The Board Exam Looms

I take the NPTE in a couple of days, and I am not as confident as I would like to be.  I’ve learned a lot and taken four practice exams, but each exam throws out things I haven’t studied.  I guess they can’t cover every scenario in the big review book.  I just hope these practice exams have exposed me to enough to pass the real thing.

I’ve been a little surprised at myself all along for “going public” with my dream from the beginning.  Usually, if I have a goal and I don’t know if I can accomplish it, I keep it quiet as I work toward it, so that I won’t be embarrassed if I don’t succeed, or change my mind and decide not to go for it.  This time, though, as soon as I was seized by the notion of reviving my license and going to Haiti, I put it out there.  I’m not sure why, but I think it is because the idea seemed so fitting that I saw it as a foregone conclusion.  I also wanted to pressure myself to keep at it, in case my resolve wavered.  Plus, I am getting lots of support from all of you!

So, here I am at the brink of the Big Test.  Will I pass?  I think I will, but I might not.  I have no buffer zone, as my results so far are just passing.  And if I don’t pass?  I will be seriously bummed.  But I will carry on, because Haiti needs me anyway.  And I can try again.

My Heroes

This patient population is a dream clientele.  They are pre-selected, by temperament, choice, and training, to be hardworking, compliant, and respectful.  They don’t complain.  They are determined to get on with their lives, whether that means returning to their posts or moving on.  These qualities, along with the fact that they were willing to sacrifice for our freedom, makes it an honor to work with them.

The sailor who was injured on his Harley was telling a comrade that the main problem he’d have getting back on his ship is pain management, because no one can be on narcotic pain meds while serving.  But he said that, from his commander to his therapist, everyone was willing to facilitate his return to duty, and that seems to be his goal.

A soldier, who lost his right leg below the knee and had severe fractures with external fixation on the left leg, had been an Army corpsman, or medic.  As for returning to duty, he told me he was “closing that chapter.”  He just signed up for classes through the GI Bill to start working towards a psychology degree, because he likes to talk and listen to people and wants to “help people who have been through what I’ve been through.”

Another young man, “Benton,” is from Belize but was injured serving in the American military.  He has an above knee amputation on the left and a large area of skin grafting on his right foot.  For him, as for many with IED injuries, the rehab for the salvaged leg will be more complex and long-term than the adjustment to the prosthesis.  Still, it is usually more functional and less energy-consuming to walk with a rehabilitated, intact limb than with a prosthesis, so that's why they work so hard to save them.

Benton charmed with his quiet manner, wide smile, and mischevious humor.  He had been a teacher, working with children from first to eighth grades, before joining the service.  He is also very determined.  When he had only done a couple of days of walking in the parallel bars with his new leg, he really, really wanted to take it with him overnight (most of the clients live in rooms in another building on the base during their rehab).  He managed to cajole his therapist to allow this, insisting that he wouldn’t wear it for too long and would be careful to note any pressure areas on his skin.  He left the PT department that day with his prosthetic limb tucked beside him in his wheelchair, the above-knee socket draped over his shoulder and a big smile on his face.

At one point when I told Benton what I was hoping to do in Haiti, he responded in his quiet Caribbean lilt, “You’ll do it.  I can see it in your face.”  Imagine, this young man encouraging me!  Benton, you’ll do it too, whatever it is.  I can see it in your heart.

The Admiral Visits

On July 1, the 5C PT department received a visit from a VIP, an admiral with an entourage that included his wife and half a dozen uniformed personnel.  The admiral was there to show his concern for injured military members, whether or not their injuries were sustained in battle.  His demeanor was equally sincere with the sailor who suffered an incomplete spinal cord injury from a rocket propelled grenade as with the one who got his foot mangled when, as he explained to the admiral, “I was T-boned on my Harley, sir.”  And if the admiral noticed this sailor’s t-shirt touting the Chicken Ranch brothel in Las Vegas, he didn’t show it, pressing a medallion in the man’s palm as he shook his hand.

Afterwards, I Googled Admiral Robert Willard, and learned from Wikipedia that he is Commander of the US Pacific Command. “He is responsible for the world’s largest fleet command, encompassing 100 million square miles and more than 170 ships and submarines, 1,300 aircraft, and 122,000 Sailors, Reservists and civilians…he is the supreme military authority for the various branches of the Armed Forces of the United States serving within its area of responsibility… only the President of the United States, who is Commander-in-Chief of the Armed Forces, and the Secretary of Defense advised by the Joint Chiefs of Staff (JCS) have greater authority.”  Well, OK, then! 

First Day at NMCSD

My first day went fine - I jumped through all the hoops to get on base, cleared through security, briefed on regulations, and photo-badged, all on time.

In Casualty Care PT, I saw several young men with unilateral and bilateral amputations.  In most cases, there is major involvement of both limbs due to the mechanism of injury.  The first person I saw was injured at the end of April in Afghanistan by an IED, resulting in bilateral trans-tibial amputations - unfortunately, a seemingly classic scenario.  He was a very nice guy.  I started by asking him about his workout (he was doing mat exercises on his own) and he just started talking - he has 3 sons, he can't wait to see them, as he hasn't since he deployed in February, and the military is working on getting his family transferred out here.  He was at Walter Reed earlier and was treated like royalty - lots of celebrity visits (military bigwigs, including General McChrystal, visited him).  His wife is with him, and he's pretty independent with a wheelchair, but is just getting started with his prostheses.  I hope to see him each day.

There's lots of new, computerized equipment that I've never seen before, and I got to observe a gait evaluation in the Gait Lab.  There are 12 cameras mounted around the ceiling perimeter of a large room, in which the volume has been calibrated.  Small reflective balls are placed over all the significant joints of the person, just like the motion capture technique you've probably seen on TV.  There are force plates in the floor that capture step forces.  The images are converted to a complex stick figure and graphs to analyze different motions.  Very cool.  Plus, this particular individual, a young woman who is a dependent of a military member (hence able to be seen at this facility) with a congenital deformity and a new prosthesis, had her 8-month-old baby girl with her who needed feeding, and guess who had open arms?  Yay, baby fix!

I'm pretty independent - there is no hand-holding or leading me around, but they welcome me to observe and ask questions.  It will be up to me to seek out opportunities, so I have to be bold and speak up!

Because I Asked

Book-learning and practice tests are one thing; actually knowing what to do in a PT setting is another.  I needed a way to get some hands-on review and training, but I couldn’t find courses by searching online that might serve my needs.

When I took the review course last February for the PT board exam, the instructor, Ed Kane, saw that I had graduated from the same program from which he had, at Duke, and we had a nice chat about people we both knew.  He had just seen my favorite professor and mentor from Duke, Pam Duncan, the previous weekend at a conference in San Diego.  That was a fun connection.

After the course concluded, I thought I’d ask him if he knew of any programs or courses that would help me get some amputee training.  I approached him and thanked him for the excellent course, and he acknowledged me, then moved on to the next person.  Darn.  Opportunity lost.  Or not… as I collected my things, I resolved to make myself approach him again with my question.  I knew I had to put myself out there to get to Haiti, and as a shy person, that isn’t that easy for me to do.  But I did go back and ask him.

He answered that he didn’t know of any courses, but “what you really need is a clinical experience.”  As a retired Navy captain, he mentioned that he knew “everyone” at the PT department at the Naval Medical Center in San Diego.  He told me to send him an email and he would get me hooked up.

Wow!  That would be awesome!  He had told the class that, because of advances in field trauma care, Combat Support Hospitals, and evacuation to the US Army and DOD-run Landsduhl Regional Medical Center in Germany, soldiers survive injuries today that would have killed them in earlier wars.  Consequently, the military hospitals have the most advanced amputee centers in the U.S., and one of the major such hospitals is the Naval Medical Center in San Diego.

If I could do some hands-on work in a setting like that, it would be a great learning experience.  Plus, I would have a chance to work with our injured soldiers, something that would be certain to be profound.

I did send Dr. Kane a message, and he did forward it to the then-chair of the PT department at NMCSD.  About 10 days later I heard from her that she had forwarded my note to the new director, with an optimistic mention that she thought we could work out some hours for me.  I didn’t hear any more for about a month and was about to write back when I heard from the director, asking me if I was “still interested” in an amputee clinical experience.  I assured him that I was!

His message included a string of emails to various other people to see if they could accommodate me.  It was humbling to see the communication that took place:  questions about how to handle my unique non-student status, about medico-legal concerns, about what needs to happen from a volunteer standpoint in order for me to be there.  They mentioned ideas about what experiences they could offer, such as prosthetics, gait lab, and even pediatrics.

Even the Director of Volunteer Services made special arrangements for me, guiding me to complete the volunteer requirements from afar and seeing me on my own for the orientation.  The process for becoming a volunteer at a military facility was almost as complex as my application for PT licensure.  I had to apply to the Armed Services YMCA, provide proof of a negative TB test, fill out a lengthy background check document, get fingerprinted, and finally get a photo ID badge from the office of the Military Police.

And now, here I am, in the midst of a cutting edge rehab department called Comprehensive Combat and Complex Casualty Care, or 5C PT for short, observing and helping hardworking soldiers overcome devastating injuries, a process that they are enduring for their country, for us, for me.

I am here because of the generosity of many people willing to help me get ready to help people in Haiti, but ultimately I am here for one remarkably simple reason:  because I asked.

One Family’s Devotion to Haiti

Guilaine Salomon and her brother Philippe were born in Haiti and are of Haitian heritage.  The children of diplomats, they lived there until Guilaine was 8, when the family moved to Latin America where their parents continued their diplomatic work.  Eventually they came to the U.S., and Philippe later returned to Haiti while Guilaine settled in Sonoma. 

With Haiti’s grinding poverty and social and political upheaval, Philippe was disheartened to witness the neglect of children in Port-au-Prince.  But one occurrence shook him to the core. Seven years ago, he saw a man leading a group of children, perhaps 7 to 13 years old, down the street.  They stopped at a car, where another man opened the trunk, and Philippe saw that it was full of guns.  Big guns.  These the men proceeded to hand out to the children.

At that moment, Philippe knew that if this was the destiny of Haiti’s children, he had to act.  So he did something he never dreamed he would do:  He started an orphanage.  “I had to get these children off of the street,” he said.  He had raised his own 10 children in a sturdy old one-story house in a large mango grove in Port-au-Prince.  It was quietly empty now, and Philippe thought, why not fill it with children again?  And so La Maison des Petits de Diquini (House of the Young Children of Diquini) was born.

* * *

In December, 2009, Guilaine, her husband, and her two teenaged daughters headed to Haiti after Christmas, loaded down with supplies from Costco ranging from toys to turkeys to take to the orphanage.  Guilaine worried about the frozen turkeys in their carry-on bags, as hard and heavy as bowling balls, getting detained by security or falling on someone’s head from the overhead bins, but the turkeys, and the passengers, made it safely to Port-au-Prince along with the family.

Guilaine and her daughters were gathered with the children and staff of the orphanage watching a James Bond movie on TV when the earthquake struck.  First came a distant thunder, then a massive shaking, then silence, then screams.  While those at the orphanage were not physically hurt and the building remained standing, it was only when Guilaine went outside and across the street towards the nearby Hôpital Adventiste de Diquini that the magnitude of the disaster began to set in.

Tumbled buildings, shocked and injured people, and devastation were all around.  And Guilaine did not know the fate of her husband, who had gone downtown before the earthquake.  Determined to maintain a calm demeanor for her daughters and the children, she hurried back to the orphanage and told staff to gather as many mangoes as they could from the grove out back to give to the people she knew would descend seeking help.

Thankfully, Guilaine’s husband showed up the next day, having walked back to the orphanage.  Philippe’s girlfriend and her 7-year-old daughter were pulled from the rubble of their apartment the next day as well, due only to the determination of a friend who insisted that people keep digging for them.

Haitian citizen rescuers assumed that officials would soon arrive to help with rescues and dispose of bodies, but there was no help forthcoming.  Philippe was among those who said, “We have to take them to the cemetery and bury them.”  Haitians anxiously awaited word over the radio from their government leaders, but there was silence.  There was no leadership at all from the devastated government, even though some of its members had survived.

* * *

Philippe came to Sonoma in April to attend a fundraiser for the orphanage and for another school sponsored by Sonoma’s Patty Westerbeke.  La Maison, with a capacity for 22 children, had only 11 in residence at the time of the earthquake.  Several months later, they are stretched with 35 children and counting.

Philippe shakes his head at his own audacity for even starting the orphanage, something for which he had no formal background and no particular forethought until that day with the guns.  Yet he has found his calling.  The children call him “Papa,” run to greet him with hugs, and follow him around the grounds like little ducks.  He is as determined as ever to give these children a home, an education, love, and a future of hope.

To learn more about La Maison des Petits de Diquini, and to help, visit http://www.wix.com/slim_839/diquini

The Leg Bone’s Connected to the…

I opened up my big Study Guide to the first page of review information and the first thing I found was Levers:  1^st Class, 2^nd Class, 3^rd Class.  OK, I get that.  Then the review quickly descended into minutia:  the bones of the wrist:  scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate.  Tendons that make up the rotator cuff of the shoulder:  supraspinatus, infaspinatus, teres minor, subscapularis.  What movements do these muscles cause?  Abduction, internal rotation, and external rotation, depending on the muscle.  I turned to my trusty Anatomy Coloring Book and started coloring, using my eyes, my hands, and prolonged attention to try to internalize these details.

I recently attended an excellent NPTE review course taught by, it turns out, a fellow Duke alum.  Ed Kane, PT, PhD, ECS, SCS, ATC (yes, he’s highly qualified) gave us not only factual information, but test-taking strategies and insight into the layers of knowledge and reasoning being tested.  The 5-hour, 250-question test is meant to ensure entry-level competence in PT, and requires roughly 75% correct answers to pass.  In the sample tests given during the seminar, I had about a 50% correct rate.  I think that’s not too bad for being 22 years out of practice!

Back home, I reached the review of special tests to distinguish certain musculoskeletal deficiencies, such as Yergason’s, Adson’s, and McMurray’s tests.  Surely they don’t expect one to know these tests by these random person names, do they?  Um, yep, they do.  Why can’t they call Yergason’s test the Bicipital Tendon Test, Adson’s the Shoulder Extension Thoracic Outlet Test, and McMurray’s the Meniscal Tear Test?  And disease names are worse:  Osgood-Schlatter’s disease?  Charcot-Marie-Tooth disease?  Come on!

I find it really annoying that I have to memorize a whole layer of irrelevant terms.  Yeah, it was great that you discovered these maladies, Messrs. Osgood, Schlatter, Charcot, Marie and Tooth (Tooth?), but I’m renaming your diseases to suit my limited memory capacity.  Osgood-Schlatter’s disease, a rupture of the growth plate at the tibial tubercle, is henceforth dubbed Not-good Tatters of the tibial epiphysis.  I’m calling Charcot-Marie-Tooth, an atrophy of the peroneal muscles of the lateral calf, “My leg, not my Tooth,” not to be confused with Legg-Calvé-Perth’s disease, the avascular necrosis of the femoral head (so I’d better be careful with my names).

Looking ahead in the 437 pages of densely organized outlines in my review guide is risky.  Realizing that I’ve got to learn about the endocrine and metabolic systems, or name all the cranial and spinal nerves and know what effect a lesion at any location will have, or know about descriptive and inferential statistics, is intimidating, and seeing the sheer volume of information can be overwhelming.  How can I possibly relearn all this stuff?  If I step back and fathom what I’m trying to do, I might abandon it all, deciding it’s too much.

And yet, after hours, days, and weeks of looking up terms (love my laptop!), hand-drawing or coloring anatomical structures, reviewing videos, and creating charts, I see that I am relearning it.  I get it!  I remember why I went into this field in the first place:  because I find it fascinating.  And I find something unexpected about studying it again:  it’s fun!  I rediscover amusing PT terms like “ipsilateral” and "homonymous hemianopsia" and muscles like the tenor fascia latae, that cute muscle at the upper outer thigh that you see in elite athletes like runners and gymnasts.

So now, when I look ahead to the remaining 300 or so pages in my guide, still feeling somewhat daunted, I also think, “Cool!  I’m going to know all this stuff when I’m done!”  (Or maybe 75% of it, anyway!)