Ponseti

Today (Tuesday) was the start of an amazing educational experience. Today's post will be more like a recap of the day with some extra commentary on the side.

Note about pictures: I tried to upload some last night, but the computer here gave my memory card a virus, so I had to format my card and lose all the pictures that I had taken from Sunday afternoon onward, which is fine because I can retake most of them as they were of scenery in the area. I will upload them this weekend when I have WiFi in Kathmandu.

6:30am: Woke-Up, showered, got dressed, retook pictures from around the area from rooftop

7:30am: Ate breakfast, chatted with my roommates Veronica (from Australia) and Asim (from England)

8:30am: Left for HRDC

9:00am: Arrive at HRDC, and begin work

Tuesdays and Wednesdays are surgery days at the Hospital and Rehab Center for Disabled Children (HRDC), so really the only thing happening all day is surgery and PT for inpatients. No new patients are admitted or seen. To see surgeries, I have to choose a specific patient and write-up a patient history and summary of the diagnosis and evaluation in order to observe their surgery. I will probably begin that tomorrow.

So, for most of the morning I assisted with the casting of the children receiving Clubfoot treatment via the Ponseti Method.

The HRDC here in Banepa is the #2 hospital in the world for patients seen with Clubfoot with about approximately 400 cases a year. Clubfoot is a congenital condition that is characterized by 3 main aspects. Inversion of the subtalar joint, Adduction at the talonavicular joint, and Equinus of the ankle joint. If untreated, it becomes and amazingly gross deformity in older children and adults.

The Ponseti Method is a standard treatment for this malformation that was developed in the 50s that recently became popular again in early 2000. The treatment uses a series of plaster casts over several weeks to manually correct the position of the foot. It has a very high success rate (~90%) if done early (typically before age 2) and if done correctly. The method may be applied to children up to 10 years of age, although they may require more casts and possibly surgery, although it is quite common to do surgery in infants as well. The surgery is a minor heel release of the flexor digitorum longus and tibialis posterior to fix the equinus, which is an inability to dorsiflex the ankle.

Anyway, back to my experience. Since it was my first time, I assisted by helping to hold down the patients, so that the cast could be applied correctly on the affected leg. Often times, the patients have bilateral clubfoot, so they requite two full leg length casts. The casts remain on the children for about 6 days before the foot is further realigned and a new cast is reapplied. This continues for at least 5 weeks.

After a couple of times observing while helping to restrain, I switched places with Veronica, and directly assisted the physical therapist on the leg to casted. This involved holding the leg in the correct position while pulling on the first digit to help lengthen the tendons that run down the calf and into the foot that assists in dorsi flexion and some eversion.

After taking a quick break, Damu, the physical therapist that I am staying with, allowed me to apply the last layer of a quick cast to one of his patients. The material that we are using is a quick set plaster of Paris quick casting tape roll. Fellow student athletic trainers, if you have seen Hoagie apply a synthetic dynacast to an athlete this is basically the same stuff but 10x cheaper and doesn't stain your skin since it is just dried plaster of Paris (that is reactivated by warm water) on a cloth mesh (sort of like stretchy tape material without the adhesive). The wrapping of the last layer, smoothing, and molding it out, is similar to wrapping an ACE wrap around a sprained ankle, except that it goes around the entire leg.

After the pre-layer, cotton, and first layer of casting is applied, the foot is manually adjusted. This is when the crying starts because the the manual adjustment HURTS.

Damu said that by the end of my 6 weeks, I should be able to apply an entire cast from start to finish on my own.

12:30pm: Lunch

Today we didn't eat at the hospital. Instead, Veronica, Lydia (of Switzerland), and Prakash went to a stand outside of the hospital and ate stir fried noodles. It was pretty good. Cheaper than the hospital food too. Prakash explained to us a lot of information about the ethnic groups and castes of Nepal.

1:30pm: Retun to Work

The other physical therapist that I'm getting to know pretty well, Anu, was complaining of her neck being really tight, so I offered to stretch it for her (go Team ATR), and she had never learned how to stretch the neck before, and neither had Prakash. I did the whole "Talk to your armpit, Listen to your armpit" Spiel. I stretched some necks and helped the PTs to practice, and they loved it. I'm going to check if they remembered how to do it correctly tomorrow. We also talked about back mobilizations, and it was a great educational exchange between myself as a student athletic trainer, and the PTs who were students themselves, as they are finishing up their clinical rotations for their certification in physical therapy (a 3 year prerequisite to entering a 3 year BS degree).

2:00pm: Post-surgical patient physiotherapy department follow-up and evaluation

3:30pm: Depart HRDC

Banepa.

Sunday afternoon, with Shanika, one of the Projects Abroad staff, took me out on the Arniko Highway to Banepa. This dusty little town on the way to Tibet.

I'll have pictures of the trip from Kathmandu up later, but we went from 4000feet to 4800feet, and we're way in the hills. It is quite beautiful.

I'm staying at the place of a physical therapist who works at my placement. His name is Damu, and he is a wonderful guy, so pleasant and open. His wife is absolutely lovely as well, she works as a peace officer throughout the country. They are both such wonderful people and wonderful resources here in Nepal.

We stopped by the hospital that I'm working at as well, just to drop off some stuff, I didn't start working until the day after, but it was kind of a shock to see the patients. HRDC is the Hospital and Rehabilitation Center for Disabled Children. It is a mostly American and Swiss funded hospital that specializes in orthopedic pediatric ailments. The hospital itself is very well organized and actually has a department that does community based rehabilitation where they have divided the country into several districts and operate mobile camps and satellite campuses to conduct rehab where the patients can't make it to Banepa for treatment. It is quite the amazing hospital

It is the building on top of this hill.

The first day of work was great. I got to see so many different things. These were problems that you would never see in the United States, I didn't really even know what to make of them. Some of the most common things that are seen at HRDC are clubfoot, athrocryphosis multiplex congenital, osteomylelitis related problems, and polio, among many others. HRDC is also the only hospital in Nepal to conduct the Ponseti method of clubfoot treatment, which I will explain here if any of you want me to, but otherwise read it here.
http://en.wikipedia.org/wiki/Ponseti_method

Oh, by the way, this hospital, for orthopedic injuries, is on top of a freakin' hill. A huge hill. I'll have pictures of those later, and the 20 minute hike I have to climb up everyday along the rice paddies and terrace farms.

These patients are often seen quite late because of many reasons, some because of lack of money, others because lack of mobility. For a developing country whose major geographic element is the mountain, I can only leave you guys to imagine what that's like for healthcare access in this nation.

There is one patient who I have begun to really connect with, and she makes me want to learn the language more, so I can understand more of what the doctors and physical therapists are saying. She has the most beautiful smile and pleasant demeanor. She's from a super rural village in the northeastern part of the country and has been in this hospital in and out since she was 5 years old. She hasn't been back to her village since she was 5 and only sees her parents once a year. She has been in a boarding school in Kathmandu while simultaneously getting treatment at the hospital. When she was younger she had a chunk of her leg removed due to a bone infection (osteomyelitis), and now that she has finished growing, they put her through surgery to insert a leg lengthening device to spur osteogenesis over a course of 3 months in attempt to lengthen her leg by 10 centimeters. She is so amazing. She is also an amazing example of the diversity of people in Nepal, she is of Sherpa ethnicity, and has strikingly East Asian features, but is just part of a massive spectrum of East and South Asian features of the people here. It is quite beautiful to see such a melding of people, cultures, and religions in this country. In some ways it's almost a natural melting pot, unlike the United States, which has developed its heterogeneous population through immigration.
More on her later.

I spent today in the out patient department, the physiotherapy room, and the ward where the inpatients are. I really enjoyed my first day and I look forward to delving deeper into the workings of this hospital and its people.

If there's anyone you guys want me to write about here, and clarify, I would be more than willing to look up the information and have a separate post for it. It would give me more ability to tell you about cases, anonymously of course, where I see it happening here in real people.