A few shots from clinic

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?

When do you stop CPR?

Long after I realized the mans injuries were too extensive to survive but not until his wife said arret and gently reached out with her bloodied hands to stop my chest compressions. Coming to Nepal I knew clinic would challenge me in ways I couldn’t even comprehend, yet I looked forward to those challenges and the personal and professional growth that would hopefully follow. I knew I would help many people, and anticipated it would be the ones I couldn’t help that would stay more present in my mind. And it’s true, they do, but not in a way I ever expected.

There appeared to be confusion ahead, someone mentioned rockfall and an injury. I asked if there was a doctor present, said we were a medical team and offered to help. People cleared the trail and we were ushered ahead. My heart raced, do we have the skills needed to help? A man was unconscious in the middle of the trail with an obvious head injury and a woman kneeling at his head. No one seemed to be taking charge, I was so grateful to have Jacq and Susana with me. We later realized our porter, Peking, had been there for quite some time before us. The woman started speaking rapidly in French, I said I spoke a little French and asked her to slow down. It appeared the man had been hit in the head by rockfall 15 minutes prior. He was just below the rockfall and looked to be in pretty bad shape. We quickly moved him slightly down trail to a safer area. I felt little to no pulse and Jacq started started chest compressions as we tried to gather more information. We checked his pupils with my headlamp and they were fixed, we were told he had been unconscious the entire time. I took over chest compressions and quickly realized how extensive his injuries were. The woman at his head was covered in blood and his wife, she told me they live in the mountains near Toulouse. She asked if I thought he would be ok. I expressed my concern with his injuries and difficulty for rescue. We then realized the man had been hit by a rock and fallen off the trail and it had taken an hour and half to get him back up to the trail, where he had been for 15 minutes. It quickly became clear he not only had a significant head injury, but likely a spinal injury from the fall and it had been too long, he would not survive. There was nothing more I could do for him. At this point all my attention shifted to his wife. The rest of their party and the other guides and porters stood back, they had also been there much longer than us and I can only imagine what this first hour was like. We were told a helicopter had been called, a teahouse was ten minutes down the trail and a landing site further below. I said we need a stretcher, trekking poles or branches I suggested. I continued chest compressions as his wife was asking me what I thought. I gently said it was a bad injury to his head, I was worried about what further damage had been caused by his fall and pulling him back up to the trail and feared it had been too long. She nodded. I said I couldn’t feel a pulse and he wasn’t breathing on his own, but I would continue chest compression as long as she wanted me to. It would be a long trip down the trail, waiting for a helicopter and then a half hour flight to Kathmandu as well. She had amazing composure and seemed to be slowly putting everything together. I continued compressions and allowed her time. “We live in the mountains, the Pyrennes, I can’t believe he will die in these mountains.” She started to cry. It was truly heartbreaking. Here is a woman whose name I do not know yet and we are in the most intimate moment. She reached out and gently pressed my hands to his chest “arret” and she looked up at me “Merci, thank you for trying.” People arrived with two big pipes, ropes and big plastic rice bags to form a stretcher. Bistare (slowly, which is my most used word in clinic) I said and then asked for 5 minutes and waved people away to clear the trail as I had no idea how long it would take to get this man down and what shape he would be in. Jacq and Susana cleared the trail and we stood back and gave her time. My thoughts raced to my family, his family and my years of guiding. She knelt there for a few minutes and then stood up. We rolled him onto the stretcher and I kept saying gentle and bistare. I picked up his bloodied backpack in one hand and his wife tightly grasped my other as we slowly followed them down the steep and winding mountain trail past the tea house to the a wide spot on the river. Just days before we stood happily gazing up the valley and to the adventure that was waiting for us. I lead her to the river and helped her wash the blood off her arms and face. The three of us sat with her next to the stretcher waiting for the helicopter, watching monkeys cross the river and swing in the trees as other groups looked on. I gently rubbed her back, uncertain what else to do. Susana brought out her space blanket to more fully cover him and we held it down with river rocks. There were three others in their party but they had mostly stood back, I expect in shock. One came down to sit with her and I started to gathered blue yellow and white flowers into a bouquet for her to place on his chest. I expressed how sorry I was for her loss and hugged her, she was grateful for our efforts. I think it was over when the rock hit him she said, he never put his arms out as he fell down the cliff. Loading the helicopter was less than graceful and a very difficult sight, but as it took off she waved and blew kisses. We stood in quiet shock and it started to sink in more fully. I no longer could keep my composure and felt a heaviness settle over me with tears in my eyes.

We still had three long hours hiking uphill, I was lost in my thoughts. Personally, the mountains are my playground and it shook me to the core to see such a tragedy in a place that gives me so much happiness. We are in such a rough country, yet I do not think the outcome would have been any different on any trail anywhere else. My heart goes out to the guides and porters, obviously shaken and overhelmed. I spent ten years guiding and gratefully never had to deal with more than minor injuries. And to the couple, they remind me of my parents who traveled extensively and loved to walk and hike all over the world. It could easily have been my family. Someone lost a husband, perhaps a brother and a likely a dad. Shortly oceans away they would be getting a terrible phone call.

That evening from our little hilltop village we could look way down the valley to the river. They has been out of electricity for 9 days which seemed appropriate. Our group, the four of us, two guides and two porters ate Dahl baht together by candle light. Later we climbed up to the roof and sat under the nearly full moon to talk. Shaken and sad with graphic images flashing through our mind we talked about what happened, could we have done more and what our roles had been. We will never know what occurred before we arrived, but I truly believe we were meant to be there. Medically there was nothing that could be done and I came to that conclusion quite quickly and clearly, allowing me to focus my attention to his wife. I spent two hours in one of the most intimate moments in ones life with a woman whose name I would only later learn. It was my hope that I could offer some calmness, comfort and compassion. Allow her some time and space to process before being whisked from deep in the mountains to the chaos of Kathmandu and the reality that awaited her.

I sat under the moon for hours before finally going to bed, and was then bolted awake with an image at 3am. I returned to the roof flooded with moonlight and prayer flags gently blowing in the wind. What was it going to take for me to process? I bought prayer flags the next morning and the following two days my heart and body felt heavy. I wasn’t sure if the flags were more for myself or for the couple. We got up at 4:30am to hike high up to Gosandkunda Lake, a sacred Hindu lake. At first glance I saw the place across the lake where the flags were meant to go. Everyone in our group had a moment with the flags and then Peking, our porter, and I hiked up. We tied the flags togther, one for each if them. Peking tied one end to the trident at the base and I climbed up to secure the top. It felt peaceful and calm, and as if a large weight was lifted off my shoulders. I was suppose to be there for some reason. Her friend had asked for my email and I looked forward to one day hearing from her. In time, I hope she finds comfort in the care I we tried to provide and I will share photos from our sacred lake.

At the end of our trek I returned to Kathmandu to a short but wonderful email from her friend. They were back in France, grateful for the help and compassion and sent details on the funeral in hopes we might light a candle or hang flags. We are back in Bhimphedi and clinic has reopened after the holiday. Tomorrow morning we will be up early to walk out to my peaceful morning viewpoint for a quiet moment and to hang flags at the same time as they will be remembering in France. Exactly one week after his passing. Those flags will be hung with a much lighter heart.

Before I left for Nepal I was told, “You do the best you can and it’s usually enough.” And it’s true.

Some photos along the way.

The road between Bhimphedi and Kathmandu.. The good sections at least. Others require four points of contact and no photo taking. It’s a four hour ride that puts Six Flags to shame.

Kathmandu to Langtang National Park. Seven hours in a Land-cruiser with a great driver. One section of the road had a massive washout and it’s always comforting to know they are in the process of building a new road and this will be closed soon.

Heading out the first few days through lush forests, teeny little teahouse and a roaring river.

Morning stop for tea to give the backpacks a rest.

Kyanjin Gompa our highest town the night before climbing Kyangin Ri.

A week in the life of clinic.

I just completed 7 days in clinic and it feels like I’ve been here a month. We were open for 7 days straight and I saw 61 patients. Off to a slow start for clinic standards, it should pick up after the holidays. Still sorting out exactly how I fit in with the team. We are all meant to be primary care and refer out as appropriate to the health post or the hospital in a larger city. Since it’s been slow everyone has had acupuncture first and then those with musculoskeletal pain are sent next door to me. So many people have musculoskeletal pain so I’m not lacking referrals. I would say one third of my patients this far have cervical or low back pain and most with radiculpathy, another third have knee pain and then a mix of carpal tunnel, plantar fasciitis, shoulder injuries, SI, old fractures, and pain of unclear origin. Everyone seems to have numbness and tingling as well. Posture is generally terrible and much of the pain is expected from heavy labor in the fields and the methods of carrying crazy heavy loads (mostly on their heads). Patients come in with labs, X-rays, MRI’s and CT scans and little information on the possible diagnosis. Many people have been told they have ‘bone degeneration’ and there is nothing that can be done. I feel very lucky to have our diverse team three TCM acupuncturists one who was an ICU RN for 10 years and one was a chiropractor plus myself. So between us we have been able to work through most patients concerns. Blood pressures and blood sugars are so much higher here, 160/100 isn’t that unusual. We have to strongly advocate for people to go to the health post or hospital, and at some point decide to deny treatment until it is addressed.
I have done so much education, other practitioners, our interpreters, as well as patients. And imagine that will be a main theme the entire time. Patients will ask for needles and herbs and I explain I heal through movement. Specific movements to restore balance in the body and decrease pain. Some people are very excited and other skeptical. I have been able to significantly decrease reports of pain and show objective increases in ROM/function with just a few treatments. I have an amply supply of kinesiotape and have used it for edema reduction, scar management and posture. Our interpreters are used to the language of acupuncturists and new to my type of assessment and treatment, I am cautious with interpretation and often ask a question three to four different ways… Sometimes getting three to four different answers. This adds a whole different level of difficulty to taking a patients history. There is so much I want to do and help with, but constantly reminding myself to start slow and simple. Everyone gets assessed, a brief treatment if needed, a good dose of education, one or maybe two exercises and is encouraged to return. The clinic is free so many people can easily can and will come three times a week. Others walk one to five hours to come to clinic and do not have the luxury of frequent visits.
A sampling of patients;
45 year old male chronic low back pain x 2-3 years radiating down one leg in recent months painful and limited range of motion
25 year old female sudden onset quadraparesis and neuro symptoms x 2 months, one week in hospital and diagnosed with MS in chart in English and never told or did not fully understand. Suspect CVA or congenital concern and highly encouraging MRI
56 year old female chronic knee pain, extensive OA, hurts even to look at her X-rays
24 year old female 4 months pregnant with pulsating mass in abdomen, I directed the case to Jacq as she has ten years experience in ICU and most recently cardiac. We suspected an dissecting aneurysm and in the US she would have been sent into surgery immediately. The health post was closed, none of the ambulances we called would answer. The pt was monitored until her husband arrived and the ambulance was finally on its way. Once the ambulance arrived the pt was missing, we found them and continued to impress the severity of the situation to the family. They agreed to take the ambulance 3-4 hours to Kathmandu and the practitioners paid for the $60 ambulance ride. The surgery will cost $2000 and they require payment prior. Last we heard the government was going to forgive 50% of the cost, she was transferred to another hospital and is just coming out of surgery. Clearly well beyond the scope of our abilities, we educate and advocate to the best of our abilities.
Aa a team we have to figure out what we can treat and when we need to advocate for pts and refer them out. Pretty wild to think what we worked through in just one week. There are so many people we can and will help and then some we simply can’t. I’m certain I’ve chosen the right program to volunteer with. Being here in Nepal and going to know Good Health Nepal (the NGO partner with) has been wonderful. Everyone’s hearts are in the right place and there is a strong desire and a goal to develope a sustainable program here. I continue to be so grateful for everyone who helped male this possible for me.

Finally some photos!

The hills around Bhimphedi.. Warm and damp as monsoon season continues. Looking forward to a little drier weather and clear skies.

Getting clinic up and running. Carrying supplies through town feeling rather ridiculous but people excited about our return for another year. Our clinic is an old library where I can’t imagine the books lasted long without fully molding. You can see my little room, the interpreters killed a snake that was living in the ceiling the day before I arrived, but not to worry there are still plenty of creatures residing there with me. And our smiling faces at the end of our first day. We’ve got a great team of interpreters.

Favorite Time of Day

Mornings are my favorite time of day. I seem to wake consistently at 6 just as it’s getting light, despite the fact that everyone else seems to get up about 4. My roommate and I each have our own routine which allows for some quiet time. I stretch out on my yoga mat to counteract the effects of my camping cot and then head down the valley for a walk. My village is alive with life and appears to have been for hours. The road is filled with motorcycles and honking sumo’s, school children, chickens and cows as it continues onto Hatauda and then to India. There is a constant smell of third world village and burning trash. It’s really my only alone time and I’ve come to savor it. My walk is filled with friendly namaste’s and the school children shyly calling out ‘hello’ and ‘how are you’. Standing at my spot looking down the valley I take a few deep breaths, taking in the moment and knowing I will look back and miss this. It’s beautiful and lush. This is important… And helps me deal with all the not so pleasant aspects of life here, of which there are pleanty. Back home breakfast is a little after 7 and always enjoyable with the most variety of our meals. Instant but hot coffee and fresh warm goats milk, rumor has it we get French press on the weekend. We sit outside eating mostly watching the rain and village life go by and getting ready for our day. My fellow practitioners, our interpreters and our house auntie are quickly becoming like family. Mornings are slow and we don’t have to be at clinic until 9.

Photos coming when the internet allows.

Goodbye Kathmandu, goodbye ‘luxury’ hotel

It’s hard to believe its barely been a week since I left Portland. My team converged in Kathmandu with a few days set aside for sightseeing with our local guides, eating and ‘luxury’ accommodation. Kathmandu is incredible and gives your senses and your lungs a full workout. After two days we happily piled ourselves and our massive bags into the sumo (jeep) and headed south away from the city into the jungle. Passing through monastery filled hillside villages I had my first glimpse of the snow capped mountains to the north, but that will come later. Racing up and down the windy jungle roads we held on tight. A flat tire, a broken jack and an incredibly bald spare added a little more excitement to the already invigorating ride. Tsering, our Nepalese ARP Liason, kindly pulled in front on his bike for speed control for the final 45 minute descent into Bhimphedi.
Bhimphedi is much hotter and more tropical than I had imagined. It’s a small village nestled in a deep green lush valley. Pretty tiny with a few roads extending off the Main Street. We were warmly greated by many of the interpreters at Auntie’s house where we will be staying. From Aunties it’s a short walk to a point that looks down the valley which will be perfect for a quiet moment each morning. The river below is good for sponge baths and laundry. The clinic is just a few minutes walk away. Our main clinic will be here with three practitioners and two others will work at a second more remote clinic in Kogate. I’ve got the best of both worlds and will be splitting my time between the two clinics. We are all still trying to figure out exactly how I will fit in, being the only PT among many Acupuncturists, but I think it will quickly become clear once clinic opens. It has already been pretty incredible working with the interpreters, I think we we all eager to learn and already forming a strong team.
The clinic is two sparse rooms. I’ll be in the smaller hobbit hole room with a plastic chair, massage table, Theraband and kinesiotape. A few of the interpreters eyed the Theraband, I explained what I studied and showed them a few exercises. They got excited. “Oh we need you here, we want to learn from you and you will have to do lots of teaching. We have three people who had a stroke and so many with back and knee pain.”
With one last day before we open, this morning I laid awake in bed listening to the pouring jungle rain, our interpreters laughing outside and drinking milk tea while the insects and roosters went early morning crazy. I’m in a small room with two others and many more people in our teeny home. People are so pleasant and friendly, there is very little alone time or private space which takes some getting used to. Walking through town the school children shyly run after us calling out namaste.
We have a few more classes today, final clinic set up, more trainings with the interpreters and then tomorrow we open. We’ve been told to expect a long line out the door waiting for us. It’s good to be here!

Counting down the days.

Fundraising complete thanks to family and many generous friends. Bags are mostly packed and weighed. Final coffees and beers with friends to say ‘goodbye for now’. And then, after nearly a year and a half of thinking about, dreaming about, committing to and finally planning, on September 13th I’m off. Off to a land I’ve always known I would visit and was patiently waiting for the right reason. I’m so happy it’s finally here.

Next stop Nepal.

I’m not sure if I found The Acupuncture Relief Project or if it actually found me. Regardless, I am very excited and a little nervous, but mostly just curious, open and ready for this next journey. Travel has always been an important part of my life. I’ve explored many areas of the world and through this experience, I look forward to spending more time in one area, being present and making a difference however small or large that may be.

I’ve been intrigued with The Acupuncture Relief Project since I first learned about it, and with time it became increasingly clear that it was the right next step for me. I have looked into volunteer programs many times before; however this one resonated with me on many levels. I have wanted to volunteer overseas for awhile, have always known I would spend time in Nepal and I am currently at a turning point in my professional career that brings me closer to working side by side with more holistic healthcare providers. Reaching out to past practitioners in the last few months, hearing their stories, why they chose to volunteer and what they have gained from their experience, has made it clear that this is something I want to do as well as something I am suppose to do.

This September I will join fellow practitioners to volunteer in Bhimphedi, Nepal. Like much of rural Nepal, it is an underserved region with very limited access to health care. People may trek for hours with the hopes of receiving services at the regional health post and many will have never seen a practitioner before. Our team will provide cost efficient primary health care services with trained local interpreters to treat a wide variety of conditions and diagnoses. My goal will be to treat 15 people a day, 6 days a week. I expect that this will be both one of the hardest and most amazing experience in my life. I believe this will be an incredible opportunity to help an underserved population, to grow both personally and professionally, and to deepen my knowledge and skills as a healthcare practitioner so that I may best serve my patients and my community upon my return.

After years working as a Physical Therapist I am ready for a new challenge, to move beyond a strict western medicine approach and to learn more about myself both as a person and a health care provider. Through both personal and professional, experiences I am increasingly aware of the effectiveness of working in a multidisciplinary team and complementary medicine.  It will be an interesting challenge to offer a skill in a country that doesn’t really recognize my profession. I am excited to work side by side with fellow practitioners in a new, very different and challenging setting. I can’t even begin to imagine how my perspective on health care will change and I look forward to experiencing how effectively we can treat with limited resources.