Wednesday, March 21, 2018

Two are better than one...

"Two are better than one, because they have a good reward for their toil. For if they fall, one will lift up his fellow. But woe to him who is alone when he falls and has not another to lift him up!" 
Ecclesiastes 4:9-10 ESV

There are currently two women with foot drop in our ward. Foot drop occurs for these women when they're in prolonged childbirth; the baby's head pressed on the nerves that run from the spine, through the pelvis, and down to the muscles in the legs and feet. In mild cases, this will resolve on its own within a few months. But for others, they experience severe leg muscle weakness and the inability to lift their toes when the walk, so they limp and drag that leg. I don't have the ability to perform nerve tests for these women to see if they'll regain nerve function and therefore muscle strength, but I can at least work on correcting their walking so that they're safe and they can move around on their own in a more efficient manner.

When these women came for Tuesday clinic a few months ago, I recognized their foot drop. Along with a reminder card of their date for surgery, I gave them a card to come for physical therapy the next morning where I showed them a few exercises to do at home and another card to see me the day after surgery.

They came after their surgeries like they were supposed to, but due to a communication mix-up, one came as I was nearly about to leave for the day! After finishing treating all my patients, the woman translating for me asked the obvious question: "Since you're not seeing them for urine problems and we taught them basically the same exercises today, why can't they come together next time?" She was exactly right!

So today we did a brief session of exercises on the plynth before working on walking and balance exercises. Here they are working on an exercise to strengthen the muscles on the outside of their hips.

The plastic buckets by their feet are holding their catheter bags. It's a bit of a hassle making sure these don't get in the way or get accidentally tugged on during therapy, but we make it work!
Then we moved out to the "babban parlour" (big parlour/room) which we use as a waiting room during Tuesday clinic. I like to use that area for therapy because it's just outside my clinic and because it's a big open space that's quiet and free from distractions.

I knew at one of the ladies would really need help balancing during the sidestepping, heel-to-toe, and backwards walking, and the other lady would probably benefit too, so I just had them hold each other's hand while they walked. It was fun to see them laugh at their own mistakes and losses of balance, as well as to see the stronger lady slow down  to match the pace of the other. Here, they're doing backwards walking to get work on ankle mobility, balance, and body awareness/"listening" to their feet.

At the end, I asked them, "What that hard to do?" They both laughed and nodded. Then I asked, "Was it easier to do it together and help each other?" Again, they nodded. Both of these women identify as Christians, so I hope to come back to this topic in the future and talk about how God holds our hands when we are going through difficult things--He doesn't leave us to falter. But we have  to reach out  and take His hand and put our trust in Him.

It's not every day that I see Jesus show up in my clinic or that the Holy Spirit brings the Word alive right before my eyes. But today was one of those days.

Monday, March 19, 2018

Meet my friends: Lami

This is my friend Lami. She started working at my housing compound over 20 years ago and she’s seen dozens of short term missionaries come and go during that time. She’s an invaluable help as she cleans and cooks for us once a week.

Lami cooks for me on Mondays, and I can count on her knocking on my door and calling out, “Salamu alaikum” (peace be on you -- originally an Arabic blessing that has carried over into Hausa) about 8am. We greet each other, then ask how the other’s family is, how the weekend was, and how we slept the night before.

We finally get around to looking over the shopping list I’ve hurriedly put together just a few minutes before, making sure that she can read my writing and understands any specialty items I may have written on the list. We also chat through the dishes I’d like her to make for me. I’ve found that when I stick to her well-known repertoire of recipes, the results are almost-always guaranteed to be delicious!

My list today:
  • 6 pink apples
  • 1 bunch carrots
  • 1 bunch coriander leaf (cilantro)
  • 2 pears (avocados)
  • 2 mangos
  • bananas
  • 50N lettuce (you can get about 2 heads for 50N)
  • tomatoes
  • vinegar
  • 1 can of kidney beans
  • 2 cans of tomato paste
  • 1 mudu sugar (a mudu is about a quart by volume)
  • 2 mudus flour
  • 1 mudu rice
  • 2 packages simas (margarine used for baking)
  • 1 container of plain yogurt (which I will use as starter for my own yogurt. This is really the only source of fresh dairy available so when we have a "runny stomach," yogurt is a great follow-up to the strong antibiotics.

I bet that looks a little different than your grocery list! No meat, no packaged products, very little dairy. But that's a pretty normal shopping list for me!

So after giving Lami money to shop with, I headed out the door to work and she headed off to the main market for vegetables, the one store in town that sells fresh dairy items, the Western-style (ish) supermarket for the canned items, and the local provision shop for the rice/flour/sugar.

I walked back in from work about 1pm to the smell of  baking bread and frying onions and garlic. I think those are some of the most heavenly smells! She was making homemade English muffins and this fabulous carrot/cilantro/lentil soup that I absolutely love!

But we did have a bit of a discussion about which pan to cook the English muffins in. It went something like this:
"I didn't know which pan you wanted me to use. I think this one is OK." (My Calphalon non-stick skillet I brought over with me)
                           "That's fine. It doesn't really matter to me. I think there's a big pan in the cabinet if you want                                    the pan to be very hot."
"Oh, that one! It's eaten too much!"
"You know that big, big one that's too heavy. It's taken too much food. That's why it's so big!"
                           "Ah, I understand."
"So if you're missing any food, you check the cabinet. You'll find that pan has eaten it!"

I've never heard that a 16" Lodge brand cast-iron skillet got to be so heavy because it ate too much! I guess there's always a first time for everything! Turns out, that cast-iron skillet was brought over by a missionary many years ago and it's been passed down to various other missionary wives. The current owner had overhead me complaining about not being able to make good cornbread without a cast-iron skillet and she agreed to let me borrow it while I'm here.

Ah, never a dull moment when Lami is here! I've learned that it's just better to stay out of the kitchen while she works since she makes a bit of a mess. (But it's always cleaned up when she leaves!)

On another note: I'm amazed that this woman can turn out loaves of bread in 90 minutes flat--including mixing (forget measuring anything!), kneading, rising, and baking. I am super spoiled by her homemade bread.

And if I happen to be home while she's cooking, I ask questions about her life and family, or she tells me how it used to be in Nigeria or within the mission community.
I've learned a lot from her during the year she's worked for me and I am proud to call her my friend.

Sunday, March 11, 2018

2018 VVF Reunion

The main hospital gate (viewed from inside the compound looking out on the busy main road outside)
Reunion is undoubtedly the best part of our year! Last year, I'd just arrived in country a week before, I didn't understand any Hausa, and I didn't really know what was going on--this year, I could follow along with the program and I knew many of the patients that came to celebrate!

Reunion is three-day event, Thursday through Saturday, but women start coming a week or so in advance! That meant that our Tuesday clinic this past week was insanely busy with 68 women (usually, it's 20-30), so we had to split clinic into two 6-hour days!

It was fun to come through the main hospital gate each morning and greet the women sitting on the steps outside the VVF center. They spend most of their day chatting, re-doing each others' intricate hair braiding, and relaxing.

The program started on Thursday with food, crafts, and movies after sundown. Our kitchen team usually cooks for 20-30 women every day (all food for VVF patients on the ward and in the hostel is provided free of charge), but cooking for this many women involved getting a few more hands to help out!

When I asked what they were doing, I heard, "washing the meat." I didn't bother to ask any more! Then the meat was liberally seasoned with sliced onions, ground red pepper, and seasoning cubes (mostly salt and MSG)

These women spent several hours peeling the large yams with sharp knives, then slicing them into chunks for boiling. Later, the yam was pounded to make a starchy dish eaten with spicy red stew.

Here, the kitchen staff are cooking up huge pots of red stew to serve with the pounded yam. One missionary refers to these large cooking vessels as "cannibal pots"... they certainly are big enough for that!
Friday continued the celebration with some group cooking activities, one-on-one spiritual counseling provided by our chaplaincy team and pastoral students from the local seminary, meetings with former patients (especially those who've had radical surgeries as we're looking to get follow-up information that could be used in future research papers), and a musical group that came in to entertain the women with songs and group games.

These women found the shade of the huge mango trees to be a perfect place to set up their afternoon of cooking. They're making "puff puff," a yeasted sweet dough similar to cake donuts that's scooped with bare hands and dropped into hot oil. The puff puff would be served for breakfast the next morning.

The woman in the center is Esther, or as we call her, "Mama VVF." She keeps an eye on all the women staying in the hostel and helps run some of the skills-training programs.

But Saturday is really the big day!

The women cueing up for breakfast!
The reunion celebration is held out in the "VVF Village," a place near the back of the hospital compound where there's a 100+ bed hostel, a two-storey training building, and several homes for VVF staff members. There's also a large open area where we set up tents and hundreds of plastic chairs for everyone. But people don't stay seated for long... when the music gets going, everyone starts dancing!

Even the little-est ones can't help but dance!

Even my colleague Grace got up to dance!

Later on in the program, four women told their stories. They were all fairly similar--in childbirth for 3+ days, eventually taken to a local hospital where the baby was pronounced dead/had a cesarean to remove the dead baby, started leaking urine within a month or so, finally found their way here (2 months to 35 years later), and at least one surgery before they were finally dry.

Once again, one of our youngest attendees couldn't keep from dancing as music played between each woman's testimony.

Later, we had a Freedom Ceremony for fourteen of our recent patients who were dry. This is similar to the Freedom Ceremony we have every Tuesday morning before clinic; they danced, sang, and each received a new piece of fabric. The key phrase was "Mun gode Allah!" (We thank God!)

We had a special presentation of several manual sewing machines, sewing tables, and knitting machines donated by a group of students in the UK partnering with a Nigerian PhD student who is writing her dissertation on our VVF women. These women had gracefully shared their stories with this student and also been designated as women in need who could benefit from these machines.

After a few more speeches by hospital administration and donors, we ended the celebration with more dancing.

And then I was snagged into tons of photos with various women. Out came flip cell phones as each woman wanted to take photos with the baturia (white woman)!

Then we got this selfie of us three SIM missionaries who serve here at Evangel VVF Center. Those smiles were certainly not forced--we'd had a wonderful celebration!

Thursday, March 8, 2018

Life as a Missionary PT Part 7: Home Exercise Programs

This is part 7 of a series of posts about what my ministry is like.

Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.

Being able to design a good home exercise program is a necessary skill for any physical therapist. We can't undo in a few 30 min sessions per week what the patient is doing the rest of the time, and we can't do enough exercise in that session to really cause lasting improvement. PT sessions are more about the PT providing hands-on training and techniques, and then providing education about what the patient can do on their own. Sometimes, we really just teach the patients how to help themselves.

In order to make sure our patients can remember their exercises, we will write them down, give them handouts, or pull from the exercise banks in specialized computer programs to create individual HEPs (home exercise programs). Some clinics go so far as to email the HEPs to the patients or have them use specific apps where the app will send push notifications when the HEP has been updated.

That's all well and good, but no matter how simple I make the exercise instructions, how few exercises I prescribe, and how much I try to get the patient to buy into it, there are few patients that will actually follow their HEP. 

So at the next visit when I ask, "How did your HEP go?" I'm not usually surprised to hear some sort of excuse. Believe me, I've heard quite a few!

But what if I'm only going to see this patient once or twice? Then the HEP is super important, and I may even give them several phases of exercises with dates to start each new phase.

But what about when a patient doesn't speak English? Ah, not to worry! Most computer programs have multiple languages installed and you can switch between them with the click of a button.

But what if they're illiterate? Well, that's easily solved by giving them a picture of the exercise and talking them through it, using an online HEP generator that as short videos of each exercise, or even emailing them links to YouTube videos.

But what about if they're an oral learner? (Yeah... that's not the same thing as being illiterate. I didn't know that until I started working almost exclusively with women who not only don't speak English, but they don't read or write in their own language, nor do they see pictures as relaying information.) Working with oral learners is a whole different ball game.

If you saw this, what would you think the woman is doing?

image courtesy of Visual Health Information
If you said, "She's getting up," you'd be right. If you looked at it well and replied, "She's getting up from a stool without using her hands, and it looks like she's keeping her right foot tucked under the stool while she stands up," you'd get extra points.

What most of my patients see is a stool and three women: one is leaning forward, one is standing, and there's also a trunk and upper body of a third woman. That's it. They don't immediately see that action is taking place, nor is the picture telling them anything about how the woman is getting up.

What about this one?

image courtesy of Visual Health Information

You probably see a woman who is lying down and then lifting her hips up in the air. If I explained that the small arrow on the left and the solid line semi-circle/dotted line means she is to squeeze her pelvic floor muscles, you'd probably say, "Oh, I see that now." I bet that I could then ask you to lie down and demonstrate this exercise and you'd probably do all right.

My patients have a really hard time with this picture. Not only have they probably never seen a bridging exercise before, the concept of describing an internal muscle contraction by arrows and lines on a picture is foreign to them. 

So what I usually do is 1) teach them all the HEP exercises while they're in the clinic, 2) tell them their HEP, and 3) have them repeat it for me at least once.

That takes time, it takes patience, and it takes keeping things really simple. I can't give them five different exercises, even if two of them are the same exercise done in different positions, they will probably not remember it and then I've wasted both of our time. (Oh, and I also don't usually have them count any higher than 20, since some may not be able to do that.)

So I do things in 5s or 10s. Hold this position or exercise for five seconds, relax, do it five times, then do this five times per day. Or squeeze 10 times very quickly, relax, do it 10 times. Or I give them three exercises, each to be done three times, three times per day. 

(All my PT friends are gasping right about now! We were taught never to prescribe 3 sets of 10 for an exercise nor to just pick a number willy-nilly; every exercise, every duration, every frequency was to be carefully thought out and appropriately advanced for each patient. Yes, well, this is Africa!)

Once a patient is ready to go home--either she's achieved her goals, her progress has plateaued, she wants to go home/her spending money is finished, or for some other reason--I try to give them a pictorial handout with the three or four most important exercises for her to continue doing. I don't both with written exercise prescriptions, but I might write a large number beside each picture to remind them how many of each one to do (some of my patients can recognize numbers, even if they can't read). I spend time talking about each  exercise, reminding her that the woman in the picture is doing the exact same thing as she is supposed to do. I then ask her to tell me each exercise and what she is to do. If necessary, I correct her, then ask her to tell me again. If it sounds like it takes a while, you're right, it does!

The first few months I was here, I spent hours online trying to find pictures of various exercises, only to find that there were very few photos I could actually use. In the US, I can use photos of guys without shirts, women in shorts and sports bras, and people using various household items for exercises. Here, I want to be mindful to use illustrations instead of photos, use only women as models, and to have them appropriately clothed---oh, and if they're actually doing the right exercise, so much the better! Drawing the illustrations myself was out of the questions; I'm not an artist and my stick figures were more confusing than anything!

I remembered that when I was working in the US, I used a computer program with hundreds of illustrations that were highly customizable. If I wanted the same exercise lying down, sitting, and standing up? No problem. Want to make it a woman instead of a man? No problem. Want to change the wording and give more detailed instructions or change the sets/reps? No problem. Want to flip the image so it shows the person working the right side instead of the left side? No problem.

I looked into purchasing the program for myself, but the steep price tag is definitely geared more towards clinics that can purchase multiple licenses for all its workstations and clinicians. So I decided to go out on a limb and ask the company for a corporate donation of their basic software and several of the modules/exercise banks. To my surprise, they agreed! A week later, I had the download link and all the exercises I would need to treat my orthopedic and pelvic patients. With this program, I can easily create HEPs, save routines, modify existing exercises, and then print/save/email as PDF. While I use it several times a week in the clinics, it's also come in handy many times with missionaries and friends reaching out to me for PT help.

A huge shout out and a thank you to Visual Health Information!


And if I ever need to create an HEP for a feline friend, I'll know exactly where to start:

Sunday, February 25, 2018

Life as a Missionary PT Part 6: PT Examination

This is part 6 of a series of posts about what my ministry is like.

Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.

In physical therapy school, I was taught that the most important part of an initial PT session was the physical examination. Patients may tell run-on stories, may have poor memories, and I may not have time to ask a lot of questions in my subjective history-taking, so I need to rely on my examination skills to make sure I'm getting the real story. We spent semester after semester breaking down each body system and each joint/muscle group, learning groups of tests that would rule in or rule out conditions as well as specific tests that would indicate underlying levels of dysfunction. We also learned to perform several tests and how to ask questions in specific ways that would help us figure out if our patients were magnifying or faking an injury. Bottom line of therapy school: examination is key.

Anyone can be trained to follow a diagnostic flowchart and perform various special tests during an exam, and it's easy to train someone: "If you see ___ problem, prescribe ___ exercise." Where the PT's knowledge and advanced training comes into play is the assessment where we try to figure out why the patient is moving that certain way, what dysfunction led to the injury, and what seemingly unrelated issues are playing a role in the pain/injury the patient is seeing us for. This is the part that comes with practice, and this is the area where a PT can always improve in.

But for me and the patients I see here in Nigeria, examination isn't the most important part. 

What is important? Asking questions about her symptoms and explaining how I can help. 

First, my patient will guide me towards her diagnosis if I simply ask good questions. She don't really care about the examination tests I do (and with the language barrier and Hausa having a simple vocabulary, she often doesn't understand exactly what I'm asking her to do or can't describe what she's feeling), and there's really no "normal value" to compare her to. My patients don't fit the standard type of pelvic therapy patient, and many times, their internal anatomy has been damaged and reconstructed in an atypical manner. The tests that work in the US usually don't work here.

Second, It's important she understand that I know what her problem is and that I have a plan to help her. I always explain that medication is not a permanent fix (or may not help at all in her situation), and except for a few patients I'm purposely seeing pre-op, surgery is not the answer. In this society, there is a huge value placed on medication and surgery; if you go to the doctor, you leave with a prescription for something or a date for a surgery. That's normal here and that's expected. So when I explain that I am not offering either of those, I have about five seconds before she mentally "checks out" to explain that I'm not holding out on her--I have something different that is actually better for her particular issue. Sometimes that works, sometimes it doesn't. But I still spend several minutes during the initial visit explaining it to her, and I often circle back around to it in later PT sessions. She's got to buy into therapy because she is the one who decides if she'll keep coming back to see me, not some worker's compensation case manager, not a concerned parent, and not a doctor who refuses to do surgery until she's failed conservative therapy.

Another thing we were taught in PT school was to keep an eye out for the unusual. The saying, "When you hear hoof beats, think horses, not zebras," was pounded into us to remind us to look for obvious answers first and not immediately think of the weird or unusual diagnosis. (I mean, all you have to do is look up any symptom on WebMD and you'll discover that cancer is ALWAYS among the list of possible explanations!) But there are typical presentations and patterns that we commonly see among patients. So we were trained to start with the most obvious and simple explanation and keep our eyes, ears, and hand skills on the lookout for unusual things that might point towards a more uncommon diagnosis. 

It's different here. What if I find an unusual condition? What if I discover that what I thought was simple pelvic dysfunction is really something more complex or something more sinister? What if her problem will only get worse because she is HIV+? What if reserach has shown that therapy is not the most effective treatment, but the other treatments are not available here? 

Is it wise to treat her for the other conditions I find on examination (dysparunia, SI joint dysfunction, foot drop, pelvic floor trigger points), when her main complaint is stress incontinence? Any pelvic physical therapist reading that last sentence might say "Any/all of those 'unrelated' symptoms could actually be causing her stress incontinence. Go ahead and address those!" But can I explain that in a way to my patient that will help her understand why I'm not directly treating her main complaint? And if I don't teach her something to help with her stress incontinence on the first PT visit, will she come back for her follow-up visits? For me, the answer is usually "no" to both of those questions. 

Sometimes, I feel like I'm shooting in the dark because I don't have access to diagnostic testing, a detailed and comprehensive medical history, or a team of others to brainstorm with, so I want to ask every question I can think of and perform every test I can in order to figure out where to start with treatment--but more information doesn't always mean a more accurate diagnosis or better treatment. Is it right to perform these tests when I know my patient does not have access to the treatment for a diagnosis those tests might uncover? Oh medical ethics... how I use thee way more here than I did back in the US! These are hard questions that don't have clear answers.

So I do the best I can with what is available here. I do the most thorough exam that is practical and useful for this setting. I ask God to show me what the issue is when I really have no clue. And I'm careful to say, "I believe ____ treatment will work because you have ____ issue," without promising anything. Because the last thing some of these women need is another doctor promising they'll be cured, and waking up after yet another surgery or another day of therapy and finding they're still wet. There's so much more need here than I can address. There's only so much patient education and explanations I can give to a village woman with no education. 

But there are a few that "get it;" they understand the connection between pelvic muscle exercise and symptom reduction. These are the women that go from skeptics to believers. There are a few more that didn't exactly follow the treatment protocols or do the exercises I assigned, but still have improvement--they're happy, I'm happy, regardless of how it came about! And there are a few more that will see me once and instead of staying for follow-up, will go home... only to return a few months later with the same exact problem and receive the same referral to therapy where I tell them the same thing. Even in the US, it takes hearing it more than once to convince some women to try pelvic PT!

I'm slowly learning how to identify and address the one issue that will give my patients the fastest improvement. If she sees improvement, maybe she'll stick around and maybe I'll have the chance to perform a more complete examination and address the underlying issues. Sometimes I only get one shot with these women.

But you know what? Jesus usually just got one shot with those He healed. So maybe the best thing I can do is pray, invite Jesus' presence into the clinic, and allow Him to work through me to effect whatever healing He wants. And isn't that better than any physical therapy session I could design?