Physical Therapy

                This adventure is coming to a close  We left Moundou this morning, and we will be leaving Chad tomorrow afternoon.  Now it is on to a new adventure.  It feels like I’ll be heading back home to Lewiston, but no.  We’ll be going back to Tacoma and starting completely new jobs.  The time here in Chad has been wonderful and I got to work with some wonderful people, both staff and patients.  There may be some boring physical therapy stuff in this blog, but some of the boring stuff was some of the most important (and my PT friends may enjoy it). 

                Also, I refer to Bekki a lot in this blog since she’s the person I came over to train and spent the most time with.   However, I did spend a lot of time working with another volunteer, Patricia.  She will be there for the month that Gardner’s are gone, so it was important to get her used to some of the therapy also.  She was wonderful and her fluency in French allowed her to build great relationships with the clients.  She knew everyone’s name.  Even if I heard their names I could seldom pronounce them right.  In all fairness though, if I told them my name the closest they could usually get was ‘beeeell’ (Bill was easier than Will).

                I am actually leaving pleased with what was accomplished in regards to physical therapy while I was here.  After the first couple days here I was not so optimistic.  I just kept praying for God to carry me through.  It was a practice setting that isn’t my specialty, with patients I couldn’t talk with, in a country I’ve never been to, and surrounded by a culture I only superficially understand.  Whatever I was able to do here was all Him.  The last day Bekki told me that, in regards to therapy, for the first time since coming she finally feels like her head is above water.  Praise the Lord!  I encourage any other therapists to come and visit, and eventually she’ll get out of the water onto solid ground.

                I saw fantastic changes in patients while I was here and was able to show Bekki some therapy exercises/techniques.  But one of the things that I am leaving most contented with is some of the simple organizational things.  I organized her therapy supplies; a notebook, a bag, 2 boxes, and part of a book shelf.  She also has arm pulleys set up in one ward, a hand full of walkers, a hemi-walker, a few canes, 6 ice packs, and 3 ice massage cups in the OR freezer.  I also wrote her up a guide to PT in Moundo as a Word document.

                The notebook has a bed labeled on each page and we developed somewhat of a documentation system.  For any patient we are working with, we put the date, any notes from rounds (often none after the first day), and then label the next line ‘treatment’ and would write out what we did.  I gave Bekki a crash course in PT short-hand.

                The bag contains the therapy essentials: 2 gait belts, TheraBand, goniometer, hand exercisers, Edge (instrument assisted soft tissue mobilization), massage cream, towel, timer, tape measurer, pens, etc.  And she can add other things temporarily if needed for a specific patient. 

                The rest of her supplies were organized into the 2 boxes.  One contained upper extremity equipment (slings, grip strengtheners, splints, adaptive spoons, etc.), and the other contained everything else (walker tips, knee brace, etc.).  A lot of the stuff in the boxes is nice to have, but not necessary to carry around every day.  We had one woman, a tough old lady, who had surgery on her left leg and also had a broken left proximal humerus.  Her fracture just would not sit straight and looked like it wouldn’t heal well, so we got her the sling with an abduction wedge and it looked (and felt for her) much better.

                Bekki also had a large supply of PT sheets for exercises, transfer technique, and other information.  The problem is that she has too much.  She got whatever she could from multiple therapists and therefore had a lot of overlap.  Other stuff, some from me, isn’t really applicable to the patients that she will see in Moundou.  Now that I had a better understanding of her caseload I was able to prioritize the handful of sheets for her to keep in the notebook.  The rest were organized into 4 different folders: PT- Upper extremity, PT- Lower Extremity, PT- General, and Other.  There was a packet of exercises for amputees in the mix that I made sure to show her, but otherwise she probably won’t use a lot of it.  If she does need to look for more information I hope that it is a little more organized for her.  And, more importantly, when other therapists come some of the leg work for organization is already done.

                By the end of my time there we were also able to get into more of a schedule.  After rounds we would work for a few hours (about 9:30-12:30).  Then if necessary we would come back in the afternoon (about 3-5).  This left the middle of the day for lunch, shopping, laundry, etc.  It’s important that Bekki is able to prioritize patients and use her time wisely, as ‘therapist’ is just one of her many roles there.  Abundant spare time is not a luxury that she has.  First time patients (early mobilization the day after surgery) are always top priority, then progressing mobility, range of motion, bed exercises, etc. 

                I tried to get in the habit of just getting all the ice packs after doing either the morning or afternoon sessions.  You have to go all the way to the OR to get them.  Not only does going there and back slow you down, but if Bekki leaves the Ward she will invariably be stopped by a patient or a staff member to do something else.  The Chadians seem to like the ice, I think partially because of the novelty.  The last day I was walking around with the small cooler of ice packs and went right by this young Arab boy.  He looked at me wide-eyed, like he’d just been passed over by Santa.  I did give him an ice pack.  I was doing ice massage on another patient with plantar fasciitis and he tried getting his kids to touch it.  I don’t think that they had ever seen ice before.  The older girl was brave and even put a small ice chip in her mouth.  The younger boy seemed scared, but maybe more of me than the ice.

                Initially Bekki and I worked as one therapist.  The morning allowed us to get at least all the higher priority patients done.  The afternoon was almost always enough time to finish the rest of the patients and do one or two patients twice.  The last couple of days we would separate for a lot of the patients, or at least parts of their treatments, and we got everything done in the morning.  All I did in the afternoon was go back for a quick second treatment and pick up ice packs.  That being said, there is still always more for a therapist could do.  Most patients could be seen twice a day, we could do more arm exercises (pretty much all I did was some triceps extensions on bed bound patients), and we could extend treatments with more stretching/more sets of exercisers/etc.  If the Gardner’s are able to get a full time PT graduate from Loma Linda they would like to also start an outpatient program.

Bekki and me some soft tissue therapy

                Now to the more interesting part of the therapy, actual patient care.  It was amazing what God was able to do to the patients’ attitudes during my time there.  Chadians have somewhat of a fatalistic mindset.  If they get sick or injured they see themselves as victims of fate and will not actively try to move forward.  It is very different than our American mindset that we can be masters of our own destiny.  Neither extreme is good.  But, for the Chadians it means that they don’t get up after surgery.  They just lie around and wait to be better.  Bekki has already come a long way improving this.  She no longer has nurses trying to tell her that someone can’t get up because they had surgery a few days ago, have a catheter, or have an IV.

                Like America, a lot of the patients don’t like to do things after surgery.  The patients would get up with us, but most didn’t do much unless we were there.  There were a few exceptions, but those were all patients that had been there longer already or had less extensive injuries.  Typically the first day we would start passive motion, usually a couple basic bed exercises, and begin mobility.  Then we would progress from there.  After we walked with someone, we leave them outside in a chair.  The family takes care or wheeling them back to bed eventually, or they walk back.

                By the time we left people had gotten used to a more consistent routine and seemed to look forward to us coming.  I missed a great opportunity for a wonderful picture on Friday, but my phone was dead.  We had gotten all the therapy done in the morning.  All the women were sitting outside by a tree, and all the men were lined up sitting in the veranda between the wards.  I walked into the wards and at least half of the beds were empty.  Very different than walking in and seeing a bunch of patients laying around, just waiting to heal without activity, and then hobbling out on crutches.

                Also, I was able to see people start to get up on their own.  Something they wouldn’t have even considered in their Chadian culture without being shown that it was not just ok but actually good for them.  Sunday was the culmination of this.  We got a handful of patients done right after rounds, and then we were back at the house for a short time since we were also getting ready to leave.  When we got back to the Wards, we saw patients we didn’t expect already up and walking around.  People looked happier and more hopeful to be able to take some control back.

4 patients sitting around outside.  The young Arab boy surprised up by getting up on his own before we got there.  The man hidden behind his mother just got up for the first time after six weeks of traction.  The other man we don't see for therapy and gets up and sits outside much of the day.  The Arab woman on the far right also surprised up by already having walked outside before we came back for therapy.

                I’m sure everyone wants to hear some personal stories of specific patients.  I will, of course, pander to the masses and highlight some (but by no means all) of my favorites.  And, as I mentioned earlier, I don’t know anyone’s names because I don’t speak French, Arab, or Ngambay.  I generally referred to people by their accident or something and people got the idea.  That being said, it’s amazing how you can still form a relationship with people without direct communication through language.  I did usually have Patricia (who is fluent in French) or Bekki (who speaks a moderate amount of French) with me.  The last few days I would separate from Bekki and do quite a few of the patients on my own.  They knew who I was and why I was there.  I smiled, used hand gestures, demonstrations, and memory to get everything done easily.

                There was a young Arab boy who was a joy to work with.  Unfortunately his story is not all good.  He had a surgery to fix his femur fracture.  He seemed to be doing so well when he started to have some puss over his incision.  Infections are rampant here.  He went back into the operating room to be opened up and cleaned out.  After that he had a lot more pain.  The next day (Thursday) I tried to just slightly bend his knee and he cried out in pain.  During dressing changes he would actually cry into his shirt, something unheard of in Chad.  We did exercises on his uninvolved leg and some triceps extensions Thursday and Friday.  We don’t do therapy on Sabbath.  Sunday I was expecting to do the same.  But, when I showed up he was already up and walking outside!  He was beaming.  His infection seems to be doing better now, but please pray for him.

                The same morning two young Arab women did the same thing.  I usually referred to them as ‘Arab lady 1 and 2.’  She had been getting up with us, but I hadn’t seen her up on her own.  One was already outside with her walker and getting into a chair when we arrived.  The other told us (and I actually believed her) that she had gotten up and walked back and forth in the ward that morning (she was shy and didn’t really like going outside).

                There was another lady that unfortunately had to have a trans-femoral amputation on her right side.  When I started there they were still trying to save her leg, but her infection just seemed to get worse and worse until Dr. Gardner had no choice but to amputate.  She seemed depressed.  Patricia, who did her dressing changes every day, had the idea of having another amputee patient talk with her.  He was the only one there and was about to go home.  He showed her how well his had healed and talked about getting his prosthesis soon.  I think that helped.

                The woman mentioned earlier with the humerus fracture, which I referred to as ‘arm lady,’ also made improvements by leaps and bounds the last couple of days.  The first couple times we would get her up and tell her to start walking she would shake her head and kind of do this clicking noise that Chadians seem to do when saying no.  But, she would still do it.  Hopping a few feet the first day and a few more the second.  She had to use a hemi-walker in her right hand and was non-weight bearing on her left leg.  She had progressed to bearing quite a bit of weight on that left leg over the next 2 weeks.  Wednesday Dr. Gardner was asking me about her going home with crutches because she was saying that she couldn’t afford to stay anymore.  We wrote the order for a crutch, but I wasn’t very optimistic.  Two days later my outlook had changed.  She was up with her hemi-walker going all the way to the bathroom (at least 100’ away) on her own.  I never got to see her try a crutch, but she has a realistic chance of walking out now.  That’s all the women.  We had many more men than women.

                One of my favorite patients was one that was in traction all but 1 day that I was there.  I called him ‘traction guy.’  He had dislocated his hip pretty badly and was put in traction for 6 weeks.  By the time I got there it was stable enough that we could remove the traction for therapy and do strengthening bed exercises in a safe range, exercise his uninvolved leg, and of course triceps extensions.  He loved us coming and would just smile.  I would see him twice a day, just repeating the exercises on his injured leg for the second treatment.  He seemed to really like that he was doing something to help in his recovery and not just laying around for 6 weeks.  Sunday he got up with a walker!  He felt a little unstable in his hip, but did not dislocate again.  We gave him a lot of education on hip dislocation precautions.  This is difficult because they spend a lot more time on the ground than we do.  He’ll probably go home within the next week, but that will be Patricia’s decision.

First time being up in six weeks.  Excited, but a little uncertain too.

                We had a couple guys in external fixators for tibial fractures that seemed to be doing much better over the few days we saw them.  They both had a lot of pain the first days and just walked around their beds.  By the end we would walk them both outside to sit in the veranda.  The men and women often sat in separate areas and the men tended to claim the veranda early.  There was one old man that seemed to pretty much spend all day in the same spot on the veranda every day.  I think he would get up right after rounds and head out.

                There was a young man who broke his tibia in a soccer accident.  I referred to him as ‘futball kid.’  He was very motivated.  His whole family was.  His father was the chief of police and his oldest brother was in charge of the ER at the general hospital.  He was starting business school soon.  He got better very quickly and was motivated to do his exercises.  He will probably go to the Handicap Center for more therapy.

                We had another patient we referred to as ‘Klondo-guy.’  He was a motorcycle taxi (Klondo) driver that the Gardner’s picked up from the side of the road when they were travelling in their ambulance.  He had surgery for a tibial fracture.  The surgery seemed great and he never complained of pain there.  But, first he had knee pain and he couldn’t do much.   After a couple days of therapy that was a lot better and then he started complaining of plantar pain.  We did some basic plantar fasciitis treatment and although it wasn’t 100% better he felt ok to go home.

                There was a young Arab teenager who probably had the most drastic improvement while I was there.  He had a right femur fracture.  The first day like four of his family members moved his leg for him and pretty much completely lifted him up to the walker.  I don’t think he really did anything, but at least he was up.  In subsequent visits I’d pretty much have to force the grandfather’s hand off his leg so I could set it down when he was sitting.  The Chadian Arabs are more affluent and they tended to not be quite as tough as the other Chadians.  Of course, still much better at handling pain than Americans.  We worked a lot on his knee range of motion.  The last week we were there I don’t think we really walked with him much at all because he was walking around on his own so much.  He would always give me a big smile when he was up and walking.  He was just waiting to get crutches when I left, and then he’d go home.

                It was an amazing opportunity as a physical therapist and as a Christian.  As a therapist it challenged my clinical skills in ways that I would never experience in the States.  As a Christian it demonstrated my complete dependence on God and need for daily miracles.  Thank you all for reading and God Bless!