Adapting

I have started to adapt which is a little frightening considering what a shock some of the treatments were when I initially arrived. The mothers of the children as well as the other assistants are much more receptive to my presence and as a result I feel more comfortable in asking questions and (attempting to) speak Spanish.

This week has been fantastic because one of the therapists (who is called Professor Carlos) has decided to teach me everything he knows. For this reason, I have seen a wide variety of patients and have been working collaboratively with Professor Carlos to carry out treatments.

In my first journal I said that there are few assessments done on patients. However, I was wrong about that because I saw 3 patients get assessed this week! It seems they are assessed upon arrival at the clinic using the “Millany” assessment which determines the child’s neurological age as well as the course of treatment. In my first week, there were no new patients, therefore I did not see anyone get assessed. He explained the assessment and tested me to make sure I understood, which was great. Something of interest to me, is that you might imagine that there would be a filing system for all of these assessments. ..well there is. They are shoved in no particular oder in a folder inside the therapists personal locker. I really like organization, so for me, this was a shock, but it seems to work for them.

One concern I have is that patient confidentiality at Toñito is virtually nonexistent. Everyone knows everything about everyone else and patients are spoken about loudly in hallways, stairways and in rooms with open doors. I think this is an example of a cultural difference between Canada and Peru that I am learning to become accustomed to. It seems as though in Latin America, the family unit and their involvement in eachother's lives, is given higher importance than protecting privacy and independence. Tonito has a family feel which I like and it seems like no one is trying to keep any information from anyone else.

Some of the interesting things I saw and have done this week are: Traction, ROM on a quadriplegic (scary because their methods of ROM are different than what we have learned as they do it very quickly and force the limbs and as well as extremely quickly as if it’s a race), “Recreation Therapy” (we played outside all morning, there was 1 client and 3 adults…I think it was more for the therapist!), Percussions on a quadriplegic (I only observed this)
I now have a patient of my own (picture on the left) under the therapist's direction. She is a very very cute little girl who is 18 months old, but is only just learning to crawl. We work on core strength, functional tasks like rolling over, sitting up, balance and crawling. I absolutely love working with her and she loves therapy and giggles the whole time.



One major issue that I have is that not all of the children like therapy and some of them are put through these awful, rough therapy sessions and scream the whole time in pain. They will likely never walk, never talk and never be able to feed themselves so why are we trying to rehabilitate them to do so? What are their goals? It seems to me like torture to no benefit to the client and their quality of life is ultimately compromised.

Peru is so different from Canada and it is sometimes difficult to accept new ways of thinking or different ideas about medical treatments or therapies. For example, Professor Carlos and one of the other assistants tried to tell me today that it is very common for a stroke to occur when it’s cold out and this is very often the cause of CVA. I argued, but to no avail. Another example is that transfers are conducted completely contrary to how we were taught in Canada. Therapists at Tonito often drag or carry the kids from point A to point B even if the child could potentially transfer independently or with assistance.

It has also become very clear that the equipment available at Tonito is not up to the standards of a Canadian hospital or rehabilitation facility. Today I was advised to make sure I have the wheelchair brakes on before I move a client. However, as you may have noticed if you watched the video, the wheelchairs are a little worse for wear and the brakes are so rusted and broken that they are totally useless.

One other thing I have observed that is frustrating for me is that patients are also told to crawl and drag themselves along the ground as a form of therapy even though they can walk. I asked why they are practicing to crawl when they can walk and the response was that they practice because they don’t walk properly and also to increase strength. From my training and experience, there are other ways to achieve the goal of increasing strength and correcting gait. However, that is just how things are done here and this gringo is not going to be changing anyone’s mind!

Even though it can be crazy in this place and I don’t necessarily agree with many of the things that go on, I am enjoying it the experience and I find it fascinating. I think the therapist I have been working with does know a lot of useful and interesting information and he loves to teach me, so I am thankful for that.

Below is a picture of a typical wheelchair. Definately a little worse for wear!

Overview of Placement

Interesting week to say the least. I'm still trying to get over the fact that there are no toilet seats, toilet paper or soap in the clinic. I guess I expected a little more in a clinic in a nice part of town where parents have to pay for the service, but I guess resources are still limited.

The clinic I will be an intern at is called ‘Toñito’ and was founded by a man named Dr. Silva. He had a child with developmental delay and decided to start this clinic for other children with brain disorders or injuries. The clinic is large and has one small room for Occupational Therapy, one small room for SLP, a classroom, a therapy pool (which is unfortunately freezing cold), several rooms for sensory stimulation, and 3 very large open area gym areas where I will be mostly working. This clinic is in a nice area of Lima and parents have to pay for the services. Having said that, much of the equipment seems primitive and the setting is not totally professional by our standards.

The experience has been very hands-on and the people are very welcoming and seem happy to have another set of hands. There is one doctor, 3 physiotherapists, one speech language pathologist, one occupational therapist and a teacher. I will be working alongside the physiotherapists to carry out therapy programs for various clients who are approximately 1 year to 18 years old.














The main gym where I will be spending most of my time will have up to 8 or 9 different clients working on various things. There are many assistants, volunteers, parents and nannies who also help with the therapy. One client can take up to 5 people to assist in an exercise. There is little in the way of charts, goals or paperwork of any kind for the clients. In that regard it is different than Canada.















My major challenge has been my struggle with the language. People speak very quickly, so I am constantly having to ask them to repeat things or slow down. However I have been able to communicate by acting and copying. The language will come in time, and I am able to learn the different exercises without too much trouble. The exercises are quite repetitive for each client, so once I have them all down, I will feel more confident.

Because of the language barrier, I am unable to get all the information I would like to about the specific reason behind each exercise. I want to ask why we are doing what we are doing (sometimes it is very clear, but often it is not).
Another difference from what I am used to is that the therapist does not meet for one child at a time for 20-30 minutes. They seem to haphazardly jump from one client to the next, then back again in what seems like no particular order. However, one thing that I have learned about Peru is that although things may seem highly disorganized and random, there is almost always a complex and intricate system that takes time to work out. I suspect that is what is going on at this clinic. There is a method to the madness, I just haven’t discovered it yet.

Some other issues that I struggle with are that most of the children hate the exercises and are literally forced to do them and they scream the entire time. It seems like often they are screaming for a reason and could possibly be in pain as some of the activities can be a bit rough (in my opinion). However, I have not worked in a therapeutic setting with children prior to this, so I cannot say if that is normal or not, but to me, it does not seem therapeutic or client centered. I question some of the methods used as they seem a bit archaic and contradict some things we have learned in school. For example, maintaining good posture and alignment while sitting with equal weight bearing on both sides was something that we learned to focus on and there were several occasions where this theory did not seem to apply while kids flop around on a ball while sitting in terrible alignment. But again, I am not an expert and I do not always know what the client is working towards so I am trying to leave my judgments at the door in order to adapt and learn.

One final issue that concerns me is the cleanliness. Assistants, volunteers and therapists go from one client to the next without washing their hands EVER. There is not even soap in the bathroom, let alone caviwipes or any sort of disinfectant to use to wash the equipment after it is used. Sometimes it feels like we overdo it in Canada, but this is definitely not okay!

After discussing all of the problems, I should also mention the interesting and exciting things I have seen. We work a lot on teaching children to crawl by first manually practicing hand over foot and hand, then teaching the child to go on all fours etc. This is very similar to what we learned in class, so it has been fantastic to make some connections from what I learned in school to what we are doing here in the clinic. We also work with clients on a ladder (which I apprehensive about) to climb up and down the ladder and swing (as if they are monkey bars) to practice grip strength, grasp and release as well as reaching. The part of this activity that I question is the way in which the child is held. Sometimes I think the arms are going to come loose from the sockets due to the lack of support of the body, especially children with low tone whose joints seem quite lax.

Also, there is an exercise on the ladder where the ladder is adjusted to mimic a seesaw. The child will climb up halfway, then the ladder will tip in the opposite direction and crash to the ground and will now be angled downwards so the child will crawl down.

We also work on equilibrium training, working on reflexes, core stability, getting up, and rolling over.

What I like about this placement is that it will be a unique challenge to learn the language and adapt to the methods used here.

Introduction

I have decided to start a blog to share my experience working in Lima, Peru in a rehabilitation center for children with neurological disorders. The reason I wanted to share this experience is because of the different approach to therapy compared to what we might see in Canada. Please feel free to respond with comments and thoughts as I am interested to know what other's may take from this.

I hope you enjoy reading!