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.