Clinic Life

I spend six days a week working at clinic and the evenings discussing and problem solving cases with fellow practitioners. So I must admit it’s not what I want to write about. It’s much more fun to describe 4 1/2 hours riding on top of a sketchy bus with 30-40 other people dodging ungrounded electrical wires, beautiful Himalayan treks and celebrating Nepali holidays with the locals.
But here’s the day in the life of a Physical Therapist in our Bhimphedi Clinic. I tend to wake with the daylight and go for a quiet walk in the hills from 6-7. Breakfast and then off to clinic with our amazing interpreters. We open at 8:30 and often have people lined up waiting for us. I have my own small room adjacent to the main clinic. It’s bit more rustic. There is a teeny padlock on the hobbit door and I open the two unscreened windows, one with a small gecko that never seems to move and there is a bared window in the back that opens to the mosquito breeding grounds to allow for some air flow. I check on my large spider friends, I have two, to make sure they have stayed put near the roof, hoping their nests won’t hatch until after I’m gone. I’ve come to ignore the rodent droppings so long as they are on the side of the room and occasionally sweep out the accumulating sawdust from ants in the ceiling. Today we had to chase a small goat out of my room and a few days ago a dog was quietly taking a nap in the corner unnoticed. Over the weeks my standards have adjusted, I insist on clean hands but a lot of other things have gone by the wayside. Most of my patients have never seen a health care practitioner, occasionally they have had an X-ray and been told they have ‘bone degeneration’ or ‘the nerve’. Some more complex patients have further workups done. Prior treatments might include oral pain meds, oral steroids or injections. Often arriving with a bag of bubble packs of pills, not knowing what most of them are for. People are mostly very kind and grateful for the medical attention. People arrive individually and sometimes by the bus load having traveled for hours. For the most part we treat first come first serve and people often wait for hours. If time allows they get acupuncture and physical therapy, but more recently just one or the other. The clinic is free and most people come 2-3 times per week. Today I got a large bag of dill and 4 limes from different patients as a thank you.

Some of the people listed below were first visits and others had been seen up to 6 visits.
1. 46 y.o. M – slowly resolving migrating muscular right knee pain of unknown origin and new onset low back pain (LBP) with spasms
2. 77 y.o. M – unchanging bilateral (B) knee and LBP with advanced osteoarthritis (OA) and complete ACL tear on the right and MCL tear on the left
3. 64 y.o. M – steadily improving idiopathic right hand paralysis for 35 years
4. 56 y.o. F – slight decrease in LBP and B knee pain from advanced and crippling OA
5. 56 y.o. F – significantly resolved radicular LBP, continued pain from knee OA
6. 46 y.o. F – right knee pain, ligaments intact, suspect early OA
7. 17 y.o. F – B knee pain of unknown origin, B hyperextension, complete ACL and MCL tears
8. 52 y.o. F – radicular neck pain x 15 years
9. 9 y.o. M – 7 years left sided weakness and decreased coordination of unknown origin, progressing well with therapy, after the 5th visit the pts mom tells me he fell off a high table when he was 2 months old and hit his head
10. 54 y.o. M – resolving acute knee pain, bone and soft tissue bruise from a fall
11. 61 y.o. M – leg weakness and decreased coordination after 2 neck surgeries with possible cognitive involvement vs alcohol abuse
12. 40 y.o. F – slowly improving central LBP, poor posture and carries heavy loads on her head daily
13. 55 y.o. F – significant scoliosis and postural deformity with chronic pain
14. 63 y.o. F – B knee pain, OA and multiple ligaments laxaties
15. 58 y.o. M – B knee pain, OA and B torn ACL’s
16. 31 y.o. F – central low back/sacral pain
17. 32 y.o. F – pain and edema from 1 year old leg fracture (suspect tibial plateau), pt removed the cast herself after only 35 days, complete ACL and PCL tears
18. 29 y.o. F – cervical pain with B UE radiculopathy almost fully resolved
19. 47 y.o. M – fully resolved scapular pain, new onset right buttock pain
20. 11 y.o. F – spastic cerebral palsy with quadriplegia, positive response and extensive family education and training

We’ve gotten very busy and all see about 20 people per day averaging 100 for the clinic. Kogate is more remote and much quieter when I’m there. There is less time to discuss and research but still equally important to correctly diagnose. And of course it seems I’ve suddenly evaluated some really complex or unclear cases which I’d like to spend more time with. I often send someone out for an X-ray and occasionally an MRI. Sometimes it’s done and often it’s too expensive. I have yet to have an X-ray actually returned with a report. Such high standards I’m used to. Typically we can figure it out, but yesterday I took photos of an X-ray and texted it to friends back home for further clarification. (Thank you!)

Six weeks into clinic and I’ve found a good flow. I’ve found a balance between my knowledge and what is realistic and applicable in this environment. My treatments and exercises have to be straight forward and fairly simple… And mostly it works. I do so much education on basic anatomy and how to keep your knees and back healthy, or as healthy as possible when you carry 30 kg’s on your head everyday and squat the other half the day. I really love the challenge of patients with neurological issues, but until recently I’ve had far more orthopedic patients. Most people get introduced to Mr. Skeleton, which is not a typical sight. And I explain that the bone in your thigh joins the bone in your lower leg to make your knee which is held together with four bands (front, back, and each side) and then there is a pillow in the center to cushion it. For the most part that’s my explanation of ligaments and the meniscus. Occasionally I pull out the anatomy book but often that’s too much detail for most people. I’ll be honest and it’s the children that really tug at your heart. The teenagers that come in with knee pain, having never seen a doctor in their lives, and complete ruptures of one if not more ligaments in their knee and you know they are in for a lifetime of knee pain because it’s reinforced by all the 40 year olds who already have OA and significant knee pain that started 25 years ago. I’m impressed with how compliant people are with their home exercise programs. Sometimes it amazes me what can be accomplished in 15-20 minutes and that’s with everything being said at least twice for interpretation. I have a week and a half left in clinic and I’m starting to think about what I’ll leave with my patients. The other 5 practitioners are acupuncturists and there are 7 acupuncturist coming in the next camp (nov-jan) and then 4 in the last camp (jan-March) so there will be follow through of care for them. It’s been amazing working so closely with other practitioners. We all have our strengths and it’s been amazing to be the rouge PT. My skills are definitely appreciated. I’m starting to realize how hard it will be to leave my patients, I feel like I’m just getting started.

Young girl with suspected cerebral palsy.

Meeting a skeleton for the first time. The girls were agreeable to hold hands only after many trials of running into the room, touching him and running back out screaming only to encourage the next girl to do the same.

Ankylosing Spondylosis

Because gait training is so much more interesting when you get to start on rough rocky pathways up and down hills. Parallel bars anyone?