monday too). Not surprisingly, I didn’t quite get the memo in time … I’d already scheduled a full list of patients to see tomorrow, whoops!

Peruvians themselves will joke about how many holidays and days off work they get. Friendship day, mother's day, father's day, women's day, children's day, lover's day, worker's day, etc. - and usually the kids get each respective day of school off (or the preceding Friday/following Monday!) By the time you add in religious holidays (Saints days, holy week, Christmas, etc.) - the calender is blooming with holidays! You definitely won't hear me complaining :)