Friday, February 16, 2018

Life as a Missionary PT Part 5: PT Introduction and Subjective History

This is part 5 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.

Most of my patients have never heard of physiotherapy, and even fewer have any idea what a physio does or the types of conditions they treat. So it's not surprising when the fistula surgeon tells them that instead of having surgery they're going to work with physio.

In the US, when I meet a patient for the first time I say something like, "Hi, I'm Kate (or Dr. Kate) and I'll be your physical therapist. You'll also get to work with ___, my PT Assistant. I see that Dr. ___ sent you to us to work on ___." Then I'll usually ask them what their main issue is and what finally brought them into PT. Sometimes I get the run-on story that seems to have no point and no connection whatsoever to their physical impairment, but I've learned to listen well and try to guide their storytelling so that it answers my questions.

Here, it's very different. First off, names and titles don't play as much of a role in this clinic; she just wants to know I can help her. Also, I have another woman with me to translate. That means that when a patient enters the PT room, there are two sets of greetings and answers back! Sometimes a woman will come with her small child (those are the fortunate ones to have had a live child, despite sustaining a fistula), so I'll ask after the baby. Just this morning when I went to call my patients who were sitting on the front steps of the fistula center, I interrupted a mama giving a bucket bath to her toddler girl. Instead of finishing the girl's bath, she just handed the water dipper off to another woman and followed me to the clinic!

So, we get settled in the clinic. Me sitting on a step stool, the translator in my desk chair, and the patient on a plastic chair that we can wipe down if she has an accident. 

I take a quick look at her brown patient card, taking note of the number of surgeries she's had, the types of repairs we've done, when the last surgery was, if we've prescribed specific medications for overactive bladder before, and the number of children she's had.

Then I tell her something like, "The doctors didn't find any hole that is making the urine to come out. But we think that the muscles in your vagina are weak or aren't working correctly. There's no surgery for this, and you don't need any medicine. I will teach you exercises to help your vagina." That always elicits a strange look from them!

I don't usually ask much about her history other than what is on the card. Here, people either don't have a health history, or don't know how to describe it. And I don't do a medication review except occasionally asking "That medicine we gave you before--the one you take at night--does that one help you?" Sometimes I really don't want to know what traditional healing concoctions she's tried!

So I ask about their symptoms right now. Again, these questions are worded differently than if I was asking someone in the States. And I find myself talking in broken English to my translator because it aids in literal translation to Hausa and occasionally the patient will understand my English question. 

"When you cough, the urine it do come?"
"When you feel pressed, can you go to that place (toilet) before the urine drops?"
"Does the urine drop small small or much?"
"When you wake up in the morning, is your bed wet?"
"If the urine starts to pour, can you stop it?"
"Do you have to put rag?" (incontinence products are not available here, aside from a few places that carry adult diapers, so most women place rags inside their underwear to absorb leakage)

I find that sometime she'll have a hard time answering these questions. Maybe it's a difference in the Hausa that we speak, maybe it's the fact that she don't know when she's wet, they just know that she's wet, maybe it's the fact that she's embarrassed. I also find that a woman's age, her religion, and education status play a role in how well she understands my questions and accurate her answers are. 

That all takes about five minutes. A far cry from the 15-20 I might spend in the US. But I get the information I need, or all the information I'm likely to get from her anyhow.

In the States, after I get the history, I always ask my patients what their goals are. Sometimes the goals are pretty obvious (reduce pain, walk without an assistive device, get back to sports), but sometimes they're more unusual (be able to hold urine for 2 hours so she can go on a retirees-only bus tour, be able to pick up a bag of deer feed without pain). I don't really have to ask about goals here--they all want to be dry. If they can tolerate sex again, or be dry at night, that's a bonus!

I'm learning how to do PT treatments with little information; just enough so I'm not shooting in the dark, but not near what I'm used to getting in the US. But that's OK. I can always ask more questions later, and I'm learning to be better in my examination skills so I can find the answers out myself. And that is what the next post will be about...

Thursday, February 1, 2018

Life as a Missionary PT Part 4: Prescriptions and Referrals

This is part 4 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.

So what happens next after we do the clinic exam and we don't find a fistula and therefore don't schedule her for surgery?

If the woman needs further gynecologic care, or is pregnant and needs referral for free prenatal care, we'll send her with her brown card and tell her what days those particular departments run clinics. Or if we suspect the woman is HIV+, we refer her to the on-site AIDS center where they will do testing, counseling, and provide medications.

We have limited access to imaging--really only x-rays and ultrasound--at the main hospital of which the fistula center is a part, and our lab does the more common tests (like HIV, malaria, hematocrit, blood glucose), so we can write out the order slips for those tests. If the test is related to VVF, especially the blood tests we do pre-operatively, the tests will be free of charge to the patient.

In the case of a patient who is leaking urine or stool, in the absence of an identifiable fistula, we have a couple of options. If the leakage is only every once in a while, occurs with specific activities, or she complains of difficulties urinating/leaking after urinating she'll be referred to pelvic PT for pelvic muscle retraining. Other women only leak at night (often because they can control their leakage by urinating fairly often during the day), so we'll prescribe her a medication to reduce bladder spasms and help with incontinence caused by an overactive bladder muscle. She'll pick this medication up from our nurses' station and they'll tell her how to take it properly. Others will complain of a recent onset of urinary leakage, usually combined with other symptoms that make us think she has a urinary tract infection, so we'll treat her for that.

Referrals to pelvic PT are pretty easy because I'm usually sitting in on the Tuesday clinics, I read her intake form and main complaint, and all of us in the exam room work together to decide the best course of treatment. I have the opportunity to say, "I'd like to work with her," or "I think she could benefit from pelvic PT for ____," or if it's a easy re-education thing, I can teach her right then and there. I've gotten very good at demonstrating the technique of double voiding to ensure complete urination and reduce urinary retention... "When you feel like you want to piss, you go to that place, and squat down. When the urine is finished, stand up, shake your waist like this, then squat down again. More urine will come. Then you can stand up and fix your skirt." It's funny to see the nurses mimic my own motions as they translate it for the patient!

Since clinic can run into the afternoons on Tuesdays, I will usually see any new patients on Wednesday mornings when a nurse or Ladi are free to translate for me. This is something that's new for me; in the US, I'd want the doctor to see me that day if possible. Especially if I'd traveled many hours to come to the hospital and waiting til the next day means that I'd have to stay overnight in the hostel. But here, the women don't mind at all! Many would have to stay another day anyway, since the buses and vans leaving from the motor parks leave by noon. As long as I can see my patients by about 10am, they can travel that same day. Or, if they're going to remain with us for a week or two for PT, staying overnight that first night helps them get started settling in and meeting Mama Esther that runs our hostel. Also, the free meals we provide to our patients in the ward and in the hostel is another incentive to stay.

The referral system is pretty different than what we have in the US. There, the doctor will usually fax over a drug prescription, submit orders for imaging or bloodwork directly into the patient's medical record which is then forwarded to the correct departments, or the patient may walk out with a paper referral form for physical therapy. Very little is trusted to the patient to keep track of and there's little opportunity for the referral to get lost or illegally changed. Here, everything is written and handed to the patient who is then responsible for going to the the pharmacy to "collect the drugs" or for going to the right place on the right day to be seen in that clinic.

Tuesday, January 30, 2018

Life as a Missionary PT Part 3: Clinic Visit and Diagnostic Testing

This is part 3 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.

When I get to the center on Tuesday mornings, I change into scrubs (us women can only wear scrubs during Tuesday clinic and while in the operating theater. The rest of the time we wear long-ish skirts as is culturally appropriate) and make sure there are enough copies of all the forms we'll need in clinic.

I love sitting in on clinic because 1) I can dialog with the physicians about which patients might need therapy, and 2) by filling out forms and scheduling patients in the surgical schedule, I can keep clinic moving faster.

As we're getting set up, one of the aides will bring in water to fill our instrument sterilization containers. While there is an autoclave and sterile instrument packing protocol for instruments used in the operating theater, we use a system of bleach water and soapy water with timed immersions to sterilize our instruments used in clinic.

This is what our clinic room looks like. It's not big at all, but it works for us. I love the fact that the VVF center is built up about 8 feet above ground so that we can keep the windows open for natural light (and to help us get a better view of the fistula), but no one can see in. We do have one tiny ceiling bulb and a ceiling fan we can use when the electricity or the hospital generator are on, but it doesn't do much good.

I sit in the corner (back left in this photo) so I'm out of the way and can fill paperwork.

Later, one, two, or all three of our fistula surgeons will trickle in, as well as one of our nurses who serves as an assistant during examinations. Ladi will poke her head in the room and hand me the patient's brown card as well as the intake questionnaire form she's filled out. I get started filling out their examination finding form, we'll call in the first patient who's sitting out in the hall and clinic begins.

Fistula is an abnormal opening between the bladder and the vagina through which the woman leaks urine uncontrollably (because there's no sphincter to stop the urine as there is in the urethra), but that fistula can occur in many different locations. The most common cause of fistula is prolonged, obstructed childbirth where the baby's head presses on the mother's internal tissues for a long period of time, cutting off blood supply, and resulting in that tissue dying off--causing the hole.

In order to get a good idea what the surgeon will encounter during the operation, and to decide whether the surgery can be done through the vagina or must be done via a more complex abdominal surgery, we have to actually see where the fistula is. To do that, we insert a catheter into the bladder and then fill the bladder with purple dye. Usually, it's pretty easy to see where the dye is leaking out. 

Then we drain the rest of the dye out and the exam is done. As she's getting re-dressed, we'll discuss when to book her surgery, I'll fill out the scheduling book and her reminder slip, and one of the physicians will fill out the exam findings form. We hand the reminder slip to the nurse who either explains to the patient in Hausa or if she speaks a tribal language, we call in the family member to translate for her. Often, the exam is done in less than five minutes and the whole visit is less than ten minutes. 

If the fistula isn't immediately visible with the dye test, we may ask her drink water and come back in an hour. If she's recently delivered her baby and the fistula is fresh, we might just leave the catheter for two weeks and hope the bladder can heal on its own. Or if her case has failed all surgical attempts, we may send her the head nurse and to the chaplains to discuss a radical and permanent solution that diverts the urine from the kidneys elsewhere. Thankfully, this center has surgeons who are trained in performing the more complex cases and our team works together both in clinic and while the patient is in surgery to come up with the best solution for our patients.

Sometimes, a woman will come back and say that she's still leaking. We may find another fistula that we missed or, as is often the case with the larger fistulas, has converted to a pinhole fistula. We schedule these women again for repeat repair surgeries.

We also have patients that come for their 3-month or 6-month followup visit that say they're dry! We're always happy to do a quick exam and make sure the surgical site looks good, answer any other health questions they have, and clear them to "meet with their husbands again."

If, during Ladi's interview, the patient is complaining of urine or stool leakage but we can't find a fistula with the dye test, then we start thinking about using medication or sending her to me for pelvic physio. Often those patients leave the clinic room a bit discouraged because they thought they'd get another surgery, but yet we're saying there's no structural reason for the leakage. 

And then there's usually one or two each week who come into the clinic room with a smile on their face and a bulging belly! They've come, just like we told them, to get a referral card to the antenatal (prenatal) clinic and schedule their cesarean delivery--all of which is free of charge to them because of our gracious donors. Often what caused the VVF in the first place was the fact that she had a small pelvis, so we don't want her to try to deliver naturally again. Or if she's had a VVF repair, we want to protect that repair site and not risk it breaking down again during delivery. 

We have all sorts of women come each Tuesday, each with her own history of fistula onset and her own course of treatment. We are also blessed to have a medical team that's highly skilled, collaborative, and that trains the more inexperienced members so we can correctly diagnose and treat these women.

Sunday, January 28, 2018

Meet my friends: Grace

This is Grace, or "Sister Grace" as I call her. She used to work at the Christian publishing house next door, but when there were huge lay offs a while back, she started up this little food stall outside the gate. She's a mother and grandmother herself, and was one of the first people to be patient with my poor Hausa when I was first taking Hausa lessons!

She arrives about 8:30am and gets set up. I'm leaving about that same time for work and so I call out the morning greetings as I go around the corner to catch a keke. She brings out the large umbrella, her small plastic table and a few chairs, the propane stove, and the plastic buckets that hold her dishes and water for cleaning vegetables and washing dishes. Then she'll walk to the back of hte compound and fill a few buckets from the huge water tank, go around the corner to buy vegetables from the shops there, and go the local provision shop to buy a carton of Indomie (ramen) noodles and a crate of minerals (sodas).

By about 10:30 she's ready for business and starts serving up meals to anyone who passes by. Her usual customers are the staff from the publishing house and the bookstore as well as office workers in the church denomination headquarters and the Christian guesthouse nearby. There are often many visiting pastors and Christian workers who've traveled to the city for a conference or some other meeting at the headquarters, and since they often go to the bookshop to buy Sunday School material or commentaries for their sermons, they'll find their way to Grace's shop.

Some days, I'll be home from the hospital in time for lunch. In the keke on the way home I'm thinking through what's in my fridge that I can easily reheat on the stove (I don't have a microwave, and even then, our electricity is inconsistent). If I don't like my meal options, I'll eat at Grace's shop.

As I come over, I call out the mid-day greetings and ask how the shop is going. I'll look through the plastic bucket on the table filled with cool water and bottles of minerals, choose one, and pop the top off with the opener hanging off the center pole of the big umbrella. Then I'll find an empty plastic chair, sit down, and ask her to make me "Indomie and egg."

She also serves a local salad made with cut up romaine lettuce, shredded carrots, sliced tomatoes, thin rings of purple onion, and heavily seasoned with a mix of Maggi (similar to chicken bouillon, but loaded with MSG!), crushed peanuts, and salt. I haven't tried it because I'm wary of any vegetables that haven't been bleached, but I hear it's good!

When I ask for Indomie and egg, She knows not to add extra peppe (finely ground red pepper that's in little tubs in the first picture), and will often add cut up carrots and onions to both my noodles and to the egg. Here, Indomie noodles are often served as noodles, not soup, so after the water's boiled and she's added the noodle packet, she will remove it from the stove and let it sit until the water has been absorbed.

Then she'll start making my fried egg, using two to three eggs, a healthy amount of Maggi, and a handful of chopped veggies. Once the egg is done, she dishes the noodles out into a shallow bowl, slides the egg on top, and hands it to me.

I'm halfway done with lunch--the bowl is usually overflowing with noodles and the egg is twice that big!
Sometimes, there will be a pastor or two sitting and eating lunch there too. We'll usually get to talking (always him asking me a question first, as is culturally appropriate), and invariably the conversation will turn to President Trump. I will give my customary answer of "You know, I don't follow the news so well now that I live in Nigeria. So I'm not sure exactly what is going on right now. But I do know the Bible tells us to pray for those in authority whether we agree with them or not. I pray regularly for both President Trump and President Buhari." That answer usually satisfies them and means we can move on to another topic--often the weather and how baturi (white) people like the cold, the current fuel scarcity and it's resultant high prices and 2-day-long lines, or asking about how each other's Christmas and New Year celebrations were.

The conversation wanes by the time I'm finished with my lunch, and then I'll ask Sister Grace how much I owe her (the price can change week to week as the price of eggs and minerals fluctuates), but it's around 380N ($0.79 USD). If I don't have small change (bills less than 100N), I'll sometimes pay for the pastor's lunch as well. That often sparks a small dispute with the pastor, but I will just say "We're all God's workers and it's all God's money anyway."

I hand her back the empty mineral bottle, drop by bowl and fork in the soapy water bucket, thank her for cooking for me, say my mid-day goodbyes, and walk through the gate to my compound.

Grace will stay until about 4:30 (most of the offices close between 4 and 4:30), then from my apartment I'll hear her bringing all of her stuff back into the compound and telling the guard at the front gate "Sai gobe" (see you tomorrow).

I'm learning to love the rhythm of life here and all the people that make up that rhythm.

Friday, January 26, 2018

Life as a Missionary PT Part 2: Intake and Subjective History

This is part 2 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.

So what happens on Tuesdays when we run clinic? Well, we have to back up to the evening of the previous Tuesday all the way until early this Tuesday morning. When women come, they are sent to the main hospital's medical records area to "buy a card." This costs 650N ($1.82 USD) and looks like this:

This history is pretty common "A woman of 41 yrs old ____ by tribe from _____. Christian P1+0 none alive no education. Leaking for 240 months in a delivery at home no footdrop no previous repairs."

A medical resident/house officer will get a brief history, take vital signs, record her main complaint, then write something like "refer to VVF for proper management" At that point, she will keep her card and will wait around for the next Tuesday morning.

When she comes into the VVF Center, one of our aides will take her card, write on it her VVF patient number (we're in the 3,600s now!) and issue her a small green patient ID card which she will show on subsequent visits so we can find and retrieve her patient card. Everything is done her by patient numbers since we have so many women named Hadiza, Ladi, Mercy, Sarah, Talatu, and Kadija!

Then she'll be shown to the waiting area. All the brown patient cards are given to Ladi, our clerk, who will call them one at a time.

While waiting here, Ladi will tell them a bit more about what fistula is and isn't (some of our women have been told it's because they were cursed!) as well as what to expect during their visit. Then one of the female chaplains will come share the gospel or read a small passage of Scripture. After that, the women who are being discharged after surgery will come in and we'll have a "Freedom Ceremony" where they dance and sing!

One of the songs that they often chant while dancing in a circle (there's not much room when all the women are there!) is loosely translated as "Now that the urine has stopped, no problems, no problems!" Another favorite is "Ni Zan Je" which goes like this in English "I will go with Jesus anywhere, no matter the roughness of the road. I will go, I will go!" Read more about that song here.

Historically, another song actually written by a patient treated here was used more often. This article gives a bit more history about it: Fitsari 'Dan Duniya: An African (Hausa) Praise Song About Vesicovaginal Fistulas

After the dancing and signing, the women who are being discharged home (or to the hostel to await another surgery) will receive a "wrapper" or a 6-yard piece of brightly colored fabric they'll use as a wrap skirt.

But for the women who are coming to see us in clinic, they'll wait until Ladi calls their name and then they'll come into this room:

Ladi will go through a series of about 30 questions to ask about their medical history, family background, marital status, history of pregnancy/sex/menses, and find out what their main complaint is. Everything used to be entered on the computer, but now it's done by hand with Ladi asking the questions (remember that most of our patients are illiterate) and recording their answers on the form. Then one of us will go and type all that into the master Excel spreadsheet/database to be analyzed later.

In recent months, we've been especially interested in demographic information on our follow-up patients, especially their rate of divorce compared to time since onset of urinary leakage (and if there's any different between if they're in a monogomous or polygamous setting), and if their risk of divorce is inversely correlated to whether they've given birth a live child before or not. It's actually rather interesting to see what's going on in these women's lives outside of the actual fistula they're coming to see us for. Expect to see some published literature on this in the next year or so!

Then the women will sit in the hall just outside the exam room and wait until we're ready to see them.