The Week

This post is going to be organized by days this week.

Monday, June 21st

A lot of new people came to the hospital today. We got 2 new volunteers from the organization that I'm here with. Both of them are living with me and Veronica at Damu's place. Julia, from France, and Mark, from Ireland. They are both very pleasant people and are great fun. 

Also, with the departure of the last two physiotherapy students from Kathmandu College, three new have arrived on their last rotations of Physical Therapy school! They are a bunch of great guys, and they all have a lot of teach and have such a strong will to learn. It's really good, and I'm enjoying the new energy a lot!

Wednesday, June 23rd

This was a great day at the hospital, perfect for my birthday, haha. I was bored at the hospital in the morning, so I played with the kids in the play/education room for a while and ended up making origami balls/balloons. You know, the kind that you would blow up after you do all the folding, yeah? and I came to think...

Dude, this origami stuff would be great for post-burn contraction patients who are affected in the hands and arms to regain fine motor movements of the fingers and hands. Not only that, but it'd be great for any of the kids to learn and fine tune their memory and get their fingers and brains moving. I'm going to test the origami therapy on a patient who recently got surgery to release a couple of his fingers from a post-burn contraction. I'm going to challenge him, once he's ready, to make an origami ball using only his thumb and his affected fingers.

And you guys, the "origami therapy" only gets better...stay tuned.

So today, Shyam, one of the most senior physiotherapists, will start letting me work with patients 1-on-1 with their in-bed exercises. More on that later. I have also started working with one of the student physiotherapists, Sudan, with his patients as well. We have been collaborating on his patients to refine and keep excellent progress notes on those patients. Which brings us to the second half of the "origami therapy" idea...

This specific patient that we are working with, let's call her sally, recently underwent major spinal surgery, and in addition to her physical exercises, must work on her breathing as well. As many of you may know, post-surgical patients are often given spirometers for this purpose. This patient, however, didn't want to do these exercises, so I came up with the idea to make a series of origami paper balls in a variety of volumes and used different paper thicknesses to create levels of increasing difficulty for the patient to blow up the ball. This idea is really only being used with this patient right now, and is super quantitative, so we are still using the spirometer every couple of days to qualitatively measure the lung capacity and strength, but I think I may have stumbled upon something interesting......

Today, my responsibility with Ponseti method assistance also increased, and some of the other physiotherapists have begun to trust me with assisting them with patients and allowing me to do more of the casting. Hopefully in the next two weeks they will begin to teach me specifically how to adjust the patients' feet.

Besides all that, it was my birthday, so everyone at the house skipped the usual Dal Bhaat dinner and went out for some food on the town. I ended up having some chili buff momo's, butter chicken, lassi, and naan. It was a quiet birthday, not bad, not bad.

Friday, June 25th

I arrived back in Kathmandu on Friday afternoon after a quiet half-day at the hospital. I was excited to be able to update my blog with lots of new pictures, but not too excited about the exorbitant amount of foreigners and smog, but whatever.

Friday night was chill, I just went clubbing with some of the other volunteers. Nepali clubbing is always an experience.

Saturday, June 26th

Saturday deserves a better post, but I am really tired right now, so I will leave it at that for now.

Satuday
Bouda
Shivapuri
Dinner

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