Student Post: Orthopaedic Camp

Since the day we arrived here we had heard about the “Dr’s Camp” that was going to be happening while we were at the campus. January 18 – it seemed every child we had seen so far was going to come. We approached the day with a mix of excited curiosity and trepidation as we could not quite fathom how so many kids could be seen in one day. There was no official count of how many were expected and to us it seemed everyone was coming. At this point we are well acquainted with rooms crowded with children and their various family members. It’s always a little chaotic but it always some how seems to work, like many things in India.

The suspense continued to build as we waited for the doctors to arrive from Bangalore and finally, fairly late in the morning, we met the three orthopedic surgeons over a cup of tea. In typical western style, we were all wondering how we could possibly have time for tea. There were going to be at least 100 children to see! But we sat, sipped our sweet tea and got to know the surgeons, some of whom have been coming to Samuha since 1992 as part of the Bangalore Orthopedic Society. They reminisced about children they had treated and commented on the shift from primarily treating children affected by polio to the now highly prevalent Cerebral Palsy within the last 20 years. By the time we finished our tea we all felt confident in the surgeons and figured it must be time to start seeing children by now!

India a001 (176)
Orthopaedic Camp Opening Ceremonies

We were wrong. Obviously, it was the time for a welcoming ceremony and introductions. The training hall was packed full of children and their families – we could barely make our way to the front. We tried to imagine what would happen if we tried to run a clinic day like this at home with so much “wasted” time and could only picture a lot of anxiety! It was hardly wasted time as by the time the introductions and candle lighting ceremony was over we felt like a team and there was a familiarity between the professionals and the families. Something was said in Kannada, the local language, and the room emptied.

India a001 (168)
Phil lighting a candle during opening ceremonies of the orthopaedic camp.

Within moments, three metal examination beds were quickly set up and the doctors were seeing children. The aim of the day was a screening clinic for children with various disabilities who would benefit from an orthopedic surgical intervention. It was under five minutes for each child and over 105 children, plus a few adults, were seen. Of those, 26 were referred for surgery. Not once did we feel that a child was unfairly assessed as much thought went into each interaction. It was impressive to see the skill and knowledge of these surgeons as they knew well what was feasible, the limits of resources and carefully considered the outcomes and risks. They consulted with each other over difficult cases and with us, creating a cooperative atmosphere and an incredible learning opportunity. Nearly every child walked away with a recommendation for physiotherapy. Before coming to India we were all pretty sure of our role as physiotherapists and the benefits of physiotherapy but after all of our experiences here, such as this surgical screening clinic, we all feel better prepared as advocates. We have seen the stark reality of what a lack of physiotherapy interventions and education looks like. At the same time, we have also seen the significant benefits of either physiotherapy as a stand-alone intervention or in conjunction with surgery.

India a001 (238)
Sara discussing surgical interventions with a client and an orthopaedic surgeon

The day was so much more than we could have ever imagined and we saw more variety of cases in one day than many practitioners will see in a year, a lifetime, really. If you can even imagine, we saw all of it in less than 3 hours. It was incredible. As students, where else can you see over 100 clients aged 6 days to well weathered and wizened with pathologies including Cerebral Palsy, congenital Osteogenesis Imperfecta, post-polio, Rickett’s, achondroplasia and pseuoarthrosis tibia.

DSCN2331
The Orthopaedic Surgeons completing an assessment during orthopaedic camp

For the 26 who were referred for surgery, meetings are held and funding arranged through various sources. So many aspects are thought of and taken care of, such as volunteers for traveling to Bangalore and care for other children who might be left at home. It was so wonderful to see the comprehensive and cooperative spirit here. The day ended with discussion about the possible underlying causes for the high rates of Cerebral Palsy and other disabilities in the area leaving us hopeful that investigation and recognition of these factors might lead to a decrease of disabilities in the future.

DSCN2333
Sara inspecting X-Rays during the orthopaedic camp (not quite the way she was taught in school)

As we all reflected on the day we had respect for the programs here and the people running them. However, we also had even more respect for the resiliency of the adults and children living with disabilities here. They live, they adapt and they cope as well as circumstances allow and often in ways that we can’t comprehend. The day was educational, inspiring, and real.

– Josina, Sara, Madison, Krysta (UBC Physiotherapy Candidates)

*consent has been provided for all images

UBC Students’ 2nd Post: The Spinal Cord Injury Rehabilitation Centre

Two years ago, Samuha’s Spinal Rehabilitation Centre (SRC) was opened a short distance away from the Early Intervention Centre campus. It is the only rehabilitation centre of it’s kind in the entire state of Karnataka. It is currently equipped to support 6 residential Spinal Cord Injured (SCI) clients for 3 month stays each. Samuha is in the process of expanding the centre to have the capacity to host 16 SCI patients at a time. The SRC is unique in its ability to host clients long term and provide effective rehabilitation throughout their stay.

Exercise area at Samuha's Spinal Cord Injury Rehabilitation Centre (SRC) with specialized training equipment for wheelchair access, stoke rehab, and other neurological conditions.
Exercise area at Samuha’s Spinal Rehabilitation Centre (SRC) with specialized training equipment for wheelchair access, stoke rehab, and other neurological conditions.

Following a spinal cord injury in India, most people will spend some time in the hospital, where they may or may not receive physiotherapy treatment. Once they are discharged from the hospital, they return home, sometimes to villages hundreds of kilometers from the nearest hospital. Depending on their financial situation and mobility level, they may or may not be able to transport themselves to see a doctor for follow-up visits. Unfortunately this means that many of them end up spending much of their time lying in bed, without any mobility aids such as wheelchairs to get around in. When asked about this, the head Community Based Rehabilitation (CBR) worker at the SRC, Ayallappa, expressed concern that these patients spend most of their time sleeping and depressed in bed. What often happens when SCI clients are not well educated on their condition and do not receive the support the need, is that they end up spending too much time in certain positions and develop pressure sores. Without the proper attention, these pressure sores will worsen and likely become infected, leading to a very poor outcome.

SRC Outside
Parallel bars and outside exercise area at Samuha’s Spinal Rehabilitation Centre

When clients are admitted to the SRC for their 3-month stay, they are provided with a rural wheelchair (3 wheeler chair for rough terrain), a bed and 3 square meals a day. They are also able to use all the facilities on site, which include, a rehabilitation gym, accessible bathrooms, accessible laundry facilities, gardens and a learning hall. They are cared for by staff on site and are rehabilitated in the gym by CBR workers during the day. Many of them come to the SRC with pressure sores and the staff diligently clean and dress them to allow them to heal. They also often have to learn to sit independently, transfer in and out of bed into their new wheelchair and complete all the strengthening and stretching exercises they are given by Ayallappa. Over the course of their stay they become independent in their mobility and develop really strong upper bodies!

A physician from Koppal has started volunteering his time to come to the SRC every 15 days to ensure the patients are medically stable and provide them with any medications or treatment they require. He has also started teaching the CBR workers how to properly care for the pressure sores and how to monitor for signs and symptoms that might require medical attention. He is also able to provide them with professional consultation on equipment they may benefit from.

SRC - VBall
Two of the clients at Samuha’s Spinal Rehabilitation Centre (SRC) enjoying volleyball!!

Now that you know about all the wonderful things happening at the SRC, could you imagine if they were able to address some of the missing pieces? Firstly, if they had air or water mattresses to sleep on, their incidence of pressure sores would decrease (according to the physician) by 50%. Secondly, if they were able to provide waterproof and more durable cushions for the wheelchairs this would help with longevity of the cushion and also to decrease the incident of pressure sores. Thirdly, the supplier that they get the specialized rural wheelchairs from has stopped providing those wheelchairs. Samuha is now unsure how they will be able to purchase these chairs to provide to their clients. If you know of a good supplier, please contact Phil. Lastly, since it is the only centre of it’s kind in the state, they are not able to accommodate even close to the number of people that could benefit from a stay here. Samuha has been cautious about spreading the word about SRC, because they know the demand will be so high and they won’t have the resources to provide a high quality of care to all those who could benefit. It’s unfortunate to know that some people may be stuck inside because they haven’t received the care they need post discharge from hospital. They are currently in the process of expanding, but this will only add 10 beds. So many more would benefit from this amazing centre!

SRC - Sara Dancing
Sara and her friends at the SRC enjoying a great core and sitting balance exercise class!!

During the day, we have started running group exercise classes to keep everyone engaged and they have really enjoyed being able to play their own music through our mini portable speaker. The guys also love when we get a group volleyball game going outside and you can tell the social aspect of the SRC is extremely beneficial. When asked by a prospective patient’s wife whether or not her husband should become a resident, all of the current residents raved about their experience at the SRC and how much strength, mobility and independence they have gained. We all look forward to our days spent at the SRC because the atmosphere is calm, laid back and friendly. Samuha has definitely created a great atmosphere for recovery and we’re so grateful to play a role in it.

– Krysta, Josina, Sara, & Madison (UBC Physiotherapy Candidates)

2 Week Review: Clinical

Samuha and India have been absolutely incredible so far. We arrived to Samuha on January 6th, and I can’t believe that 13 days have gone by. It feels as though we arrived yesterday. But, looking back at the amount of life changing experiences we’ve had and the amazing friends we’ve made, it seems as though we have been here for years.

Prabhaker, Josina and Madison EIC
Josina, Prabhaker, and Madison in the Early Intervention Centre

Everyday is packed with clients and cases that a physiotherapist in Canada likely wouldn’t see over an entire career! Many of the clients we see are suffering with severe and complex disabilities. This places extreme pressure on families who then require one of the family members to stay home to care for the individual who has a disability. Often times it is the mother who stays home, which takes away from the family’s income. Other times it is a sibling who stays home, missing out on education.

Some of the clients we have seen with CBR workers to date include:

– Many, Many children with Cerebral Palsy (I would estimate that 80% of the children we see have been diagnosed with CP). For those of you who don’t know, CP is a blanket term for any insult to the brain in children up to 3 years of life.

Now the question is why!? Why are there so many children with CP in rural, southern Karnataka? Well, according to Hampanna, the high prevalence of CP is due to unqualified doctors who are administering oxytocin to speed up delivery. In addition to this is the high number of home deliveries and large distances to hospitals

– Children with CP aged 8-10 who have never seen a health care professional!

This has been a sad but educational experience. Often these children have developed severe contractures, have very poor trunk and head control, and are often left to lay on the hard floor. This is mainly due to a lack of awareness of normal child development as well as available treatment centres and options for families.

This has been very educational as we can see first hand how important early intervention truly is. During our evening meetings, the students often say that they now have a better understanding of the value of physiotherapy.

– Post Polio syndrome

Although India has been declared polio free, the effects are still visible in a few patients.

– Bowing of limbs due to malnutrition

– Osteogenesis Imperfecta

– Pressure sores on spinal cord injury clients, children with spina bifida, etc.

– A client who had a “spinal cord stroke” that is likely a Guillian Barre or another neurological disorder.

– Strokes (40 year old, 24 year old)

– Bone Tuberculosis

– Spinal Cord Injuries resulting from falls at work

In one instance a client was working for the government on the electrical lines, was electrocuted and fell 20-30 feet.

– Non union of tibia

– Muscular Dystrophy

– Parkinson’s Disease

– Living Conditions and school situations

Home visit

The clients that we have had the opportunity to see with the CBR workers are the lucky ones that are being treated by the incredible staff at Samuha. You really start to think about how many people are not receiving the treatment they need. For instance, the Spinal Cord Injury Rehabilitation Centre (SRC) at Samuha is the only one in the state of Karnataka! The SRC can now accommodate 15 clients. The total population of Karnataka is 64 million!! That’s almost twice the population of Canada!

Another barrier to treatment that families encounter is that the Indian Health Care System is quite complex. I am in no way an expert on the health care system. But, after many talks with Hampanna physicians, surgeons, and families I have a bit of an understanding of the system and some of the opinions for and against.

Briefly, the Indian health care system included public and private hospitals. There is no universal health care in India. Consultations and medical procedures are paid for by the patient. It is recommended that individuals and families have private health insurance.

Many people in rural India are not aware of the insurance and coverage available to them. For instance, farmers are eligible to pay into a health insurance policy where they pay a relatively small sum per family member to receive medical services. But, most of the farmers around Koppal and Samuha are not aware of these programs.

Similar programs exist for children with a disability. But, again families are not aware and do not know where to seek care.

Part of Samuha’s role is to increase awareness of funding schemes and helping families and clients navigate the health care system. Another very important and needed service!

Students’ First Impression of Samuha

From the instant we stepped off the train onto the Koppal platform, the group of Samuha staff made us feel welcome and respected. They loaded our bags into their Jeep and us four girls got our first glimpses of Koppal from the back of motorcycles driven by the staff. The town is bigger than we were expecting, with many shops lining the streets, cows meandering around and cars, motorcycles and buses blasting their horns. We pulled into the campus, just outside of town, and relished in the calm and safe atmosphere created by the staff. After eating our breakfast with only our right hand (the left hand is the toilet hand), we settled into our room for the 5 weeks. It’s a simple and spacious room with 4 mosquito net clad single beds and our own bathroom with a squat toilet. We are sleeping just upstairs from the Early Intervention Centre (EIC), the staff offices and the kitchen and mess hall where we eat all our meals.

Josina and Madison enjoying their time learning in the EIC
Josina and Madison enjoying their time learning in the EIC

During the day, the calm of the campus is disrupted by the arrival of many families bringing their children, sometimes as far as 300 km, to be seen at the EIC. We quickly learnt through observation of the Community Based Rehab (CBR) worker, Prabhaker, who works in the EIC, why so many families come to him. His years of experience show in his ability to apply his depth of knowledge to each case with ease, all the while explaining everything to the child’s parents. As he works, he asks us for feedback and suggestions, even though we feel we have much more to learn from him than he does from us. Throughout the mornings, we see children with Cerebral Palsy (CP), Spina Bifida, malnutrition, and more. Prabhaker breaks only when chai is brought around and even then, he only pauses for a minute. He will work tirelessly until every child at the EIC is seen, regardless of how long it will take. The entire dedicated staff work diligently to provide the best care possible to their clients.

India 089
Viresh (CBR Worker), Krysta, and Phil gait training during a home visit

During our first staff meeting, we planned the schedule for our first two weeks. Through all the discussion back and forth, we were able to synthesize one main piece of information, the staff all want to learn from us. This was a daunting fact for some of us, as not all of us have completed a pediatric placement. It felt strange and remarkable that before any of the staff had seen us work, they already respected and trusted us. As much as they want to gain from our presence, they also all want to ensure we have the best experience possible. From driving us around in the Jeep, to accommodating our allergies, to showing us how to do our laundry (it involves slamming and scrubbing our clothing on a rough cement block), they never hesitate to lend a helping hand. A perfect example of this is when they took us to the local festival. 400,000 people attended the festival from surrounding villages, all traveling in overstuffed cars, piled on tractors and crammed into buses. For some of these people, we were the first Caucasian people they had ever seen. We got a lot of attention. People tried their best English to talk to us, grabbed our hands, but mostly just stared. If we stopped, they stopped and surrounded us. The Samuha staff then surrounded us, like a protective barrier, to separate us from the crowds. They must have anticipated this, but that didn’t stop them from providing us with the unforgettable experience, even though it took away from their ability to enjoy the festival.

Sara assisting sit to stand and standing balance during a home visit
Sara assisting sit to stand and standing balance during a home visit

As the days progressed and we settled into our roles as the Canadian Physiotherapy Students we continued to be humbled by the unwavering hospitality of the staff. We were also exposed to many of the CBR workers in the field and, again, were impressed by their knowledge, skill and dedication. It is clear that we will learn a lot from the staff and will be exposed to many different and unique cases. We have already experienced so much and can’t wait to see what the next four weeks have in store for us.

– Krysta, Josina, Sara, Madison

I’m All In…

It’s official. I have put in my notice at work and am about to start working towards a career in Global Health.

For a few days after I quit I was in a sort of trance… I kept asking myself: “Is this really happening? Did I just quit a perfect clinical job, with great mentors, in one of the most beautiful places in Canada?  This is suppose to be a big snow year! What am I doing?”

But, mixed in with all of that uncertainty is excitement – I just quit my job to go head first into what I really want to do! I can’t deny that my passion is global health. Since I first learned about community based rehabilitation and had the amazing opportunity to go on a placement to Nepal (with a fantastic PT, travel buddy, and friend, Caitlin Dubiel) I have been seeking ways to get more involved and dedicate my career to this amazing field. A field that the more I learn, the more my mind is blown, which leads me to be even more fired up about learning more and contributing in a meaningful way.

So, here’s the plan:

January 2015 – I will be going to to Samuha in India with 4 amazing physiotherapy students from the University of British Columbia  to serve as their preceptor. Samuha is an incredible community based rehabilitation (CBR) project in the South of India that serves to improve rehabilitation and care for persons with a disability. Our goal will be to work with the CBR workers in paediatrics and to further develop the spinal cord injury rehabilitation unit.

The project has been supported and developed for over 20 years by Hilary Crowley and the Samuha Overseas Development Agency (SODA). Hilary is a physiotherapist who has mentored over 20 students at Samuha, she is the recipient of the 2013 Enid Graham Memorial Lecture (watch lecture here), which is the highest honour you can receive as a physiotherapist in Canada. On top of this she is an all around great person. Hilary is now serving another role – acting as my mentor in many ways.

March 2015 – I will be going back to Nepal with 2 awesome physiotherapy students from Queen’s University. There, we are going to work at the Special Education and Rehabilitation Centre (SERC) and the International Friendship Children’s Hospital (IFCH). Our goal here will be to work with the local PTs and educate the local rehabilitation assistants on paediatric rehabilitation. We will also be further developing the Outpatient physiotherapy department at IFCH that Caitlin and I helped start while we were on placement. To learn more click on the links or check out the article that Caitlin and I wrote for the Global Health Division (GHD) website.

May 2015 World Confederation for Physical Therapy (WCPT) Conference in Singapore

June 2015 Canadian Physiotherapy Association (CPA) Congress in Halifax, Nova Scotia, Canada

After this, time will tell… maybe research, maybe more field work. I’m sure I’ll figure it out along the way.