Our story with the Haiti Hospital Appeal (HHA) in Cap Haitien began eight weeks ago tomorrow.  But before that, a series of extraordinary events occurred to set the stage for our arrival: an earthquake; an unprecedented number of people sustain spinal cord injuries (SCI) and, more importantly, survive; a caring group at the HHA recognize the need for SCI rehab and take in 19 individuals; Toronto Rehabilitation Institute (TRI) gets involved and makes a generous donation to advance SCI rehab in Haiti by sending its most precious cargo – us, its human resources.  Our mission is one of education.  As the proverb goes, you can give a man a fish and feed him for a day, or you can teach a man to fish and feed him for a lifetime.  We’ve started the latter process.

Tess (occupational therapist) and I have a special vantage, since we’ve been part of the teams bookending this time at the HHA.  It’s hard to describe what we, Tony (physiatrist) and Jackie (registered nurse) walked into when we first arrived.  All I can say is that the concept of SCI and SCI rehab were quite foreign to everyone, including the Hatian staff we were educating, and to the patients especially.

I could fill volumes telling you all that wasn’t known.  There was much gnashing of teeth, banging of heads and testing of patience as we tried to implement strategies of care and to educate everyone (including nursing staff, doctors, rehab assistants and the patients themselves).  Bowel and bladder care…what’s that?  Flexion and extension of joints?  Promotion of mobility and independence?  Prognosis?  It was a lot of information that we had taken years to integrate into our practice and culture that we were now asking people to adopt and learn in a matter of weeks.  The learning curve was more like a vertical line.

Flash forward to now.  We’re here with Anita (registered nurse).  What can I tell you about the accomplishments of the four TRI teams and the impact we’ve had on the staff, the patients and their families, and the greater community?  I could start by saying that the HHA now looks and feels more like a rehab centre and that there is no better place in Haiti to be for SCI care.  We’ve had 5 people discharged (all ambulators) who are now examples to their communities that life after an SCI is possible.  More patients are now doing self catheterization and independently doing their bowel routines.  Every patient has been getting up into their wheelchairs and are learning the nuances of wheelchair skills.  Sam, our lone tetraplegic patient, now drinks from a cup independently while up in his chair, and can push independently with an upside down obusform back rest for support.  The two rehab assistants led a transfer training session for the nursing staff and students (about 15 people), using a real patient, safely and competently.  A new patient was admitted last week, and seeds of interprofessionalism were planted as the assistants and nurses collaborated to share information about him.  It has been an inspiring and fulfilling two weeks for us.

I know that these accomplishments are par for the course in established SCI rehab cantres, but they represent leaps forward from the absence of rehab that existed in Haiti before.  You have probably noted that no full-time wheelchair users have been discharged yet.  A tent in a tent city would be the “housing” that these patients would realistically return to in Port-au-prince if they were to be discharged.  This scenario would pose monumental challenges for them and potentially put their health and safety at risk.

There is much yet to be done to find solutions needed to help these individuals reintegrate back into a community setting.  I don’t know if TRI will be involved then, but I am proud to say that TRI has been here for the past eight weeks.  We hope that our presence has helped to initiate the laying of a foundation for SCI rehab in Haiti, and that momentum to advance this field will be continued through the skills aquired by all the people we’ve touched.

As a physiotherapist, I’m in the moving business.  I help enable people to be as mobile as they possibly can.  Being able to get around on our own gives us  independence and makes us feel good.  This job is often challenging when working with individuals with spinal cord injuries, but in an environment with limited resources this challenge is even greater.  Try to imagine being bed bound for four weeks.  You’d probably go a little stir crazy.  Now imagine having been in bed for over four months.  This was the reality of some of the patients we returned to last week.

For some of our patients, the need to stay in bed was called for.  Some had severe pressure/bed sores and others had uncertain spinal stability.  But another factor that had kept most of these patients in bed so long had been the unavailablility of wheelchairs to get up into.  Here in Haiti, the access to resources needed time and coordination between various aid organization, but in the end, all worked out.

On Team 3’s watch,  a shipment of manual wheelchairs and cushions was delivered for each patient.  The mobilization process commenced!  And I am happy to say that the good work that Team 3 started has now been completed by Tess and myself.

Every patient has had the opportunity to sit up in, and propel, a wheelchair, including the sole tetraplegic on site.  The looks on the patients’ faces were priceless.  First they thought i was crazy to make them try to go from lying to sitting at the edge of the bed on their own.  There was the initial uncertainty of sitting up at the edge of the bed, the fear of participating in the transfer to the wheelchair, and the beaming smiles and laughter that met the encouraging shout outs once they had accomplished their task and moved beyond their beds for the first time in months.

Getting our tetraplegic patient up was especially sweet.  He took to the chair like a duck to water.  Sure he needed someone to prop him up from behind, and another person to support his legs in front, but he placed his hands on the rims and started to push like he’d done it all before.

The ability to move around under our own volition, whether that be walking (with or without a device) or using a  wheelchair etc., is part of what gives us all a sense of independence, accomplishment, and happiness.  Even if we able bodied people tend to take it all for granted.  For our patients here in Cap Haitien, the wait for mobility was certainly long.  This was accomplished by the collaborative efforts of the staff of HHA (past and present) and their partners, in Haiti and beyond.  But now, we need to work on outdoor mobility skills, and outfitting the tetraplegic patient with a proper chair that supports him and that he can push…  The process continues!

Today’s post is from Jamie Young, a PT from Toronto Rehab who was a member of our first reconnaissance team in Haiti. Jamie has returned to Haiti with Mike Landry & Tess Devji and we’ll be hearing from them for the next little while.

Sometimes, life grants opportunities that just can’t be refused. That Tess and I were able to participate as part of Team 1 was a privilege in itself, but being asked to reprise our roles as part of a Team 4 has already proved worth it. And we’ve only been on the ground in Port-au-Prince for less than a few hours!

Six weeks ago, we met a young man at Haiti Hospital Appeal by the name of JW.  He sustained a spinal cord injury when he jumped out of the building he was in when the tremor hit.  This building was his home in Port-au-prince.  Under Team 3’s watch, JW returned home, but not to the house that had collapsed.

Today, Tess and I were able to reconnect with Jean Wesley in what could only be considered a gift from fate.  His temporary new home, it turns out, is in a kindergarten building that is literally a hop, skip and a jump from where we are at the Healing Hands guest house.  Walking with one cane, Jean Wesley, accompanied by his mother, met us along the busy street.

Seeing our former charge outside of the hospital environment was beyond joy.  It was a reunion we never dreamed of.  He was one of the lucky ones; we know that.  He could walk.  He took ownership of his own care.  He could negotiate his extremely inaccessible environment with relative ease.  He took us to his temporary digs.  His bed was an elevated stretcher on the floor.  Our floor to stand assessment a few weeks ago hadn’t been based on “what if”, but rather, “when”.

After, JW and his mom offered to take us to see the crumbled home.  It was literally the next building up the road from the kindergarten.  It also turned out that this was JW’s first time seeing the damage since returning home.  There were a few shakes of the head as the destruction was pondered, but there was also a general acceptance of what had happened and the knowledge that the future was now more important.   He pointed out where he had jumped out of the building; imagination needed as there was only open space there now.  But still, JW maintained a slight smile on his face as he told us the story.  His disposition wouldn’t have allowed otherwise.

I had wondered how i would feel about returning to Haiti.  About returning to Port-au-Prince.  JW didn’t need to wonder.  He was back home.  Je suis content! Both Tess and I were beyond happy to see him and his mom here, and in such good spirits.  The return to Port-au-Prince, to Haiti, has already reinforced why we’re here.  We just needed JW to remind us.

Well, we are just wrapping up things for Team 3. Yesterday we said our goodbyes to the patients, families, staff and friends. It is amazing what was accomplished in just 2 weeks; however, the rehabilitation journey for our patients has just begun and there is still an enormous amount of work to be done.

On Saturday evening, the Roughrider Wheelchair Group and the Walkabout Foundation managed to make their way up to us in Cap Haitian. The wheelchairs they have provided are perfect for the terrain here in Haiti. Patients will be learning new techniques for transferring and wheelchair mobility with Team 4 and then will be able to make good use of the new wheelchairs. 

Sunday was spent fitting wheelchairs and practicing wheelchair skills with those patients that were ready for the transition to the new chair. Ralf, the wheelchair designer and also a peer, taught wheelchair skills and maintenance for the roughrider wheelchair. In addition, Ralf shared his bladder and bowel routine tips for living in a hot country. Ralf has travelled to 42 countries and is definitely the expert on this matter. We were all very thankful for Ralf’s presence with us on Sunday.

So, that is all for Team 3! Our experience has been rich and we have learned so much. We look forward to reading about the progress that will be made with Team 4.

Ian, Suzy & Sylvia

Towards Independence

May 21, 2010

It is truly an amazing experience and opportunity to be here at Haiti Hospital Appeal as our patients continue to learn to live independently with a spinal cord injury. This week feels seamless. We are really getting into a great routine providing  education and treatment to everybody involved.

Each of us has provided education in a few different ways. As mentioned in a previous post, there are several local nursing students here at HHA this week. At 2:00 each day, there is a didactic education session. Ian has provided succinct and simple presentations on the bladder, bowel, skin care and sexuality. There have been some great discussions and questions from both staff and students.

Suzy and Lisa presented on general anatomy and physiology which provided a review for some folks and served as new information to others. The repetition of information has generated questions and discussions by the staff that have participated in these sessions with Team 1 and 2. Sylvia’s focus was on positioning and devices that are used to increase independence and maintain postural alignment and skin health. In addition, each patient has received 1 on 1 education and review of the anatomy associated with the bladder and bowel and the process required to be independant with these routines. 

As a result of the education provided and the large team effort, several patients who were having a difficult time adjusting to their new daily routines are now performing aspects of their care independently.

As I am writing, the helicopter has just arrived. Their cargo is from “Shelter Box”. It is exciting because the shelter boxes provided have the necessary items that the patients will require after discharge. Some examples of these times are: mosquito nets, waterproof ponchos, waterproof ground mats, water purifying equipment, stove and cooking equipment, blankets, toolkits, and a most impressive custom designed ten-person tent. These are tents that have sectioned rooms that can serve as bedrooms in the tent. Lisa, in her expertise and with her networking, was able to organize and coordinate this effort. She is focusing on bringing homes (tents) and essential equipment to our patients and their families.

The patient most recently admitted to HHA is improving very quickly. Thanks for the efforts of Team 2, we were able to mobilize and progress him very quickly. He has increased his walking distance from 3 meters (with 2 person assist) to 40 meters (with close supervision), while using a standard walker. He is now able to socialize with the other patients and families outdoors every day.

Another success story happened yesterday. After a day of scavenging through storage containers and the entire hospital grounds, Sylvia determined that the following items would be perfect to fabricate a 1/2 bed side rail for our patient who has limited use of his arms and hands. The item list: 2 forearm crutches, a standard walker, foam, a screwdriver, and of course the most prized item, duct tape. Together with some family members, a bed side rail was constructed and delivered to our patient. With the use of this aid, he can practice rolling in bed from side to side and also can assist more efficiently to move from sidelying to sitting at the edge of the bed.

It is so rewarding when long, hot days like yesterday end with a brilliant smile and an increase in our patients’ independence.

The latest update is that the new roughrider wheelchairs will be arriving tomorrow or Sunday. As such, we will be working straight through the weekend and on Monday. Sleep will be a prized commodity when we eventually get on the plane to return to Canada. 

We are making a difference in the lives of our patients and it is evident each morning when we walk into the hospital room. The sense of rehabilitation and working towards independence is palpable. Sharing what we know is possible has been an amazing experience. 

Only 3 days left for Team 3!   

Ian, Suzy & Sylvia

 

 

Today’s post is the third of a short series about the first rehab team we sent to Haiti back in March. Mandy McGlynn reflects on her experience working in Haiti below:

My name is Mandy McGlynn, and I was part of the first response team that Toronto Rehab sent to Haiti, specifically to Albert Schweitzer Hospital (HAS) in Deschappelle. It was an experience I will never forget, and one I was fortunate to share with my colleagues from Toronto Rehab, Angie Andreoli, Edith Ng and Mike Landry.

Before going further, I should tell you a bit about myself. I am a physical therapist and I work as an Advanced Practice Leader in two Toronto Rehab programs, musculoskeletal rehab and low tolerance long duration rehab.

Needless to say, my training and work experiences did not—could not possibly—prepare me fully for the challenge of providing care to those injured in Haiti’s earthquake. The difficulties surrounded not just the extent of their injuries, but also the circumstances of their lives, whether it was the extreme poverty, their dislocation from their homes or the fact that so many had lost family members and loved ones in the devastation.

During our first week, I worked with inpatients and outpatients. We saw an endless stream of patients with a wide spectrum of injuries that included upper and lower extremity fractures, peripheral nerve injuries, spinal cord injuries and, most commonly, amputations.

One of the things that stood out for me was the number of earthquake survivors who presented both fractures and peripheral nerve damage. Drop foot, for example, was all too common. Quite clearly these individuals had suffered crush injuries.

Another discovery that surprised and dismayed me was the large percentage of patients with fractures that had been treated with external fixators. Frequently, these individuals will have to be non-weight bearing for long periods of time, they are at increased risk of infection and they will often require additional therapies that could have been avoided. I have no doubt that the early response medical teams did their best under terrible circumstances in the aftermath of the earthquake, but from a rehab perspective, these patients will have a much more difficult road to recovery than if internal fixators had been applied.

For most Haitians, access to healthcare is a challenge. Distances are often a barrier, travel over rugged terrain can be hard on the patient and the cost is frequently prohibitive. As a result, many of the orthopedic patients we saw were not receiving adequate physician attention or follow-up physical therapy. For example, we met one young boy who still had his fixator in place a year after his injury, when it could likely have been removed within a couple of months.

One doesn’t have to spend long in Haiti to appreciate that Haitians are incredibly family oriented and that community support and involvement is important to them. This trait came through strongly in the way family members, friends and neighbours would rally around and help care for the injured. It seemed that every patient had one or more caregivers on hand to assist in washing, toileting, dressing and feeding. In many cases, the family would literally live under the patient’s bed during his or her stay in hospital.

I realize Haitians often have no choice but to support one another during periods of hospitalization. Indeed, the reality at Hôpital Albert Schweitzer when we were there was that family was expected to provide this care. But a benefit of this practice is that, when patients return home, their surround of caregivers are well informed about what they must do to help the patient get better. This level of family commitment and involvement is a healthcare advantage and is not so easily duplicated here at home.

During our second week in Deschappelle, I worked primarily in the prosthetics lab treating amputee patients. The experiences these individuals had undergone are difficult to imagine. Not only did they lose limbs, but many also lost family members, homes and livelihoods. Despite these obstacles, they invariably showed incredible energy, drive and dedication to their rehab treatments.

Patients requiring prosthetic limbs were supplied a place to stay in nearby L’Escale, where they formed a close-knit, supportive community. Every day, a bus would arrive filled with amputee patients scheduled to receive therapy. With so many patients arriving at the same time, and since many were children and young people, we needed to create activities both for rehab purposes and also to keep them occupied. We would often initiate a game of soccer, encouraging them to have fun, while addressing rehab-specific goals such as balance, coordination and weight shifting onto their new limb.

Prior to taking part in Toronto Rehab’s Haiti response program, I had never been involved in humanitarian work of this type. To say that rehabilitation services are needed in the country at this time and for the foreseeable future is a huge understatement. The ongoing requirement is clear, and I’m proud of the long-term commitment Toronto Rehab has made to this effort. It was an incredible experience working with so many inspiring people and I would go back in a second.

This post is the second of three from members of our first rehab team we sent to Haiti back in March. While Team 3 is in Haiti at the time of writing, Angie, Edith and Mandy were members of the reconnaissance team we sent to investigate how Toronto Rehab could be of assistance. Their work, and the work of their teammates was instrumental in setting the stage for our teams’ current engagement in Cap Hatien. Today’s post is from Edith Ng (OT)  where she  recounts her work with Welton (18 years old) following the injuries he sustained in the January 2010 earthquake.

Before I went to Haiti as part of the March team from Toronto Rehab, I wondered what I could do in 2 weeks to help given rehabilitation is often a long-term process. Now that I have gone and came back, I can confidently say that many things can be achieved in 2 weeks, although the work that still needs to happen is tremendous.

Being the occupational therapist in the team, I was given the task of seeing clients with hand related injuries at the Hôpital Albert Schweitzer (HAS) in Deschappelles, most of whom sustained their injuries during the earthquake in January. I quickly realized that although we can contribute by providing therapy, the teaching opportunities that we had were invaluable to promote sustainability after we’d returned home.

In the 2 weeks time, in addition to treating clients, I was fortunate to be able to work along side 3 rehabilitation technicians and a Haitian physical therapist. The rehabilitation technicians were graduates of a wonderful 9-month program organized by the Health Volunteers Overseas that is housed at the HAS to train Haitians in rehabilitation, since there are no physical therapy schools in Haiti.

Ameroline, a rehabilitation technician, at an after-work session on splinting

The physical therapist I worked with was trained in Dominican Republic. We problem-solved, provided treatment, and met as a group before and after each day of work to share ideas and to learn. Other than the learning needs that we identified, the therapy program in Haiti also lacked some basic therapy tools. I was able to leave behind various tools and resources with the help of many therapists around the Greater Toronto Area and support from Toronto Rehab.

It was encouraging to see the Haitian clinicians implementing their new learning, and I realized that 2 weeks may be just sufficient to promote some change. It was also wonderful to hear the clinicians asking for more opportunities to learn, as we knew that it would take more than 2 weeks to learn what they needed to know in order to manage the challenges that they face everyday. Continuing education is an important aspect of building capacity and professional development but it is often lacking for clinicians in Haiti.

Learning was happening throughout this trip for me. Among the many unforgettable individuals that I met and have learned from was an 18-years old gentleman named Welton (his name changed to promote privacy). He has never been to school, and was working on his family farm while living with his mother before his injury. During the earthquake in January he sustained a burn in his left hand and forearm when he fell into a kitchen fire. They did not have the money to seek professional help, so his mother used home remedies to try to help him.

10 days later they finally gathered sufficient funds to go to the hospital. Skin grafts and finger amputation were done but there continued to be exposed tendons, open wounds, swelling, and a lot of pain when we finally met him in March. His first question to me was when could he work on the farm again. He was quiet and was often observed crying. The psychosocial, medical, and rehabilitation needs of Welton and his family were not only an immediate need but would likely require long-term intervention from different rehabilitation professionals which Haiti does not have currently.

What we often take for granted as typical members of the rehabilitation team, such as psychologist, occupational therapist and social worker, are lacking in Haiti. Although a lot of great work is happening through the various professionals in the current healthcare system, there are still many aspects of the health and rehabilitation needs of the clients and their families that are left untouched. The need of ongoing support to provide direct services, to advance rehabilitation practices, and to enhance the quality of life of the many individuals that are now living with disabilities is obvious.

Typical homes we passed by between Port-au-Prince and Deschappelles

I am very grateful to have had this opportunity to share what we have at Toronto Rehab by extending our roles in patient care and education with individuals in Haiti where health services and opportunities to promote professional development are lacking. This is my second trip to volunteer in Haiti and I look forward to more opportunities to help where I can in the future.

Edith Ng
Occupational Therapist
Neuro-Rehabilitation Services
University Centre, Toronto Rehab