Today I had a patient that fell 5 floors, 4 months ago. He came into the clinic today and was using two crutches and not putting any weight on his right leg. He said his foot was so sensitive, he was unable to put his foot on the ground. He works in a factory and his wife said 'he got so stressed out about not being able to work, he had a heart attack.' Shortly after his fall, he was in the hospital for his heart. Today was his first day of therapy and he has not walked for four months. I evaluated him, which was a challenge because I could barely touch him because of the sensitivity. His evaluation said 'ankle pain, electrical stimulation for 12 visits.' I asked the patient if he had any sensitivity to hot or cold and he said he has not been able to leave his house often because his ankle is so sensitive to the cold (although still warm, this is the Peruvian winter). He had some obvious discoloration and extreme sensitivity to very light touch. I explained to the group that he appeared to have complex regional pain syndrome. A term relatively unfamiliar to the healthcare workers in the hospital. They were very excited to learn about it and the treatment options. We started some desensitization exercises and did a contrast bath. He stood up, was able to tolerate the pressure and asked if he could donate his crutches to the clinic! The therapists were amazed that the little treatment we did was so helpful. Unfortunately, the patient then had to go sit in the corner and receive his electrical stimulation after we treated him. Since the therapists are working for the physiatrists and have no autonomy, they are forced to do the modality requested. The physiatrists will ask the patients if they received the modalities and if not, the therapists will be punnished. I asked Dr. Barneccea, the orthopedic surgeon that picks me up each morning, why the therapists do not have any autonomy. He said it is because the therapists do not have any documentation, and since the physiatrists are their dictators, it is their license that is on the line if someone were to sue them. So, they prescribe only modalities to protect themselves.
One of my jobs while in Peru is to help to institute a documentation system that can accommodate the therapist's busy schedules. I have been working with both the physiatrists and therapists to develop a system that will satisfy everyones needs legally and most importantly allow the therapists to have some autonomy. last night, I taught one of the therapists how to do a preoperative evaluation since post-op patients are not seen for at least 2-3 months post-op. By this time most of the joints are frozen (something modalities will often not fix). After having seen multiple post-op patients with frozen joints, I have developed an exercise program to be given to the patients to complete during the first 2-3 months post-op at home. My hope is that by the time patients go to therapy, their strength and range of motion will be somewhat functional. The physiatrists were reluctant when I proposed the idea to do pre-ops because there is already a 1-2 month wait list for physical therapy. One of the therapists at the hospital and I explained that the patients would be finished with therapy much sooner and the wait wouldn't be as long if patients could get started with a home program in the 2-3 months before starting therapy. I was shocked that they agreed and are willing to try it. It seems as though the therapists are so eager to better their care but they are limited since the therapists are run by the physiatrists and the physiatrists are run by politicians. Unfortunately, tomorrow will be my last day at Almenara. It has been fun but very tiring!
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