Final Day

Last night was a great time and I even had the luck of running into a friend from Virginia.  We were in the Central Park area and I heard my name called from a voice that was not in my group. I looked up and My friend Kyle was right in front of me! He was doing a mission trip and stopped over in Granada for the night. Unbelievable that he saw me in the crowded area!! 

Saturday morning myself and one of the students woke up early to see a patient for the final time. After all the great patients experiences we had this week, sadly we ended on more of a low experience. The patient with hip pain that we evaluated yesterday answered his door and refused therapy. He reported the pain was worse from the evaluation and didn't want to continue. We tried to explain how we could do some things to reduce the pain but he did not seem to believe this or want to even hear us. We knew he would be sore after the tests and stretches from yesterday but sadly his belief may have been that it was too much. I told the student how this is a great learning experience about education, patient alliance, and dosing of tests/home exercises. We reflected on the experience and how we can both learn from it. After residency and half of fellowship training I have really learned the importance of self reflection as the best way to improve my interactions and skills. It is always humbling when you admit your faults and learn from them. Being early in my career I feel i have a long way to go!

Later in the morning the entire group went to a local retirement home and interacted with about 40 adults who lived in the home. We talked, dances, colored, and just sat with these amazing people. Many of the ladies and gentleman living here either had cognitive deficits or no longer had family who could care for them. Luckily the nuns who ran this center are able to provide great housing and care for this group of people. It was very hard to see the condition of some of these men and women. One guy was so emaciated and sick that every breathe looked like he was fighting for his life. He could not see or sit up from the bed. 

Some of the best experiences come from seeing the not so glamorous sides of things. Not often do people visit senior centers and I am so grateful we had this experience.

We spent the rest of the day exploring and enjoying a lagoon. The fresh water in located in a crater and it feels like you are cut off from the world with 360 degrees of mountains.  I spent most of the time in the water swimming, paddle boarding, and even jumping off of a 15 foot ledge. It was a perfect way to end the trip.

At the end of our time out we met as a group and reflected on the entire time in Nicaragua. 

On the bus ride home I had an amazing conversation with Viva co-founder Carrie. We talked about mission works, global health, and long term goals.  I love meeting people who inspire me to continue this passion!!

I spent the night packing and went to bed early because my taxi to the airport is at 3 am on Sunday! 

Overall, this was a great trip with some new experiences as tons of lessons learned. I cannot wait to tell everyone about it and plan my next adventure!!

Clinic Day 4

Clinic Day 4

Three of us decided we missed working out so we woke up at 5 and did P90x in the church courtyard.

We started before the sun rose and worked out as the streets began to flood for the morning.  It was a great time working out and being in the culture at the same time

The morning was even better because the shower at the home is half outside with no roof. I cannot wait until my home has an outdoor shower one day. 

I went with the same group as yesterday because the other group only had 2 patients and they felt prepared while yesterday's group had 7 patients today with one being an evaluation.

Today was the last day of clinic so we started a little early to make sure we saw all 7 patients. 

We finished our time with the twin girls providing written home exercise programs and having the family perform all of the exercises. We had trouble leaving this home because of how much progress and happiness we had with them.

Next we went to the home with both of the patients with hip pain. The 93 year old father did so well and was able to perform the stand pivot transfer without weight bearing on the affected leg with min A compared to the max A on Tuesday. He and his daughter emphasized how grateful they both felt from this experience.  We were just happy we choose this route for treatment and did not pass over him when we found out his medical history and lack of activity.  Every patient can benefit from something and luckily we found it quickly and treated it effectively.

The other patient reported doing way better after last time so today we added prone hip mobility which improved pain and ROM 20 degrees. We also added some soft tissue message to the quad before the prone stretching which increased motion as well. The student working with this patient did a fantastic job reasoning his treatment and progression as well as using reassessment to dictate care. Seeing this integration helped me believe that my method of teaching was effective to apply the methods learned in their curriculum.

The next home was the patient with Parkinson's who reported being very sore from yesterday.  We expected that as he had not danced in years but he said he could not wait to do it again.  We wanted to dance, but we had a plan of our own and that was to get everyone in the family involved and doing everything so that their was carryover. We also had our community leader speak to each person about the effects of continuing this once we leave and what will happen if it is not continued.  The brothers and cousins did a great job and were very receptive to the education.  We just hope it continues.

While the group was treating the man with Parkinson's, my third group was next door with the sedentary lady. They added some manual therapy for the shoulders, reviewed the HEP, and worked with each person who transfers her regularly to improve form and reduce the stress on her shoulders.

 We had 2 patients left to see and only 1 hour so we split up. 2 students went to see the young man with polio and myself and one student went to evaluate a new patient. He presented with hip and low back pain.  I drilled the student hard throughout the evaluation process but he did a great job thinking his was through the case and finding all of the information he needed.  After the treatment we walked back together and talked about the process transferring from class to the real world and his passion to critically think and grow in the field of PT.  That is all I can ask of a student and felt that I had completed my biggest goal with these comments.

After a late lunch we went to the market to look for some items and the got to see an active volcano with lava.  I have seen a volcano before but never one with actual red lava in the middle! It was pretty awesome

For diner we had a great meal and the night was spent as a group celebrating Three Kings Day which is a huge celebration for many of the people of the Granada community.  

On a side note:

Throughout the day I was asked 4 times if I was a CI and if I took students.  I felt so honored to be asked this by not only my group but students that I did not get to interact with clinically.  This reinforcement supports my desire to teach and mentor as I continue to learn and grow in this amazing field of physical therapy.

One more day before heading home! 

Clinic Day 3

Clinic Day 3

Woke up ready to go back to see patients.   I was back with the original group I worked with day one and we went very efficiently. We started with a quick meeting to game plan progression and treatment plans. The group really had it down and understood how much would

Be too much and what needed more emphasis.  We started with the young girl who had cerebral palsy emphasizing the progression in each position. She did fantastic today and her aunt was very involved.  We also saw her twin sister who may have ricketts with extreme bowing of her knees. The angle was about 20degrees is standing which is pretty severe. We assessed her movement and educated the patient of continuing with the physical therapy consult in country as well as the weight bearing modifications. 

After that we went to the patient who had the broken hip and was non weight bearing. His family member was another one of the evaluations we had to see so two of the students saw the gentleman and myself and one student saw the evaluation.  She was the patient who broke her hip but was able to have surgery.  She is active but has a noticeable limp and is limited with long duration walking and activity.  After the examination we treated using an assess treat and reassess method to help determine the most effective treatment, she reported much improved pain, less compensated trendelenburg, and improve prone knee bend.  We will follow up with her the last day.  The students working with the other gentleman working on standing balance/tolerance on the unaffected leg and his transfers with his family members to improve tolerance. 

The next patient was the best and most rewarding interaction of the day. The stoic patient with Parkinson's was sitting in his chair with a little more of a rock and his family said it was his birthday. We sang happy birthday in Spanish and began the session.  After some manual therapy and thoracic extension exercises we turned the "romantic Latin" music on and began. The students and patients rocked it. He was doing big movements, lateral walking, dancing, and turning.  His movements were smooth with the music. We gave him a rest but after a few seconds a faster song came on and he jumped up on his own and started dancing.  Luckily the students quickly jumped to action and began another session.  After a long session he finally was tired. When we left him he stated that "we have brought life back into him today". Everyone was so happy with the impact these three sessions have had on this patient. So rewarding!!

Another group met up with us after this patient and I went with them to perform an evaluation. The patient was a sedentary lady who spent 80% of her day in bed and 20% in a chair. She was unable to roll. Unable to perform supine to sit without max assist and needed max assist by a neighbor for her transfer.  She had extreme muscle wasting. Her chief complaint was shoulder pain and her motion was about 50 degrees in supone active and 110 degrees passively.  We brought down a pulley and she was able to improve ROM so we left her with one.  We also added rolling into her daily activity to reduce risk of bed sores, improve trunk strength and promote extension. In prone she was unable to lift her head for longer then 10 seconds which is very poor so this position would benefit her greatly.  This group of students did a great job!

After lunch most of the group went on a zip lining and the rest went up to the top of the volcano. I had to join the zip line group and it did not disappoint.  Speed, heights, and upside down are all things I enjoy so it was right up my ally. 

Another great dinner and then one of my groups met up and we worked on evaluation writing.  They had so many great questions and you could really tell how they were thinking from their writing. The organization has 6 groups of therapy students come down to Nicaragua each year so they keep documentation for future groups to review. I set high expectations for the notes and the students are working hard to write strong documentation.  

I spent the time helping them, writing this blog, and talking to Olivia finalizing some wedding stuff.  Very productive day!!

 

Clinic Day 2

Clinic Day 2

Today started with another great breakfast made by our house mom and a walk to the local church. 

Today I went with a second group of students. We have 11 groups of students so the licensed therapists took 2 groups. This group had 3 patients to see today and did not have mentorship the first day so they had some great questions.

Our first patient was a middle aged male who was in a wheelchair. The students did a great job working together to get as much information as possible but I did not fully understand what happened so we had to dive into that a little more. Come to find out he had scoliosis and they did a lumbar and thoracic fusion which lead to paralysis of his lower extremities. This scenario shows how dangerous surgery can be. During the evaluation the students perfected their technique and improved their clinical thinking. We were able to address multiple issues with this patient including core strengthening, gait, foot posture in sitting, and education. We found out that he will be having surgery for the plantar flexion and inversion. He reports he will be having a tendon release and possibly a "screw" in his ankle.  I was shocked and angry at this concept as he had 10 degrees of passive dorsiflexion and the pinning would only cause more problems!! Spent time educating him about this and trying to take control of his healthcare. Sadly this may not help but it is worth a shot. 

After the therapy and Exercise education he reported much more confident and tired. He reported doing therapy in the past with similar exercises but not "feeling it in the same muscles".  I really wanted the students to take this point with them for the future. I truly believe that as therapists we need to emphasize motor recruitment and motor planning. Making the patient aware of correct patterning has a huge impact on body awareness and reducing compensations.  For this patient to have done these exercises such as planks, hip marching and standing hip extension but never feeling glute activation makes sense as to why he was moving the way he was.  After one session he had much improved gait with video observation. We left with a plan to buy equipment to modify his wheelchair to get his foot in a better position and solidify a HEP for when we leave.

The second patient was not available but when we went by his house we looked at the ramp that was built last year and it had eroded so we devised a plan to help rebuild the ramp later in the week and evaluate him on Thursday or Friday. 

The third patient was one they saw the first day. She has Rheumatoid arthritis and a history of 4 strokes that have caused her to limit activity and function. They reported that the first day she was unable to flex her left leg but after some manual therapy and exercise she was able to move it. However she was unwilling to let the students touch her hand which was held in a fist.  She had a very supportive husband and child who informed us that she was having trouble with long nails and a lot of hand pain.  So I decided to give it a shot to see if we could change anything with her hands today. She was resistant to movement yesterday so we decided to put her hand in water to gain her trust and slowly worked on movement. By the end of the session her fist was open to where she could grip a tennis ball! We emphasized education about the importance of passive movement to maintain motion and increasing waking with her husband.

We ended the day attempting to see one more patient but they were not at home. 

After lunch we met with all of the equipment and divided it based on need to each group and then we went to find other materials we needed. However the rain started as we shopped around for materials and prepared for the next few days. We had to go from stand to stand to find all of the materials we needed but it was fun to practice our Spanish and think outside the box with the materials we could get. 

We met up with local children to play soccer again but a few minutes into the game it started to pour so we hung out under tree shelter. We used some of our clinic paper to make paper airplanes, played tag, and made a piñata. We all had a great time together. 

My favorite part of today was talking to the first group from yesterday who stated they saw all 6 patients and felt confident. They said that yesterday gave them confidence and prepared them well.  I was so proud of their effort and willingness to learn and take the advice!b

After amazing home cooked taquitos we all went out to reflect on the days and enjoy ourselves. 

All of the other groups had so many great stories and creative ideas for treatment. Throughout the night I would see groups asking for ideas and working together to help each other. Already so proud of this group of students in their efforts and cultural awareness. 

Clinic Day 1

Today was a great first day in the clinic. We began with a great meal prepared by our host mom and set off to meet as a group. We planned to have 4 house visit evaluations that quickly turned into 6 when our translator explained that another two patients had asked for therapy in the area we would be treating.

The three students I was working with did a fantastic job working together during the first evaluation.  For some of them this was the first patient they have treated. Doing this is stressful enough, but add a foreign country in a language you don't speak makes it even more of a challenge. The first patient was a young man who had polio and severe scoliosis. We did not know what to expect but we all were excited when he was doing everything without an assistive device. The students did a great job working to perform a subjective and objective evaluation finding key information and looking at functional movements and patterns for treatment. They also took photos and videos as baseline measurements for objective measures. The patient was highly

Motivated as he already does 4 exercises daily which includes 50 repetitions of each workout!  We finished with a detailed explanation of his home program an de our plan for the week.

The second patient was a young girl who was the first born of twins. She was one of the patients added on to our schedule so we only knew that she was undiagnosed. When we entered the house I decide to take the lead having had PEDS experience and missing working with kiddos. It was so much fun getting back on the floor and assessing young children.  It was quickly evident that she had a severe disability. After the evaluation I found her developmental age to be about 4-5 months when sadly her biological age was 2 years old. She was very far behind her sister and was unable to sit unsupported or hold her head up in prone for more then 3 seconds independently. Today, my emphasis was education to the mother about tummy time and working on molding and hands to feet playing. Very fundamental things that she had not been doing. The aunt was able to perform the exercises and before we left we asked if she had any more questions. The mom asked if she would be able to walk soon.  The students were shocked by this question... as we just saw how far behind she was and that she could not even sit unsupported.  We answered the question by saying how she needs to master these skills and as she progresses with her strength she can continue to work toward walking. We cannot guarantee that she will walk, but we did not want to give false hope that crush dreams by making a definitive answer. We wanted to focus on the short term goals for now.  Education will be huge with this family!

The next patient was a 93 year old man who was wheelchair bound after a fall last year. He broke his hip and was unable to have surgery (the patient said his doctor told him it was due to medical issues). The students worked on a fantastic history as I looked at the x-rays his daughter provided. The x-ray was one of the worst hip fractures I had seen. The femural head was still in place but the femur fractured at the surgical neck. The bone went upward and was in line with the iliac crest. In sitting his femur was about 4-5 inches shorter on the left compared to right. He was non weight bearing and either sat Orndorff laid down all day. Our treatment and exam quickly went away from hips to working on pressure relief, transfers with the family, and positioning. This was a very interesting case and a great experience for the students. 

One of the other newly added evaluations was his other daughter who also fell and broke her hip. Luckily she was able to have surgery so we decided to focus on the older gentleman and would evaluate her the next day.

The 5th patient was an elderly female who was bedbound and relied on her family for everything. When we tried to evaluate her she was getting changed so they told us to return tomorrow. 

The final patient of the day was a stoic male with Parkinson's. He lived with a large family and those dynamics made the evaluation hard. When the students performed the evaluation the family wanted to answer many of the questions and tell the patient what they believed. They did a great job of taking control and making sure that they got the information they needed and built a bond with the patient. He was very sedentary and believed that Parkinson's caused his pain.  We had to spend time educating him about what Parkinson's is, and the effects of lack of activity on joints and pain. He seemed interested in the treatment plan for the week including music and movement. 

We had lunch back at the house and then spent the afternoon traveling by boat to see the small islands of Nicaragua created by the volcano years ago. They have 300+ islands off Nicaragua. We got to see a few including the "monkey island" with moneys living on the island and hanging out on one that had a reaturaunt and pool. At the end of the fun we sat in a group and did a fantastic reflection. The students had some great ideas and really learned a ton about themselves, the culture, and clinic which was great to see in only one day!

After a meal back at home we ended the day at a local hangout spot reflecting on the experience.

Excited for clinic tomorrow 

Getting started

New Year's Day was a long day of travel.  Rung in the New Years with Olivia and her family on FaceTime and then went to bed ready for the day. After two flight delays I finally
made it down to Managua. The other flights of the group also had some minor delays but we all made it down that night.
We packed in 2 vans and got dropped off at our homes for the week.  We were placed with host families in either groups of 2, 3, or 4.  The houses in Granada are so beautiful and the roads are fantastic. This is a very nice town and lucky to stay in such a great area.

After a short sleep we spent Monday meeting with the organization leaders touring the town we are staying in and the area where we will be treating. After that the students were split into groups and meet with their translator to learn about the patients and ask any questions. Our faculty group worked to divide ourselves and try to maximize our help.
We are doing the care in homes which makes it a little harder to divide ourselves. We have a game plan that involves running around (which I like, but most likely will be hard to do ) which may change after tomorrow.

We headed back to our homes for lunch and then had 2 hours to get ready for the afternoon. After unpacking and meeting the neighbors host families I did a little push-up workout at had a great conversation with the host father about working out, language, and ourselves. My Spanish is terrible, but with a lot of charades I felt the conversation went well.  

The group split in two for the afternoon with 1/5 of the group teaching children yoga and the rest of us playing soccer with some more children.  It was a great time and showed just how good they are at soccer. I even got to do a little first aid on a translator after he ran into a pole and cut his eye open! He is doing great, but glad I got to get some healthcare in today.

Authentic beans and rice filled our plates for dinner and then we all met up to discuss treatment plans and watch some of the Rose Bowl.

We are all ready to start treating tomorrow!!