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!

 

Clinic Day 2

Sleep has been an issue so far this trip. After a few hours of restless sleep I actually drank a cup of coffee with breakfast (I do not drink coffee so I knew I was tired).

Emily and I headed to clinic while the students stayed back for the day. The clinic was back to normal and we got going right out of the gait.  In mentorship today my first mentee, Denis, was able to treat two patients. He is an experienced therapist of 8 years who decided to do the residency to improve his manual skills. Most of the therapists work in a hospital setting but this therapist does home visits. It was cool to see that there are other options for income and employment. Denis did great for his first patient really going through a sound examination. The patients symptoms were in the low back region and he had to determine lumbar vs SIJ involvement. Using special tests and palpation we were able to determine the driver of the patients symptoms. Being systematic with assess, treat, and reassess, the therapist was able to gain a stronger understanding of this clinical pattern.

The second student was having her first ever mentorship experience so our emphasis was gaining confidence with patient interaction, working on gainaing a flow for an evaluation, and trying to use assessment to find impairments.  The challenge for this patient was that she had two areas of pain without a clear connection between them. Being the first time treating a patient it was a challenge for the therapist to keep on track.  She was able to get through the whole exam and I think she will learn from this but was not optimal for a first session.  I hope that we can have another session over these two weeks.

After clinic Emily and I had a late lunch with Martin who is one of the mentors in country. Martin has a passion for growth in the profession and improving quality care in Kenya. It was inspiring to see his passion and emphasis on continuing education and clinical reasoning.  I am excited to build a friendship and have more discussion as we have very similar beliefs about thought process and the future of physiotherapy globally.

Day 3 to come!

Clinic Day 1

After a restless night sleep I awoke to the sounds of the Nairobi city.  All night I kept thinking about how mentorship was going to be, what the hospital would look like, and how the Kenyan therapists would view me.

After getting dressed in my suit and lab coat (which I have never work to treat patients), I practiced trying to do some manual techniques making sure I would not rip my jacket later that day. Once confident, I headed down to breakfast which was amazing. Buffet style English breakfast with everything included.  The typical Kenyan dishes were similar to Ethiopian and Ghanaian dishes, but the tea and breakfast are 100% British influence!

Once the group was ready we were out the door by 7:30 am for a short drive to KMTC (Kenya Medical Trainng College). The hospital located on the same  campus is a 1,000 bed hospital. The head of the rehabilitation unit at KNH (Kenyatta National Hospotal) told us this was the largest hospital in what he called “black africa” meaning south of Egypt and north of South Africa. It was amazing to see the size and function of such a large hospital.

 

 

Once on campus we were given a tour and got to meet many of the physiotherapist and heads of many departments.

 

 

We were supposed to start clinic at 8:00 am but once a handful of patients were present. The staff explained to us that typically the waiting room is overflowing with patients in the morning making this atypical. We found out a short time later that the entire staff of the hospital went on strike for wages. It was estimated that >4,000 men and women protested the unfair wages demanding better pay.  We heard a man on the megaphone talking at one point but could not make out the words.

After waiting for the management to determine our plan we were finally able to start our days in the clinic. The students worked with the Kenyan therapists treating patients while Emily and I started mentoring. Our first resident was Isaac who has been practicing as a physio for many years before joining the residency program. During this patient interaction there were many skills that you could tell he had developed overtime that were strong. The emphasis treating this male patient with low back pain was improving his systematic approach to subjective questioning, using questioning to help rule out red flags and origin of symptoms, as well as creating a systematic objective examination to make sure he examines all possible areas of involvement for treatment. Questioning and reflection in-action were great ways to help improve his treatment for this patient. The patient walked in with many concerns and limited movement, but walked out educated, less fearful of movement, and with less pain. After the mentorship the student expressed his beliefs on the experience and mentioned how much he felt he learned in the session. For myself and Emily this was a great boost of confidence for the week. 

One more mentor session occurred before lunch. I had the pleasure of working with Janet who was in her first mentorship experience ever. She went directly from receiving her diploma in physiotherapy to the residency without any work experience. She was extremely nervous so I worked to ease her mind. During the evaluation I worked along side her to build her confidence and help keep a steady flow. She was able to evaluate and treat a young male who was a few months post a lower leg fracture and Tibialis Posterior tendon repair. His biggest concern was walking as he thought he could put pressure and break the metal plate in his leg. She needed many cues during the session but she was able to perform all of the tests and measures as well as treatment. This patient came in using two crutches afraid to put his foot down and left with increased ankle dorsiflexion and heel to toe walking using the crutches. Combining manual therapy, patient education about his plate, and gait training was used to treat the patient, but the biggest impact was how excited Janet looked once the patient left and she had done her first evaluation!

We took a break to have lunch at the local cafeteria which was a stand alone small building on campus. The cafeteria had local dishes including Ugali (maze flour) and beef stew which was amazing. You cannot beat the price of $2.50 a meal either!

     

After enjoying our food we did one more mentoring session. I was paired with Peace who has been a physiotherapist for 8 years. She was also looking to improve her skills when she signed up for the manual therapy residency. She has a phenomenal subjective examination. She was able to gather everything needed for the middle aged gentleman with right lower leg symptoms who was one year after a severe motorcycle accident causing many fractures and skin grafting needed for his injuries. He is now walking only about 1/2 kilometers with one crutch. Peace improved her objective skills with using assessment of both limbs to help find impairments to treat. She used her past experience to make assumptions instead of treating this patient specifically. I had been making the same errors during fellowship and used the techniques my mentors used with me to teach her. It was very surreal to see the process coming full circle. 

Today was 3/3 for mentor experience and I am looking forward to many more days to come. 

After clinic I was able to workout before having the daily afternoon tea. We were given a tour of the local area around Grace House and learned of some great places to try during our next two weeks. We even learned of a place where Mark Zuckerberg has come. Tonight we had a great meal at a place that served two for one burgers.  Can't pass up on a special.

Reflection on the day rounded out the night and Day 2 awaits tomorrow.

Sunday arrival in Kenya

We arrived in Ethiopia for a short layover Sunday morning.  This is the first time in Ethiopia since my trip with the Global Citizenship Project at Shenandoah University during my junior year of school.  The smells and culture came rushing back when we landed.  Did not get to order any food but I plan to get some during my stay in Kenya.

Luckily our flights were right on time and we arrived early in Kenya.  It was surprising cold as this is their winter time and it was about 64 degrees and no humidity. Driving from the airport to the city it was filled with a variety of business, buildings, and people.  The disparity in classes is seen clearly along the drive.  We arrived at Grace House where we will stay for the 2 weeks which is very close to KMTC (the university) and KNH (the hospital). Everyone was so nice and welcoming.
After taking a small nap and unpacking, Emily and I explored and went to a local market.  We follow d this up with a meeting with the mentor organizer for the resident students this week.

I am starting to get very excited for this opportunity but worried about how I will treat and move well in a suit. Kenya has British influence and the dress code is very formal. We will see how it goes tomorrow.

I was able to get a workout in before dinner and meeting up with the SU students who did some sightseeing today. We went to the local mall and had a meal with my first local beer. We are all very excited for our first day in clinic!

Kenya 2018 Clinic Mentoring: Travel Day

Excited for this next adventure!
I am headed to Nairobi, Kenya through The Jackson Clinics of Northern Virginia. I had the pleasure of learning from the owner, Richard Jackson, while in PT school and continued a relationship during residency and fellowship training. When he approached me with the opportunity to mentor Kenyan therapists in orthopedic manual therapy I could not contain my excitement.

After a year of planning and preparing the day is finally here to travel to Kenya. Another one of his employees, Emily, and myself will be mentoring 18-20 physiotherapy students for the next two weeks.

To make this experience even better, SUPT Thrive, the student lead medical mission trip group at Shenandoah University will be also on the trip. Four students from the program will be working alongside and mentored by Kenyan practicing physiotherapists. The model for this trip is amazing with Americans mentoring Kenyans and Kenyans mentoring Americans!

We will be traveling for 17 hours and arriving in Kenya on Sunday afternoon.

Looking forward to mentoring, making new friends, exploration, self reflection, and self growth.