The Jackson Clinics

6/9/2011

Today I woke up to another beautiful morning with clear skies. It is consistently about 70-80 degrees and nice in the morning with afternoon torrential downpours, and then nice again in the evening. I can handle this!

Today was the first grand rounds presentation and the students were visibly nervous and shy to present to their peers. I had each group sit in front to present their case while I made notes on the board. As we went through the case, it was clear that the students were starting to catch on to the vocabulary that Ben had introduced and I have been reinforcing. However, we came to a screeching halt when we got to the Non Patient Identified Problem and they continued to demonstrate difficulty with prioritizing and identifying the important factors. This challenge continued while establishing the list of tactics for each impairment. To better gauge their understanding, as well as their interest, I had each of them come to the board with the marker and outline treatments techniques to address each tactic. It was interesting to see how easy this was for some residents, and yet so difficult for others. My favorite tactic today was modalities for pain management because the list continued to grow and grow, and before I knew it, they were listing off items that I had never even heard of! We talked for a few minutes about discharge criteria before ending with a very good discussion and practice for establishing goals. By the end of the first case, three residents were able to verbalize a goal that was measurable, attainable, time sensitive, patient specific, and addressed level of assistance.

The second and third groups went smoother and a little faster as well, but they continued to struggle through the NPIP, tactics, treatment techniques, and discharge criteria. However, they were beginning to show improvement with their ability to establish functional goals and required only minimal cueing from me. I think I may have intimidated them a little bit today by having them come to the board individually, but I was really proud of each one of them, as they were able to come up with at least one treatment approach without giving up.

For the final few minutes before lunch, I had one of the residents present a case on a patient with a stiff knee so they could practice and apply the development of the treatment plan of a different body part. This was an eye opening experience as Lili and I realized that they had no concept of exercise progression…. Period. We discussed swelling management (which they did a fantastic job of listing of the ARICE protocol), ROM for the knee including joint mobilizations above and below the knee, strengthening, gait training and balance/proprioception. As we talked about the progression of a quad set, they were able to list SAQ and LAQ as the next logical progression, but had never heard of a quad set with a SLR or terminal knee extensions. They were awed by my demonstration of quad set, to quad set with SLR, standing TKE, standing TKE with resistance, step up with TKE and finally step up with TKE against resistance… they were scribbling notes as fast as they could. I continue to be amazed at their desire to learn and to mature as doctors of the profession…. It truly is something else. One interesting twist that we discussed today was the comorbidity of this final patient who happened to be HIV+. This is certainly not a typical comorbidity for me and I was humbled to know how to respond. Through discussion with the residents, Lili and I both learned that swelling in the joints is a typical symptom and that it is typically contraindicated to perform joint mobilizations on them. So, I obviously have some homework for the weekend.

After lunch with Mahider and Abinet where I enjoyed delicious pieces of white bread, we returned to the lecture portion of the day where I instructed them on special tests and pathologies of the shoulder. The challenge for me was that they are not seeing these types of injuries or surgical procedures, yet. However, with the growth that is occurring in this town and likely in other parts of the country, I wouldn’t be surprised if they started to see more advanced procedures in the near future. Because of this, I felt that it is my responsibility to at least expose them to the pathologies and surgical procedures to prepare them for that day. We had a good discussion on special tests to end the day.

I have seen some pretty amazing things the last few days. Today, we saw a man “ambulating” with both of his upper extremities using push up handles because his lower extremities were contracted into flexion contractures and atrophied, such that they didn’t touch the ground as he moved across the street. I wanted to take his picture, but didn’t want to be rude or inappropriate. First I was amazed by his upper body strength, but then I felt bad for this man because so much of the work in this country relies on the lower extremities and the ability to have some functional abilities. He stands barely 2 and a half feet tall.

We also ventured out by way of the blue taxis to the Hilton today to use the internet and to get money from the ATMs for our upcoming trip to Lalibella. On our way there and back, we were approached beggars carside while we waited at traffic lights. We found a really nice pizza place for dinner where I totally risked it to have two small slices of plain cheese pizza, thin crust. Our dinner, which consisted of the pizza, a bowl of soup, a sprite and a large bottle of water came out to $8 USD for two us. Our breakfast this morning, which consisted on a pastry, a bottle of water and a macchiato for Lili was under a dollar!! It makes me feel so privileged, so I try to leave a little extra tip everywhere I can.

Tomorrow, Lili and I will be setting up a stations for the students to further practice their ROM measurements and neurological screen with supervision. One of the students, Wintona, offered us her company as we venture into the Mercato tomorrow. It should make for a very exciting day!