Zikomo!

2015-12-19 12.20.42This is Casey Nesbit, Assistant Professor and Director of Clinical Education at the University of the Pacific. It’s been a privilege to be with Abby, CJ and Sarah here in Malawi. I’d like to thank them for their commitment to the people and their contributions to the rehabilitation team. I’m still here working at the hospital and everyone is still asking for the students!

When we gathered to reflect when the students finished their last day here, our discussion lead us to thoughts about the importance of education. We asked ourselves about the sustainability of what we do here. We felt that the focus on educating our patients, their families and the community health volunteers that support them in the village was one of the best ways to make our impact sustainable. Given the sense of community here, I would like to think that the knowledge about physical therapy that we have tried to provide to the people here will spread. A caregiver for a patient with a stroke in a village, for example, will likely reach out to others in her community with similar difficulties to provide assistance and share knowledge.

Many thanks to you, Abby –  for your thoughtful creativity, CJ –  for your energetic patient interactions, and Sarah – for your courage as you faced uncertainties.

I hope you have arrived home safely and have a wonderful holiday.

Dr. Nesbit

“Tsalani Bwino, Malawi”

“Stay well, Malawi”

Fireside chat by Abby:

It is hard to say good-bye to Malawi. But I also know, that I will be back here someday. Malawi has moved me and molded me in a way that is irreversible and priceless. This experience has changed the way I see myself as a PT and as a person. I will always call upon these experiences and relationships with my patients and colleagues at St. Gabriel’s as I develop as a clinician. Throughout my time here, and despite the many challenges on both a physical and emotional level, I have never felt so supported, so appreciated, and so welcomed into an already close-knit community. I am so proud of what we have accomplished here, and how hard we worked to help our patients and share our knowledge with them and their caregivers. Zikomo kwambiri to Dr. Nesbit for providing a safe and nurturing environment for us to encounter difficult situations and rise to meet them on our own terms and in our own time. Thank you very much to all of the nurses, clinical officers, and staff at St. Gabriel’s for warmly welcoming us as physiotherapy students, and enthusiastically employing our skills to enhance patient care. And zikomo kwambiri to all of my patients, for putting your trust in me and for bringing me wholeheartedly into your story of recovery. Mwakhoza, mwakhoza, sure!!!

 

A personal note from CJ:

It has been awhile since I’ve written…this move was not intentional but mostly driven by exhaustion. Each night was a moment of personal reflection for myself and I often found it difficult to visit those thoughts again to write them down. Our short time in the hospital is difficult to articulate. We had moments of success followed by moments of difficulty. I found myself quite connected to a few patients here and on the last day of treatment I felt like I was in a haze. Like time had just warped past us and suddenly I found myself unable to treat and spend time with the patients I began so dearly to love. I found peace after talking with the group and recognizing that our efforts to rehabilitate our patients will not terminate once we leave. The culture in Malawi is so different from the United States. It’s a culture I’ve grown quite fond of even though our stay here was so short. Here – guardians, caregivers, brothers, mothers, fathers, and sisters stay at the hospital with their loved ones. The hospital even has huge infrastructure where the caregivers can cook and stay. Even though having a family member at the hospital often causes financial burdens that seems to be besides the point…

What is especially unique is each caregiver watched us intently. Each treatment session included the caregiver so that they may continue to care for their loved one when the therapist is no longer present or when they go home. It was such a rich interaction between people. It was personally and emotionally alive. A team. A family. A group that shared a common goal. To bring someone back to function. Back home to their village. After our last treatment session Dr. Nesbit gathered us all around and I found it difficult to summarize our stay. To put a final point on all that we had gone through. Ultimately the experience allowed me to simply feel human. To understand something beyond myself…beyond my everyday naggings and to understand something greater. To fall in love with a culture, and a system despite being so very different from the system at home. Even though we leave tomorrow morning I already feel the draw to come back. So – it will happen. A returning journey.

 

A side note from Sarah:

As I pack up my last “chitinje” in my overstuffed suitcase, it’s unbelievable to think that this experience is coming to an end. I can recall when my second year buddy first shared with me over a year ago how she was going to Africa to provide physical therapy education and treatment. Due to my passion for public health interventions in the physical therapy setting, I quickly jumped into the application process. After finding out that Abby, CJ and I were going on the trip, I heard many stories, read books, and attended weekly classes all in preparation for this exciting experience. I was not prepared for interactions I would have with this country and it’s people that brought me to a place of humility and vulnerability. At times, I was filled with optimism for these patients as they had a favorable prognosis. In other moments, I was heart-broken at the social injustices present, as I knew that if these patients just had different resources or circumstances, their rehabilitation would be quite different. However, after my interactions with the clinical officers, nurses, and doctors at the hospital, my hope for these patients was restored. St. Gabriel’s Hospital is filled with individuals who are working with the patients and their caregivers to achieve the best outcome. To say it was difficult walking down the hospital corridor one last time would completely minimize how the three of us were feeling. We have been given a honestly life-changing experience from these honest, genuine, and kind people. I look forward to my return to this country knowing that I will be warmly welcomed again.

 

 

 

Nkhani

“Stories”

This last week has flown by…we have been so busy with our patients and each day we are stopped several times in the hallways by one of the physicians telling us about a new patient that would benefit from physical therapy or “fizio”. We have finally found our rhythm here at St. Gabriel’s and now it is time to go home…and leave Dr. Nesbit all by herself with all of our patients! We have all grown as therapists and as people from this experience, and our patients have imprinted on us on both an intellectual and an emotional level. We want to share some of their stories:

Mr. N

This was our very first patient, who we treated for weakness on one side and neglect due to a stroke several weeks prior. He had been in the hospital for two weeks before he was referred to us. When we first started working with him, he had a very flat affect, had difficulty following one step commands, and he could not sit at the edge of the bed without assistance. Within a week and a half, he was walking with a cane as well as support from his caregiver, smiling and sitting up on his own when we walked into his room, teasing and joking with CJ constantly, and able to perform transfers independently. He has been a joy and an inspiration to work with and to witness such accelerated progress not only in terms of functional mobility, but with regards to spirit and personality as well. He wants to return to his village as soon as possible and we are confident he will get there soon.

 

Elisabeth

One of the best parts of being a PT is getting to hear about our patient’s lives through stories. It allows us to be reminded of the human aspect of patient care. We have heard amazingly wonderful and hope-filled accounts of their lives but also face emotionally devastating stories from our patients. Elisabeth was one of those patients who we only got to see for one hour one afternoon. She was with her father who had brought her to the hospital after actively laboring for several days at home in her village. The difficult birthing process resulted in the death of her child and numerous health outcomes, which without medical attention, would result in negative social implications for the 16 year old. As difficult as it was to hear about our patient and her heart-breaking story, the soft-spoken teen was willing to exercise in order to improve her pelvic alignment as well as her gait economy. All of us were deeply touched by her sweet disposition and the caring heart of her father. Elisabeth taught us how a patient is more than their medical/physical therapy diagnosis. There is always a story to be heard.

 

The Little Artist

We met this patient in the hallway of the FCCU…he was a chubby, adorable toddler tucked securely onto his grandmother’s back with her colorful chitinje. We found an empty room and settled onto the floor, and then she showed us his hands. He had some of the worst contractures any of us had ever seen. He was burned in a fire when he was 3 months old and his hands had healed into fists. One hand had recently been surgically released and the other hand was scheduled for a similar procedure in a few months. Our role was to prevent the surgically treated hand from reforming a contracture. We used what we had available to us to create a splint: a toilet paper roll, a small plastic bag, and a pair of latex gloves. He was a very quiet and cooperative patient and seemed to really like his new splint. His grandmother told us that he really wanted to go to school although it was hard for him to hold a pencil. In order to go to school in Malawi you must be able to hold a pencil. So we tied a cloth around a pen to make it easier for him to grasp and tied the cloth around his hand to help his finger flexors do their job. We gave him a pad of paper and he drew us a beautiful, scribbly truck. We told his grandmother that this little artist should definitely go to school, even if she needs to wrap his pencils in cloth each day. This little guy was incredibly inspiring.

 

Mr. V

This patient was referred to us for physiotherapy by a clinical officer from the male ward. Mr. V had a stroke with associated co-morbidities. When we first met him, he was unable to look to one side and couldn’t vocalize at all. We’ve visited Mr. V twice a day for the past week and have seen steady improvements including his ability to stand up, remain standing, and even take a few steps with assistance. He also was able to move his mouth as to respond to a common greeting exchanged in Malawi! We’ve also enjoyed seeing this patient’s personality surface as his rehabilitation progresses. For example, while working with Mr. V, Sarah accidently referred to him with the wrong patient name. Mr. V stopped what he was doing, looked at her, and gave a crooked little smirk acknowledging the fact that she had goofed his name! He has an incredibly supportive family that is working hard alongside of Mr. V. We are very hopeful and anticipate this patient has a good prognosis.

 

Grace

Grace, as her mother, as well as all of us call her affectionately, is a beautiful little girl with big, brown eyes and a stunning smile. She loves to be sung to, she likes to eat phala (maize porridge), and she likes to play with your keys and makeshift balloons made from latex gloves. She is also severely disabled due cerebral malaria which has resulted in her being highly irritable, and suffering from involuntary, writhing movements on one side and head, and spasticity on her other side. Her case is the most tragic one we have seen, and her prognosis for returning to the normal activities of a toddler is extremely poor. By working as a team and with the guidance and expertise of Dr. Nesbit with pediatric patients, we have witnessed some small triumphs with this patient including sustained eye contact, smiling, and giving her the opportunity to engage in play. In order to work on head control, we devised a makeshift supportive seat using a plastic chair, several rolled blankets, and a chitinje. In this position, Grace has been able to explore playing with her right arm as well as quiet the rest of her body for a few moments. If this child were in the US, she and her mother would be provided with extensive resources in the form of adaptive equipment, social security, medical management, and emotional and family support. These resources are not available to them in Malawi, and it has been very difficult as outsiders to accept this stark social injustice.

 

The Hip Ladies

We had a lot of fun and a lot of laughs with these two patients. They were both elderly women with high femur fractures who had been on traction of the last 4 weeks in the female surgical ward. We took a team approach to their treatment and concurrently taught them exercises they could do in bed to strengthen their legs for walking. Then, since we only had one walker, we took turns getting them up out of bed and walking around the ward. Although they were both weak and stiff from being in bed for 4 weeks, they were determined to get moving. Pretty soon, they had the entire ward cheering and laughing as they each took their turns using the walker and announcing that they were headed to their village. At one point, we asked one of the ladies if she was tired and she straightened up and said determinedly: “Tiyeni!” (Let’s go!). We were all thrilled for this opportunity to work with such lively and motivated patients, as well as provide entertainment for the entire ward.

 

Agogo in the Village

By far, the Agogo (which means grandmother in Chichewa) in the village was one of the sweetest and spunkiest patients we have seen. She is very elderly and had a stroke a few years ago resulting in increased tone of her arm and leg on one side. This patient was one of the few patients we visited in the village and every time we visited, all of her family and grandchildren were present for the appointment. In Malawi, before you enter a home you ask “odi?” meaning “can we come in?” The family would always warmly welcome us into their backyard that was already prepared with bamboo mats for us to do our treatment sessions. We worked on functional activities with this patient, which included placing a glass coke bottle or a cup in her left hand to relax her finger flexors as well as allow her to participate in household tasks such as processing maze. This patient taught us that even if you don’t have state-of-the-art equipment, you are still able to be creative and assist your patient! We were also grateful for the ability to be welcomed into their home and for Agogo’s willingness to perform exercises with us.

 

The Mango Tree Boys

While at St. Gabriel’s, we’ve had the opportunity to visit quite a few pediatric patients. In the pediatric ward, there are areas designated for various pathologies including malaria, malnutrition, respiratory infections, etc. However, as you approach the end of the ward, you reach the less severe patients who have fractured a bone, typically from falling out of a mango tree. You wouldn’t think this was overly common, but here in Malawi during mango season these kiddos are everywhere! Some of our most fun patients have self-formed a group that we like to call “The Mango Tree Boys”. They are compliant with their exercises and have become very mobile! Even on our walk this morning, we saw the group outside of the hospital ambulating using their colorful pediatric loft strand crutches and having a blast. These boys have become Abby’s shadow due to her giving them candy! They bring a lot of hope to the pediatric ward and have been a joy to watch as they progress to recovery.

 

“Odwala”

“Patient”

The last two days have been pack-filled with patient care at both St. Gabriel’s and the local village, Namitondo. We have been using a rotating system where we would each take a position of either lead PT, assistant, or scribe. Currently, we have three patients recovering from CVA’s, three patients with fractures and on traction, one patient with cancer and associated low back pain, one patient with hip muscle abscess removed related to TB, and a handful of pediatric patients with medical diagnoses including burns, hand contractures, cerebral malaria, and fractures (from falling out of mango trees!) Some of the patient’s cases have been heart-wrenching and emotionally difficult, but we are optimistic that while working with the medical team at St. Gabriel’s, we can do our part to improve the quality of life and quality of movement for our patients. Even over the course of the last week, some of our patients have improved drastically which is very fulfilling as new clinicians!

Yesterday, the four of us attending a course on pediatric CPAP devices. The class was held by a German pediatrician who provided a lecture on general principles, indications, and application of CPAP devices. After the lecture, we were even able to practice a CPAP application on a fake baby which I found to be much more difficult than anticipated! The class served to be interesting and useful for CJ, Abby, and I in our future cardiopulmonary clinical practice.

In the mornings, Abby and I have been waking up early to enjoy a leisurely run through robustly growing corn fields, bright yellow bamboo forests, and down dirt paths alongside of many children on their way to school. One of our favorite aspects of the run is getting to interact with locals going their way. Malawians are a very social and personal group of people which results in them running alongside of us in order continue our conversation! We are continually surprised by the sense of community and genuine nature of these warm people!

Although the people in Malawi are wonderfully kind, the bugs are a different story. As you can tell from many of the photos we’ve posted in previous blogs, the three of us have picked up a hobby of documenting all of the interesting bugs/creatures here. Its astounding to see the shear number of bugs as well as the diverse population native to the area. I can honestly say that I’ve never seen most of the bugs that I’ve seen here. Although I react like a typical teenage girl when I see a spider the size of a silver dollar in our kitchen, its absolutely fascinating to look at all of these unique bugs! Subsequently, we are all very careful with our bed nets every night. However, hanging a bed net is not as easy at it looks! If I have three corners of the net suspended, I consider it a success!

 

Mass and Mudzi

We started our Sunday by getting up early to attend mass (except for CJ…he slept in) down the street from the Zitha house which has become like our second home.  The acoustics were beautiful, as were many of the dresses in attendance on the women’s side where we sat.  The priest was kind enough to give part of the homily in english for our benefit.  The rest of the morning was spent leisurely strolling about our village, making friends, and getting a little shopping done.

After lunch, we walked about 3 miles through the forest to the village of Kamangira, where Dr. Nesbit’s longtime friend Matthews lives with his large, gracious, and extremely photogenic extended family.  The weather for walking was perfect…it was warm and drizzling with enough cloud cover and shade to protect the azungus from the hot Malawian sun.  We were greeted by many excited children and given directions to Matthews’ house. He was all smiles when we got there and after inviting us inside, introduced us to his father, mother, and sister.  Dr. Nesbit had brought photos with her that she had taken from last year, everyone crowded around to enjoy them.  Slowly, more and more relatives trickled in, and pretty soon the little wooden coffee table in Matthews’ living room was covered in photos and surrounded by children, sisters, aunts, and cousins all laughing and chattering together.  After awhile, we went outside into better lighting so that CJ, our fabulous professional photographer of the day, could take this year’s family photos, which Dr. Nesbit will bring with her next year when she comes to visit.  At this point, word had spread, and we were joined by many neighbors as well as extended family.  What followed was complete and utter chaos and one of the most memorable and enjoyable experiences we have had so far.

After the first round of family photos, Matthews showed us to the home of one of the family’s matriarchs. Her name…Ground Nut Auntie. We never did learn her birth name, but we did find why everyone referred to her as such. Once we arrived to her house, she warmly greeted and welcomed us into her traditional home. Inside, we found chickens and much to Abby’s pleasurable surprise, two baby goats. Matthews’ cousin quickly scooped up the baby goats and placed them in our arms. We were soon in goat heaven as the adorable animals finally hushed and allowed us to hold them like babies! While we were visiting, a gentle rain blew through the village. Prior to our departure for St. Gabriel’s, Ground Nut Auntie scurried outside only to return with an enormous bowl of ground nuts (what we azungus call peanuts) and placed them in front of Dr. Nesbit as a parting gift. We exchanged our thanks and were on our way back home. On our walk back, we soon found that we had a following of children trailing behind us. We began playing a game with the kids by pretending we didn’t see them only to quickly turn around and scaring them. The kids would freeze and then erupt with laughter! After about a mile down the road, the children returned to the beautiful village of Kamangira.

Today was filled with patient care in the hospital. It is wonderful living in the Zitha house with so many physicians as we can communicate with them regarding patient referral to PT! We visited many patients with various pathologies in hospital and even one patient in the village. We are tremendously grateful for how welcoming these patients are to allow us to work with them here at St. Gabriel’s. We look forward to seeing them all progress and recover!

 

Azungu Traps

After an eventful first week at St. Gabriel’s Hospital, CJ, Abby, and I were looking forward to further exploring Malawi with Dr. Nesbit. We packed our backpacks and set off to Lilongwe. In order to get there, we first had to get to Namitete by hopping on the back of bicycle taxi! This mode of transportation was a first for all three of us, but it was one of the most fun experiences so far. It consisted of us balancing on a seat located right behind the taxi driver. For CJ, Abby, and Dr. Nesbit, this was quite easy. But for me, trying to take photos of the gorgeous scenery, fumble through a conversation with my driver in Chichewa, and balance on a seat with no handlebars, it was quite the sight for the locals!

After the three-mile bike ride to Namitete, we crammed into the back of a minibus, which mimicked the real life version of a clown car. For Malawians, it wasn’t a matter of “if” all of the passengers could fit, but “how”. The four of us squished into the back of the bus with 16 of new “anzangas”. All the way to Lilongwe, the bus would stop at various stops among the villages where merchants with fruit, grilled corn, or candy would approach the bus to selling their goods. Although we were in tight quarters, it was an amazing and memorable experience!

We arrived in Lilongwe and went directly to the crafters market. The merchants sold items ranging from fabric and art to wooden carvings and jewelry. We did our best work to barter with the merchants and came away with beautiful pieces of cloth, hand-carved bowls, and one-of-a-kind canvas paintings. We then got a quick bite to eat of “American” food followed by a walk to the large Lilongwe market.

The large market was filled with goods delegated to their appropriate section so that the vegetables would all be in one section, fabric all in one section, clothing all in one section, etc. After walking through all of the perfectly arranged vegetable section, the four of us voyaged across one of many of the rickety wooden bridges to get to the other side of the market. We were all a little skeptical at first, but after trusting Dr. Nesbit and saying a quick prayer, we made it across to the other side (no help to CJ rocking the bridge back and forth on purpose right as we were at the pinnacle of our trek!). We made our way back to the Zitha house at St. Gabriel’s where the other visitors were preparing for a group dinner! We are currently sharing the Zitha house with a wide range of people including Scottish/German doctors and Malawian clinical officers. Our days here in Malawi have been packed full of fulfilling activity and business as well as exploration and enjoyment. We have another big day planned for tomorrow as we prepare for our second week in this culturally rich, picturesque, and ethereal country!

A personal note from CJ: While sitting in the back of a small “bus” that was stuffed to the gills with people – I suddenly realized I was flat out having a blast. The moment was strange though – it was hot, crammed with people and the bus driver was legally insane. He swerved to miss cyclists, honked at everything, pulled out against traffic, slammed on the brakes for no apparent reason, and mashed the throttle pedal all while hanging one arm out the window and blaring Malawian rap music. What a way to go out if that was the Lord’s will. While all this was happening – Dr. Nesbit looks over at me and says “CJ, in Lilongwe watch out for the “azungu traps.” Naturally – I said….”errrm, what?” What she meant was while walking along the side walk, road or wherever there would be a hole. I’m not talking about a small hole in the ground – I’m talking about like a mine shaft. Filled with pipes, nasty water and trash. You may be taking it all in – watching people barter and trade, looking at the scenery or whatever and the side walk ends and opens up to a 5 foot deep hole. Azungu traps……..

“Mwakhoza!”

“Good Job!”

Today was a special day because it was the culmination of our volunteer community health workers’ training. We began our day by splitting into 2 groups and visiting patients in their homes. The volunteers were asked to apply the physical therapy skills they had learned this week in real-life situations as well as work together as a team to educate the patient and caregivers. It was extremely rewarding to witness how much knowledge the volunteers had retained and how they were able to build on the skills they had practiced in class.

Sarah and I traveled together with Alex, our fabulous Home Based Coordinator who coordinated the training with Dr. Nesbit, with half the class to a village that was about 20 minutes away by car (Dr. Nesbit and CJ visited another patient within walking distance with the rest of the class). Once in the village, we met up with a volunteer, Benison, who had attended the same training 2 years prior, and he introduced us to our patient who had recently suffered a stroke, along with other comorbidities. Our volunteers got to work helping their patient with range of motion, standing activities, and assisted ambulation outside of his home. We were also informed that a few days before, Benison had adapted this patient’s hut with an indoor latrine as well as steps to enter that were easier to navigate. The dedication that these volunteers have to their community is astounding. The skills that we teach them over a few days are just the beginning. There is a ripple effect that is immeasurable with tests and numbers. The volunteers go above and beyond in terms of how they apply their training in ways that we as outsiders could never have imagined on our own.

We returned to St. Gabriel’s triumphant. After a quick and well-deserved tea break consisting as always of warm soda and cookies, we listened to group members present on the observations they made, the skills they used, and what they learned during this experience. We celebrated the end of class with singing, poetry, and lots of laughing and clapping. Each volunteer received a signed certificate from Dr. Nesbit and Lameck, who is the national coordinator for the Palliative Care Association of Malawi, and then we all met outside for group photos. All in all, the training was a great success. ! (good job!)

“Pangani Chonchi”

“Do it like this”

Today was our first official day of training “volunteers” practical skills they can use to help their patients. Teaching simple physical therapy skills involved quite an orchestra of people. One of us either myself, Abby or Sarah would explain the skill one sentence at a time while it was translated into Chichewa. Then the skill would be demonstrated by the other two – as it was being demonstrated it was explained again in English followed by an explanation again in Chichewa. Once the task was thoroughly processed by the volunteers they would have a brief period of time to practice on their partner which always produced many giggles and whispers. Especially when Abby demonstrated stomach massage for patients with constipation! The volunteers listened so intently at every word we spoke and watched our every move! During our “tea break” which consisted of no tea, soda and cookies the volunteers never took a break but continued to read and re-read the skills we taught them. Once we had taught them one skill – let’s take for example sequencing of stair ascending with a single point cane, Alex (our interpreter who also was trained as a physio volunteer a few years ago) would watch each volunteer perform the task we taught them. He was BRUTAL! Sarah, Abby and I would be satisfied with their performance on a particular skill but Alex would point out that they may not have performed it EXACTLY like we had shown them originally. He gave NO room for interpretation or making a skill “ones own.” It was pretty hilarious. One time after a particular volunteer really impressed me I said “Mwakhoza!” which means “Congratulations” or “You were successful” or “Well done” and the volunteers shouted with adulation at me mind you not the volunteer because I had spoken a word in Chichewa correctly and in the right context! Hahaha!

Fireside chat by Abby: The most fantastic thing about teaching in Malawi is that whenever someone shares knowledge with the group, whether you are a teacher or a student, you get to choose how the class “shows appreciation”. There are many ways to show appreciation: for example you may ask the class to clap for you like a chief which involves cupping your hands and clapping slowly so that the sound created sounds like a drum…I notice many of the young men choose this one. Or you may ask for the rain one that starts out quiet and fast and then slowly builds to one deafening thunderclap at the end (exactly how the rain comes in Malawi). My personal favorite is clapping 3x fast while chanting “Mwakhoza”, then repeat, and then “Sure!” once at the end while pushing your hands in the air towards the person who is being appreciated.

A side note from Sarah: During my time here so far, I’ve been pleasantly surprised at the sense of community among the Malawian people. Whether the three of us were visiting merchants in the village, strolling through enormous red dirt fields with the workers, or teaching to the volunteers and staff at St. Gabriel’s, it has always felt like a tight-knit family. I came to know this personally today when one of community health volunteers, Malita, greeted me and told me how her youngest daughter was also named Sarah! Being the youngest of three sisters myself, I was excited to make this connection with such a sweet woman. She told me she was my “Amayi wa Malawi” meaning “Malawian mother”. We shared a laugh together filled with joy that we now had a special bond with one another.