Thursday, May 31, 2018

Newsletter Archive Now Live!

I've added a new section to this website so you can re-read my old monthly newsletters or get caught up if you're a new subscriber.

All PDF files are password protected for the safety of my fellow missionaries and the work in Nigeria. Please email me to request the password.

Wednesday, May 9, 2018

The right time...

The Nigerian concept of time is quite different than our own in the States. This picture, while originally meant for South Africa, is still true in Nigeria:

Anyway, God's timing is completely different than our timing. And I've never seen it more true than in something that happened last week.

Tabitha* (name changed) is from a village a few hours away, she has no formal schooling and speaks only her tribal language of Tarok. Tarok is only spoken in this state of Nigeria and as of 1998, fewer than 300,000 people speak it. According to some reports, it's a language that's on the edge of extinction. But for Tabitha, it's the only language she knows. She's the first woman I've met in the year I've been here for whom Tarok is her first language. Needless to say, we don't have a staff member who can translate for her.

She came about two months ago and although we found she didn't have a fistula requiring surgery, she did have significant passive leakage from the urethra and very poor pelvic muscle awareness/strength/endurance--she was a perfect candidate to see me in the pelvic physiotherapy clinic. The next day, she came to see me with her husband. We told the husband in Hausa what his wife should expect during the exam and what we'd ask her to do, then he translated for her and stepped out. My assistant and I stumbled through the exam, but I didn't really get good information because she wasn't able to understand our visual cues. Later, we called the husband back in and told him that I thought she could benefit from therapy and that we'd be happy to see Tabitha for about two weeks. They weren't expecting to stay that long and I could sense that they weren't happy about that. So I suggested they go home and come back when she was ready to stay for 2-3 weeks and to bring a woman who could speak Tarok/Hausa or Tarok/English who could translate for Tabitha. I tried to explain that Tabitha needed to understand her exercises in order to do them properly and that someone would need to be in the room with us during the PT sessions. Her husband, like most male relatives who accompany our patients, feel uncomfortable being present for any female medical exam/consultation.

So away she went. Then, two weeks ago, she comes back to see us for a Tuesday clinic. And there's no female relative with her, only her husband. We ask the husband if he is willing to stay for two weeks and if he can accompany her to each therapy session. He mumbled something and turned away, then Tabitha started to cry. We couldn't figure out what she was saying through her tears, and the husband didn't interpret for her. I was starting to get kind of frustrated because I wanted to help Tabitha and I really didn't want her to be discouraged and go to some traditional healer or try some expensive medication that I knew wouldn't work/might harm her. I wanted to help, but because of the language barrier, she was as trapped as I was.

About this time, a woman we'd seen a few patients earlier in the clinic poked her head in to confirm that the medications she'd picked up at the pharmacy were the right ones. Then she turned to Tabitha and said something that I couldn't understand. Tabitha lifted her face and stopped crying. Then the woman told us, "You know, I can speak for her. I understand Tarok."

Here's where the story gets really cool. Rose (her real name) has been a longstanding patient in the VVF ward. Her patient number has only three digits and right now we're up into the 3,700s! She's had several surgeries, but we've never been able to get her dry. She showed up in early April complaining of leaking stool and urine, and since she isn't a candidate for any future surgeries except for a radical diverting of her kidneys, she was sent to me to "see what I could do for her." (Oh I really love those kinds of referrals...)

Rose was very discouraged the first day she came to see me. She wouldn't look me in the eye, cried during most of the session, and I couldn't seem to get any straight answers out of her about her medical history. Finally, I gave up and because she speaks decent English, I just started asking about her life, her faith, and her community back home. We talked about God's promises that one day we will have new bodies and we will be with Jesus in a place where there is no more pain and suffering. We talked about how she can pray for good sleep every night and in Jesus' name rebuke the demonic influences she perceives in her dreams. We talked about how God has a purpose for her life and that she is not worthless, like some in her village have said. Ladi (the clerk who translates for me now) and I even shared how, although neither of us is married nor do we have children, we have purpose and we can do something productive with our time. And we just prayed for peace and comfort as she planned to stay at the hostel for a few weeks while attending physical therapy.

So fast forward about two weeks to the day that Rose came to see us in clinic to get a medication refill and bumps into Tabitha. Rose offered to stay as long as Tabitha needed, and that she would make sure that Tabitha came at the right time for therapy three mornings a week. I was a bit skeptical of using another patient to translate, especially when we're talking about abstract topics and working on muscle awareness and proprioception, but I didn't have any other option.

So I would tell Rose in English what I wanted Tabitha to do, she would translate, then Tabitha would do as I'd asked or ask a clarifying question back to Rose. When Rose didn't understand my English, Ladi would repeat my instructions in Hausa. It took a bit longer than a normal initial patient session, but by the end of it, Tabitha understood her home exercise program, I had good history and exam information, and I think even Rose understood her own problem and treatment plan better since her condition is somewhat similar to Tabitha's.

Both women have seen improvement in the last few weeks, and I've seen a huge change in both of their demeanors. Tabitha now smiles at me and tests out her Hausa greetings she's learned. Rose comes to greet me when I arrive in the keke each morning and we laugh as I ask the traditional greetings: "Yaya yau?" (how is today?), then "Yaya cikinki?" (how is your body?), and then our own special greeting, "Yaya zuciyarki?" (how is your heart?)

On Monday, Tabitha told me she is dry, and had been for three days. The things that used to elicit involuntary urine leakage no longer bother her, and she was doing all of her exercises as I'd told her. Her face was all smiles and we said together, "Sai godiya!" (praise God!) But when I told her that she could go home, her face fell. She told us, through Rose, that she wanted to stay until Rose was well so they could both go home together; she didn't want to leave her auntie. Rose encouraged her to go home and to reunite with her family, and to just trust God that He would bring her own healing in His timing. Then, just like I'd prayed for Rose that morning, I asked if Rose would pray for Tabitha in Tarok so that she would understand.

I wish you guys could have been flies on the wall in the clinic. What a sweet picture to see a patient praying for another, asking God for safe return journey, good reunion with family, continued health and provision for the future, and beseeching Him to bring her own body healing.

Today when I went to work, Tabitha was still around. Rose tells me that she's waiting for her family to send money for her return journey, and that she plans to go and greet Tabitha's family once she is healed herself. As Rose and I met for her therapy today and I thought quite hard to figure out why she's still leaking despite much improved pelvic musculature and a new medication regimen, we prayed again for God to heal her in His timing.

But regardless if God decides to heal Rose's body (whether through medical intervention or through divine healing) or not, He has already healed her heart and restored her joy. And He has brought her to us just in time so that she could play a role in the healing of a village girl who only speaks Tarok.

Me, Rose, Tabitha, and Auntie Ladi

Monday, April 16, 2018

Meet my friends: Mary

I met Mary through another missionary woman here. I think I'd arrived to Nigeria just a few weeks before and I'd asked this fellow missionary to take me fabric shopping. I'd just gone shopping with her to buy fun fabric at the local cloth market and was already googling "free online dress sewing patterns" (I mean, when you drag a 27-pound sewing machine halfway across the world, you gotta use it!) when she said, "Oh, let me just take you to my tailor."

I had to think for a minute. Usually when someone says they'll introduce you to their tailor, they're a celebrity, a news anchor, a politician, or a CEO of a Fortune 500 company--they're not usually a normal missionary mom with three kids who lives in Nigeria. But here, almost everyone has "their tailor," a woman who can look at a book of fashion designs or a blurry photo on a flip phone and re-create the design with whatever fabric you bring her. If your tailor is really good, she may even suggest altering the design a bit to suit the type of fabric you brought or to fit your body style.

So, after the fabric market, my friend and I went directly to Mary's shop which was tucked behind a church down this narrow dirt street with chickens and stray dogs roaming around. I told Mary I had really no idea what I wanted, as long as it was a dress with sleeves (to fit the required dress code) and was loose (for the heat) and non-restrictive (for the movement a PT needs). She grabbed a stub of a pencil, sharpened it with a straight edge razor, and grabbed her notebook that was nearly falling apart. A few minutes later she showed me a sketched design of a pretty wrap-around dress with puffed sleeves (Anne of Green Gables reference, anyone?). I was sold.

She grabbed a tape measure off the wall, measured me about 5 places (all the while remembering them in her head without writing them down until she was done measuring), and told me a price. I think it was something like $3.70. (Oh, and the fabric was only $9.80 for a 6-yard length). I paid her and she told me to come back in a week. I was a bit blown away by how easy--and how cheap--it was!

I went back a week later to "pick my dress" (we don't say "pick up" in Nigerian English), and brought her a load of other cute fabrics for her to sew up. Ever since then, I've brought new missionaries to her and have returned many times to have her make something or just to "greet."

This was my Christmas dress

This is one of my favorite dresses--it has pockets!

She even made my parents and me matching outfits when they were last here!
When I found out that my parents were coming to visit me a few weeks ago, I wanted to get Mary a small gift. My mom brought a pair of nice sewing scissors (can all the fellow sewers give me an "Amen!"), and one morning after I saw my PT patients at the hospital, Mom and I went to Mary's shop. She was absolutely ecstatic about the scissors and even showed me the huge pile of fabric she planned to cut that day for customers' orders.

This young girl in the front helps out at Mary's shop, running errand to the market to buy buttons, hemming the fabric headscarves, and learning the basics of tailoring. 

I praise God for friends like Mary who make me laugh, who keep me clothed, and who teach me about Nigerian fashion--even if she does remind me that I've changed sizes since she first measured me all those months ago!

Monday, March 26, 2018

Medical questions like you've never heard before!

I knew that when I came here to Nigeria, I'd have to learn a lot of things. I was expecting to learn Hausa, to learn how to ask simpler and more effective medical questions, and to learn how to explain things better to uneducated patients. What I wasn't expecting to learn is how to ask questions like this! Can you figure out what each of these medical questions is really asking?

"When you pee, do ants come to that place?"
                This is an easy test for severe diabetes where the patient's urine is full of glucose.

"When you feel pressed, can you make it to that place before the urine it does drop?"
                I ask this one a lot to determine if she has symptoms of urge incontinence. Since most of my patients' homes do not have toilets or indoor plumbing, and they use the bush or a communal pit latrine, I can't really ask about "making it to the bathroom in time."

"Do you feel like you have pepe in your front?"
                It's another way to ask about dysuria (burning with urination) that is common with urinary tract infections. Also, many women don't know the word "vagina" or "urethra," so we use "your front" or "the place of urine" commonly.

"Do you have a runny stomach?"
                Do you have diarrhea?

"When you get up from bed, your eyes they do turn you?"
                This is a straight up pidgin English way to ask about dizziness or orthostatic hypotension.

"Are you purging?"
                Are you vomiting?

"Do you have heat?"
                This could be asking about fever or pain, depending on their other complaints.

"Have you taken pounded yam today?"
                We always ask this question of our post-surgical patients. They will start by eating a porridge or hot cereal, but when they progress to pounded yam we know they're feeling better.

"Go and drink 2 sachets pure water and one Coke, then come back when you feel pressed."
                This is our way of kicking urine production into high gear when a patient is complaining of urinary leakage but we don't see a fistula. It could be something called a "ureteric fistula" where one of the kidney's ureters dumps directly into the vagina instead of into the bladder. This can be congenital (from birth), or as a result of a cut ureter during an abdominal surgery. If they come back and we see clear urine gathered in the vagina and not the purple dye we put in their bladder, we can confirm it's a ureteric fistula.

"Do you take lots of pepe on your food?"
                This is the first thing we ask when a patient complains of heartburn, yet we know that asking her to reduce the amount of the super hot chili pepper powder she sprinkles on just about any kind of food is like asking a fish to stop swimming!

I bet you've never been asked any of these questions before!

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. 

One of these women identifies herself as a Christian, the other as a follower of Islam. Despite the ongoing tribal and religious tension in this area of Nigeria and the recent attacks in the villages surrounding Jos, there was peace in this room today. They were simply two women facing the same challenge, and facing it together.

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?

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.