Last Days (Clinic Day 9, 10, and Saturday)

Thursday and Friday:

As the week ends, I decided to sum up the days a little more quickly.

Thursday we arrived at the clinic and one of the physios was leading prayer. It was a great experience to pray alongside the patients to start the day. I wish I had seen it earlier and joined them every morning.

I mentored two students with one being a students second mentoring session and the second being one of the weaker ones of the trip. The first was George who was the head of the department with 30 years experience that I saw last week. He wanted to show he had learned from the first time and I could tell he was really trying to integrate the lessons from last week. He still needed a lot of guidance with the critical thinking but he was much more thorough with the questioning and trying to gather information. The focus today was to work on using objective impairments to treat. We worked on doing muscle testing to figure out which to treat and to assess joint mobility to figure out where to mobilize.  He said that he has always just treated based on what the x-ray showed or just where the patient was experiencing pain. I think that George will continue to grow so much during the residency year due his openness for change.

The second student was from a rural area of Kenya and he has been practicing 11 years.  He had trouble doing basic measurements and testing all of the simple things. I had to do a lot of teaching with him. The most troubling part of his session was that he filled out all of the objective examination  based on looking at the patient. He explained that he rarely tests and just guesses. I really tried to stress that this way of practicing medicine is unethical, not safe, and not helpful. After the session I spoke with residency staff and they were aware of weak he was, but said they changing his practice would help many patients because of where he works. They said the lower skilled therapists tend to work in the rural areas.  I loved that they are trying to not just make the good therapists better, but trying to improve the care as a whole.

At night our group went out for an Ethiopian meal with some of the residency staff. I was the only one from our group who had tasted this type of food so it was a great cultural experience for all. After we got to experience reggae night at a local bar. We had a great time.

On Friday we had a half day so we only had a few patients. Emily and I mentored together at first and then Lauren asked for some mentorship with a highly irritable case. At the beginning, he had severe pains and fear of movement. After some education, manual therapy to the abdominal muscles and obliques, and graded exposure to movement and dissipation he left with much less pain and was able to squat and even do a sit up!  It was a complete change and was so happy to end my clinical experience with this patient.

Our group presented gifts to the mentors and staff which they really enjoyed. The staff also presented us with gifts for our education and collaboration over the past two weeks. I was presented with an amazing handmade shirt. It was a perfect style for me and I could tell they picked out the fabric based on what I had been wearing all week and my personality. It was very thoughtful.

In the afternoon the students headed to the airport after our final reflection over lunch. All 6 of us really grew and learned a lot from this experience. It was hard to believe how many things we were able to do and accomplish in two weeks time.  For me, my low was that I was unable to treat more patients. With mentoring you are focused on teaching so it is more indirect patient care. It is also slower so we could not see as many patients as I would typically see I a day at home. But our focus was to impact beyond our time here, which brings me to my high which was the idea that we were able to provoke a change in thinking about patient care. Our influence as educators, if it resonates, will make a much larger impact on the country then the time we spent here. That is the best part of this work and experience, sustainability and progress!

(Some photos with our driver DJ Ken! He made our travel so much fun.)

At night, Emily and I went out with Martin for a few hours to enjoy our last time together. It was a great time!

Saturday:
Many people who stay at Grace House come for the week and travel on weeekends so it was a ghost town when we woke up for breakfast.
Emily and I packed and had our final meeting with Erastus and Martin.

We had a great trip, so much that we ran out of money on the last day which limited what we could do!  Luckily we had seen everything we wanted to except the Karen Blixen Museam. I did some research on her instead so at least I got to learn about her impact on Kenya.

We headed to the airport and prepared for our long flights home. I plan to use that time to reflect, work on my Haiti course lectures, and prepare for the next two weeks so I can hit the ground running on Monday.


Reflection:
Overall, this was such a great experience for myself as a therapist, global citizen, and humanitarian. My passion is to learn the world and make an impact as much as possible. Each journey has been teaching me more and more about myself and the world around me.  I feel so lucky to have opportunities like these and hope that everyone who read this blog was able to learn more.

Thanks for joining me on this journey!

-Kyle

Clinic Day 8 and Inservice

The midway day of the week was an eventful day. All of the mentees were late so we started by mentoring OMT therapists. Once the two mentees arrived, two others also showed up who were not on the schedule. This lead to a hectic morning.

I was happy to mentor Anthony who is a past OMT graduate. The SU students mentioned he liked to take some short cuts and use similar treatments for many patients.  His patient that we were seeing had been to therapy 11 times before this visit. Anthony explained his diagnosis and treatment plan.  I asked the patient his progress since starting therapy and he reported 30% improvement.  I asked Anthony if he thought he was on the right track or needed to reassess. He was open to reassessment.  I had Anthony look at objective impairments and check strength which is something he had not done prior to today. The patients symptoms occurred with lumbar extension.  With movement pattern changes and addressing impairments the patient was able to extend pain free post treatment. The emphasis with my mentorship with Anthony was to provide exercises, reflect constantly with each patient, and to reassess treatment effects to determine plan of care changes. 

When the first resident arrived we started the evaluation quickly to try to make up time.  This patient was post operative for a shoulder arthroscopic procedure in May. He had been in therapy but was still in pain, had limited with function, and limited range. After the subjective I asked the student if they noticed any yellow flags. He picked up on the fear avoidance to movement and hyper fixation on pain.  We worked on how to educate about tissue healing after surgery, emphasis on load to improve function, and use vs disuse. The patient appeared less tense and guarded after this education.

The objective portion of the exam worked on handling and technique for range of motion and joint mobility assessment. He learned quickly and by the end the patient said the handling was very close to my technique.

Exercise prescription was lacking in his education so I also put a strong emphasis on teaching exercises, technique, and dosing to help improve his concept of how and why to give exercises.

The second student has been strong so far in residency and choose to pick a complicated patient to challenge herself. I admired her desire and was excited for the session.The patient reported with low back, leg, neck, and shoulder pain. She has had 18 surgeries in the past 8 years along her neck, lumbar spine, shoulder, and abdomen. She would be what we call a complicated patient at home. I could tell the student was overwhelmed, so I jumped in a little to try to help her out.  I worked on trying to address function and patient beliefs to help drive the session. Her biggest aggravating factor was standing in place and her relieving factor was walking. This did not make sense to the student so I had to act out and think about this to come to a hypothesis of what could be driving symptoms. She began with 9/10 standing pain and burning down her leg after 3 minutes of standing. After addressing the abdominal region with some manual therapy and motor control training in supine and standing we reassessed her standing.  She was able to stand with 1/10 pain and no burning symptoms down her leg after over 18 minutes of standing.  The big take home point for this complicated patient was to listen to her story, educate and give hope, find impairments, and work on function. The case could not have gone any better and I was so happy to have had this teaching moment with her.

With such a busy morning, I worked way past lunch so after a short time to clear my mind, I started to set up for my inservice presentation. My topic was clinical reasoning and evidence based practice. This lecture is an expansion of a lecture I gave in Ghana a few years ago and their national physiotherapy conference. The topic and style of presentation challenged everyone’s thinking and wrapped up the large emphasis I had been placing in mentorship all week. I was worried how it would be received, but I had 3 questions during the talk and over 45 minutes of discussion after I was finished.  I loved to see they took the challenge and were thinking of ways to improve their practice.

After a busy day we went out to dinner with the head of the therapy department for goat.  We wanted to try something new, but he had decided we would do this meal again and so it was the final say. At the meal his friend, Wilson, presented us with tea from his company to bring back and share with our American friends. It was such a nice gesture and we were very grateful.

Clinic Day 7

Clinic began with another student who has learned how to practice but has created shortcuts and fell into the system of treatment.  He made many assumptions about the patient, used the script as his primary clinical reasoning, and did not try to dive deeper into the patient during the subjective.  With guidance he created strong differentials and had a much better understanding of the patients pathology. The patient was a young man with a knee injury from a motorbike accident. His injury was in December and did not start PT until today which shows how slow the system can be here in Kenya. He learned how to better use the objective measures to drive treatment and how to treat more functionally with exercises of a younger, higher level patient. The patient reported with a better confidence with movement and what he needed to do for strengthening. Andrew, the student, learned about how to determine duration and frequency of treatment today. He wanted to see the patient 2x a week only because that is what he always does. However the patient drove 800 km and had to stay overnight for just one visit.  After some explanation he was able to understand why the patient should only come every few weeks with an emphasis on HEP and self management.

The second student came late so I worked with one of the stronger OMT therapists at the hospital and Kala, one of the SU students, on a foot/ankle case. The focus was on using impairments vs pain to drive treatment. The patient had a fusion of the mid foot due to severe foot pain and deformity. His biggest limitation found during the exam was gastrocnemius/soleus weakness and hypomobility and limited dorsiflexion of the 1st metatarsal phalangeal joint. It was a great experience to use gait analysis, manual assessment, and questioning to challenge the thinking of both the advanced clinician and student at the same time.  I really enjoyed this time with them.

After that I had a few minutes so I walked around the clinic and found Tony in the Pediatrics room with Juliet. They were working with a one year old patient post meningitis. Her developmental level was about the level of a 3 month old.  I enjoy this age and really enjoyed joining in with this case. I was able to use some of my past experience to help provide some ideas and also learn some treatment strategies from both Tony and Juliet. This made me realize how much I miss treating the pediatric population. 

Before lunch the second student finally arrived (1 hour late but apparently within the Kenyan understood late time).  Her patient was one who was seen by a newer therapist 8 times before this visit. Emphasis today was determining current effects of treatment, reassessing all impairments, and determining the plan of care going forward. She had some trouble with the subjective like many of the other students and needed guidance during most of the objective aspect and intervention.  After the session I learned that she is in the residency program for orthopedics, but her job is inpatient on the wards. So sadly she does not get to practice or implement much of her coursework or mentoring into practice during this year.   Erastus, one of the lead teachers in the residency, explained that many of the employers due to not understand the residency and how each student should be working in orthopedics to work on the skills they are learning. Hopefully as the program continues, the employers will see the value and make adjustments to their thinking.

After clinic, Emily Tony and I went on a run and did a workout because of the nice weather. After that we were given the opportunity to watch the local club rugby team. We got to meet some of the players, talk to the physiotherapist, and enjoy the practice. It was a great experience for me to learn more about rugby and compare/contrast the sport to American football.  

After practice we went to a local rooftop to listen to a local band. We had a great time as a group tonight!

Clinic Day 6

The first student today was a great therapist. We are working with Cohort 6 which is the next grade. They have taken al of the didactic coursework for the is residency and half of the mentorship. His patient had low back and knee pain.  With a sound foundation I was able to challenge his thinking and reasoning. His reasoning was strong and his examination was one that I would compare to a third year DPT student from America. After this session we had great discussion about movement patterns, muscle activation, and clinical reasoning principles.  

After that patient, I co-treated with one of the lead therapists Wilfreda. She has been practicing for over 30 years and her son is Martin. Her patient was very challenging. He is coming with radicular leg pain and a Severe lateral shift. She has been working with him for 8 visits with almost no change. After redoing a subjective examination and objective examination we tried a few interventions with little to no pain changes or shift changes. However she had not done much active intervention including exercise so emphasis on graded exercises with function and movement as the goal was added today. I also emphasized patient education and explained what I was thinking and the purpose of my education so she could understand how the implement it herself.  After this session, I believe he would be benefit from a surgery based on his objective exam and response to treatment thus far.  However, in Kenya it can take between 3-5 months for this to occur so either way we need to continue conservative care as the process continues. I am hoping the education and movement will cause some more changes and allow him to avoid surgery. 

After the treatment session my student from this morning walked to lunch with us asking more questions. It was refreshing to have someone eager to soak it all in like a sponge. He stayed for an extra hour just to talk with me about patient care!

After lunch I mentored one more therapists with her patient.  The students were done for the day so they sat in on the session also.   I think the large number of people in the room intimidated her and she seemed pretty flustered. She learned the most about how to prioritize and differentiate multiple pain locations to provide effective care. 

After clinic we returned to the Grace house for tea and reflection. We had a great discussion with Martin about the students involvement at the hospital and ways to work on sustainability growth with the relationship.  I felt that they came up with great ideas and had a productive talk.

After a workout I spent some time working on a lecture before going to bed.  It was nice to get back into the clinic.  

Safari Weekend

Safari Day 1

Tony and I woke up early to see a bit of the sunrise but the high tress limited our sight. We had a gourmet breakfast in the main dining area and I made sure to try everything exotic including the quail eggs which were creamy and light.

After the meal we packed up and headed out for the Safari. Our luck was low again when we got 30 seconds into the trip and our roof collapsed down on the head of Tony and myself. Luckily we were not hurt,  but we had to take a 45 minute pit stop for him to get the roof fixed again. 

Our Safari was out of this world so the delay didn’t matter at all.

I expected the Safari to be a lot of driving and seeing a handful of animals from a distance or quickly hiding. That was not the case at all!

We saw thousands of animals from 5 to hundreds of feet away. We saw 4 of the big 5 (missing only the Rhinoceros).  We also had the privilege of witnessing a leopard hunt and kill a Gazelle.  Our guide said he has been doing this for many many years and has never seen this before. It lasted two seconds and between the 6 of us we got 2 videos and 2 photos!

We also got to see the Wildebeest migration which is considered one of the most majestic sights in he world.  We watched thousands of them cross a river to make its way into Kenya from adjacent countries.

After an 8 hour day of driving all along the Maasai Mara park we made it back to relax, eat, reflect, and get ready for a 6 am tour on Sunday.

Safari Day 2

We woke up to the sounds of the animals at 5 am. We headed out for the Safari before the sun rose at 6 am. The sunrise over the Savannah was breathtaking. We had two missions with the early tour and that was to see the cats in action and try to find a Rhinoceros. We drove and saw some of the more common animals until 1 hour into the trip our guide saw two lions in the distance. We ventured over to the area and came to not only 2, but 4 lions who had just finished their kill, getting within 10 feet of them!!!!!! We could see the color of their eyes. It was so exhilarating. We were all out of breathe when we drove away from shear adrenaline.

On the way back to camp we stumbled upon two hyenas and Lauren noticed something about 100 feet away. It was a lioness with her fresh kill! We got to see her dragging the meal along the terrain as the hyenas followed picking up scraps.  We had an action packed morning to say the least.

Sadly we missed seeing a Rhinoceros but we left the Safari so fulfilled.

We also had the privilege of visiting a Masai Village which happened to be the home of the Chief of all of the Masai people. We got even luckier to have his first born son (the next in line to rule) as our guide!  It was great to learn about the traditional culture, how the culture has changed with the times, and even purchased some items from the ladies. 

On our 5 hour trip back to Nairobi we stopped and got some nice photos of the Rift Valley. 

Back at the Grace House we reflected on our trip and recovered for our second week at the hospital. 

Sadly I only took a few photos on my phone, the rest were on the large camera. They will be posted once I return home.

What a great experience to mark our halfway point!   

Clinic Day 5

Last day of the week was clinical day 5.  It ended up being a short day due to our weekend traveling.  

I had one student who did a great job with his patient. He traveled from Mombasa for the weekend just to be mentored (which was about 6 hours). He had a patient that was in her eighties with general deconditioning and pain in multiple joints of her body.  He missed many key subjective questions but was able to get more information with my guidance. 

He picked up on her concern about arthritis and we together worked on a way to re-educate her on arthritis, movement, and function to help improve for confidence to live.  He really appreciated the new ideas for patient education that has not made it to this region of the world.

Martin and I spoke about passive modalities effect on patient compliance. He stated that heat packs and stim are expected. The patients will feel robbed if they don’t get it even if they got symptom relief with manual and exercise. He said the other population feels this way the most as they associate heat packs with therapists. He said they have been able to change the beliefs of younger patients and people who have not been to therapy before. This was a great conversation to have because we are struggling with similar issues in America with patients understanding of what a therapists can provide. 

I was also able to help one of the head therapists, Wilfreda, with a hard patient of hers.  She knew the gait deformity but was unable to pick out the compensation pattern and weakness that should be addressed.

After a half day we headed back to the house to wait for our guide to pick us up for our Safari.  He emailed us 30 minutes before he was supposed to get us stating he would arrive in 1 hour.  After he did not show we called and he said 30 more minutes.  He did this again and sadly he did not arrive until 4 hours after he was supposed to arrive.  Not only were we upset that we left clinic for nothing, but we could have also done something else with those 4 hours.  The staff of Grace House was also upset by the man because they said it was a bad reflection on them.

We were pretty upset to start the trip but after some great conversation and 5 hours of driving we made it to Masai Mara for a very late dinner and rest.

We were shocked to see that we were not camping, but “glamping”. The entrance looked like an all inclusive resort you would find in the Caribbean, buffet style food, and the tents had everything in a typical hotel room. 

Clinic Day 4

Thursday was the day we finally felt like we were comfortable with the routine and felt at home. We got started treating right when we got to the clinic.

My first mentee was a therapist who has been practicing since 2012. Abraham works in an outpatient clinic and is a partner in the practice. I enjoyed the conversation with him about the outpatient world in Kenya. He had the same views about trying to gain influence in the community, building referral with quality care, and the economic side of sustaining a business. He had very good communication skills, but having worked in the outpatient world he was more focused on efficiency and less on being thorough with questioning and understanding pathology. He made a lot of assumptions and when I forced him to dive further into the pain he ended up finding out the pain was not central low back pain like he assumed but actually thoracic pain. Had he continued with his exam under his assumptions he may have not even treated her location of pain. He reported in the multiple years of practice he never screened the thoracic spine so the rest of the session was education of thoracic exam examination and treatment. The patient left the session with no pain and new home exercises to address the source of her symptoms. Abraham is a smart man and to hear how impacted he was by this interaction was humbling. He told me that he plans to find a way to do another session next week and show how much he learned from this experience. He really took this experience to heart and said he now saw the value in being detailed and having strong clinical reasoning. I could not feel more proud of what he gained for this time together.

Mentorship session two was with the head of all physiotherapists at KNH. It was intimidating mentoring a gentleman 30 years older than myself and such a high role in the hospital. I began by just listening to his subjective and not giving input. However he did not ask many questions and left me with no understanding of what might be going on with the patient. I decided to ask him if he knew the answer to several questions and he did not know then so he ended up needing to do a second subjective evaluation. With these questions he was able to determine source of symptoms, red flag symptoms, goals, severity, irritability, and past medical history. The patient provided an X-ray with severe L5/S1 pathology. He is a prisoner serving a life sentence and this limited the treatment options for him. During the session he had two guards in the room. The objective exam was also very sparse so education was needed to help create an organized examination for someone with high irritability and severity. We decided to treat using lumbar traction due to limited tolerance to any other positions or intervention and severe radicular symptoms. After traction he was able to ambulate with full weight bearing on the effected leg with crutching which was a significant improvement from when he entered the clinic. After the session George told me that he was inspired by his mentoring experience. He said he has many therapists who graduated from this program on his staff and wanted to see what he could learn by joining. He said his eyes were opened today to how much he assumed when treating patients and that gathering more information can completely change the plan of care. He put himself on the schedule for mentorship next week because he said "this is exactly what he needs and wants to be better".

X-ray of second patient with pathology at L5/S1

Clinic Day 3

With a little sleep aid I finally got a full nights rest. Waking up refreshed make the day so much better. After another huge breakfast we all headed to the clinic.

The students jumped right in and had a busy day treating alongside the Kenyan therapists getting great experiences.  The students got to experience how patients expose skin for treatments, the flow of patient treatment, and the different levels of clinical skill based on education.

They also had a very interesting case where the MD and physio believed it was an upper motor lesion but the clinical objective measurements were lower motor.  We had a great discussion of how our examination should drive treatment and we should not be afraid here or at home to present our findings to other professionals. We owe it to our patients to treat in a team approach and to value the findings of each profession to help give the best outcome for each case.

The first mentoring session of the day was the strongest of the week.  Lydia has been practicing for a few years and was coming back for residency training.  Before our patient arrived we worked on cervical techniques as she felt very uncomfortable with this area of the body.  It was very refreshing to have someone asking to learn and desiring knowledge.

She was treating a patient who was been in PT for 1.5 years for a disc pathology. His beliefs and understanding of his rehabilitation has caused him to become fear avoidant and limited. Lydia caught on to this with some guidance and did very insightful and patient centered education.  Providing this in combination with motor control training completely changed the patients affect,  movement, and hope for recovery.   I was so proud of her ability to think this way with patients as I had not seen it since being here in Kenya.

 

The second mentoring session was with Raphael. He had also been practicing for a few years but needed more cues for completing a through evaluation and assessment. The patient also had low back pain but needed less education as she was a nurse and was much more understanding of the science behind her symptoms. He did learn new strategies for exercise prescription and motor control training. It is so interesting to see how varying the understanding of exercises and movement between therapists. Raphael really enjoyed learning how to think and we spent almost an hour going over thinking about patients after this mentoring session.

We were so busy we ended up missing lunch. The SU students presented a fantastic inservice in the afternoon. They noticed a lack of functional exercises being prescribed in the clinic and wanted to focus on how this thinking could be applied to various patient examples.  They did a lot of group thinking and examples which really got the Kenyan therapists thinking. Afterword the talk the therapists had great questions and the students left them with some great take home points

We returned home and I was able to get a P90 yoga session in between tea and dinner. We had a great traditional goat meal with our group and six of the staff from the hospital.  We had great conversation, cross cultural bonding, and a traditional eating experience. Best night of the trip so far!