The seed of the idea that eventually became “Steady Footsteps” was
planted in a little house in Nha Trang, Vietnam, in 1995. My husband
Dave and I had come to Vietnam to adopt two children and, while we were
treading bureaucratic water, a man asked me what my job was. As his
English was rudimentary (and he was an English teacher!) and my
Vietnamese was non-existent, I explained that my job consisted of
helping sick and injured people walk again. “Oh,” replied the teacher,
“Here in Vietnam, EVERYBODY does that!” Eventually, however, he invited
me to come to his home to meet his father.
His father, who was perhaps 65 years old, was lying in bed, as he had
been for five years. His story was this: several years previously, he
had been struck by a vehicle which broke his hip. As there was no
orthopedic surgery, his hip did not heal, but he was able to hop about
on crutches – until, that is, he had a minor stroke which left him
unable to use the crutches. Ever since, he had lain in the bed. On
special occasions, his son would pick him up in his arms like a baby and
carry him to an armchair where the man would sit with tears streaming
down his face. Just prior to this medical disaster, the son’s family
had been approved to immigrate to Canada. Once the old man became
disabled, however, those plans were dashed and the family stayed in
Vietnam to care for him.
As I sat on the floor and tried to absorb this information, several
thoughts occurred to me. First, although I was an experienced Home
Health therapist and considered myself able to “make do” with virtually
no specialized equipment and minimal contact with other professionals,
there wasn’t much I could do about an old, unhealed hip fracture without
access to an orthopedic surgeon. Had this man had his injury in the US
or Canada, his hip would have been surgically repaired within 24 hours
and, after about six weeks, he would probably have been walking without
an assistive device. Then, when he had his stroke, he might have been
slowed down a bit but, with a little more therapy, he would most likely
have been walking again, perhaps with a cane. Instead, he was bedbound
-- without wheelchair, walker or therapist.
Secondly, I was adrift without my most valuable tool: my voice. How
to explain to this well-intentioned and guilt-ridden son that his
father’s tears most likely resulted from the emotional instability often
associated with strokes that affect the left side of the body--not from
pain the son was inflicting on that poor old hip? Pantomime can only
go so far with abstract concepts.
And, finally, I realized that there must be thousands and thousands
of disabled Vietnamese people, spending their lives on floors and in
beds, simply because they lack the medical and rehabilitative care that
we take for granted in the west.
I didn’t know what I could do about it – but it haunted me.
Fast forward 10 years: an e-mail message from a North American NGO
pops up on my computer screen, calling for a volunteer physical
therapist to serve as a clinical instructor at the Da Nang Orthopedic
and Rehabilitation Center. Whoa! They’ve got orthopedic surgery and
physical therapists in Vietnam now! And – crucial for me – they were
asking for a clinical instructor, not a stand-up lecturer.
Even with those key elements in place, however, I knew that adaptive
aids were still unlikely to be available and affordable in Vietnam. So,
as we prepared to return to Vietnam, that was the task allotted to my
husband: design and fabricate prototypes of appropriate adaptive
devices from inexpensive, locally available materials. AFOs (plastic
leg braces) were the one essential item that I thought necessary to
import because I had been led to believe none could be fabricated
locally. When I queried volunteer therapists returning from Da Nang,
they said that, not only were AFOs unavailable, but that they couldn’t
be used in Vietnam because everybody wore rubber flip-flops! Likewise
they noted that modified forks and spoons were not appropriate because
people in Vietnam eat with chopsticks. Really. I don’t think that it’s
culturally insensitive to note that sometimes shoes, spoons and forks
can be adaptive devices.
So we loaded up our suitcases with coping saws, brace-and-bits,
riveter, reachers, sippy cups, flexible straws and 40 off-the-shelf
AFOs. My friend, Barbara Coverdale, an American occupational therapist,
devised a wrist splint from chopsticks, fabric, and elastic for
Vietnamese tailors to copy. Once we were in Vietnam, Dave spent his
time on scavenger hunts in the markets and making prototypes of
equipment that we brain-stormed together in our hotel room. Our best “out-of-the box” idea from that trip was a lap table for quadriplegics
fashioned from a plastic sidewalk café table. We merely shortened the
legs and cut a semi-circle in one long side. This provided a steadying
support and a useful working surface so that the quadriplegics and the
non-ambulatory head-injured patients who, at that time, were being
discharged home without a wheelchair, could sit up safely and feed
themselves in bed or on the floor.
I found it disconcerting to note how ineffective the activities of
the Vietnamese therapists were in that facility – especially when I
considered that the NGO that I was volunteering with had been sending
American and Canadian PTs and OTs there for five years already. Most of
the treatments seemed to consist of hot packs (in Vietnam, in July!)
and very simple passive exercises performed by the therapist on the
patient. Nobody was teaching the patients how to get out of bed and
into a chair safely or even how to walk correctly. And because there
were only 2 or 3 decrepit wheelchairs in the whole rehab center,
families were literally dragging or carrying the patients across an open
courtyard to the official “therapy room,” where the physical therapists
waited. While I was there, I resolved to focus on functional
activities and to clearly articulate my rationale for everything I did.
Unfortunately, the promised translator was only intermittently
available (and you can’t fake Vietnamese!) and the therapists tended to
wander off and leave me to treat the patient alone.
But still, I got hooked. The “gotcha” moment for me came about this
way: I had been watching a thin man with dry, cracked skin and his
despondent wife out of the corner of my eye for several days. Sometime
earlier, a falling wall had broken this man's neck and rendered him
paralyzed. Some of his muscles had started to wake up, yet--to my
eyes--there was something about him that did not look right. His hands
appeared useless, but were not held in a familiar pattern. The big
muscles in his legs were barely functioning--but his toes wiggled. This
is not how a patient recovering from quadriplegia typically presents.
Every day, his therapist would strap boards to the man's knees to hold
them straight. Then she and the wife would hoist him onto his feet, and
then suspend him by his armpits from some weird, welded-together
rolling walking frame. Once standing, he could shuffle along. Finally,
it occurred to me that this guy had crutch palsy—paralysis of the arms
caused by the pressure of crutches under armpits--a condition I had read
about in textbooks, but had never seen in thirty years of practice.
Looking closely at this man, it also dawned on me that he was dehydrated and starving.
In Vietnam, it's the responsibility of the family to feed and provide
all personal care for hospitalized patients, but his wife was penniless.
His spontaneous recovery from his neck injury was being masked by
starvation, dehydration and a new case of crutch palsy. Here’s the cool
part: I instructed the therapist to discontinue the “walking
exercises” and to work on knee strengthening exercises with him. My
husband went out and bought him some bottled water (tap water is not
potable in Vietnam), Ensure and canned beans. Two days later, the
patient was standing up and walking with minimal assist of the therapist
and wife—with no boards or walking frame. Whoa. That’s when I knew I
had to come back to Vietnam.
But my husband and I could not figure out how we could afford to
travel back and forth between America and Vietnam. Our trip to adopt
our children back in 1995 had been funded by money bequeathed to me by
my father. The second trip, including the purchase of the AFOs, had
been paid for with money left me by my recently deceased aunt. We had
run out of elderly relatives, so that funding source was no longer an
option. Our only asset was our home. It finally occurred to us that,
if we were to sell our home and purchase one-way tickets to Vietnam, we
would have enough money to live there modestly, with some left over to
fund small projects.
So that’s what we did.
The details are a bit more complicated than that, of course,
involving establishing a non-profit organization in the States and
finding a suitable Vietnamese governmental entity with which to
work--but that's another story.
Here’s the essence of what we’ve learned thus far. Poorly conceived,
hit-and-run missions generally miss the mark in Vietnam. The fact that
the seats in most rehab clinics in Vietnam are rickety old tub benches
sent to a country where bathtubs are rare is one clue.
Orientation literature provided for prospective volunteers at that
first rehab center where we worked urges volunteer therapists to prepare
a Power Point presentation on an area of their particular expertise.
Still, however, that NGO neglects to mention the fact that Vietnamese
physical therapists have only two years of the most basic vocational
training following high school graduation and that half of that consists
of internships under the cursory supervision of therapists who have had
that same minimal training. Evaluation and treatment planning are not
part of their curriculum. With that sort of introduction and a
frequently missing-in action translator, how can a well-meaning
short-term volunteer teach effectively?
The fact that an American-based NGO received a $400,000 USD grant
from USAID to build a rehabilitation wing onto a private hospital in Da
Nang for the express purpose of “demonstrating modern rehabilitation
equipment” and that, only as an after-thought, did the director think to
contact me to ask if I would care to “volunteer” to be their physical
therapist says a lot, too.
Because we’re here continuously, the veils are gradually lifting from
our eyes. And because we’re committed to doing small things that will
make a big difference, we do things that you would never see a big NGO
do. For example, we buy plastic armchairs for the patient wards and
also for families to take home. We buy good quality, Vietnamese-made
sport sandals for all the potentially ambulatory patients in our rehab
hospital. We collaborated on the design for, and fund the fitting and production
of, a new hinged-ankle AFO, designed to be worn with a sport sandal for
neurological patients unable to walk safely due to ankle instablity. We
buy rattan canes in order to give patients the confidence they need in
order for them to ambulate as well as possible.
What is the point of lecturing about the importance of getting
patients out of bed early and often if there are no chairs available?
How can you teach someone to pick up their feet if their flip-flops fall
off when they do? A rattan cane (complete with tip) costs $2.50 USD,
sport sandals are $6.25 and a plastic armchair costs $7. The AFOs are
more--but still far, far below what they would be back in the States.
How cool, and how very, very wonderful to be a philanthropist at such
budget prices! People are overwhelmingly grateful for these small
gifts and – they make a difference! Brain-injured people walk. Stroke
patients sit up and look around. I have enormous credibility with
family members. And I will tell you, here in Vietnam at least, it is
the family members of one patient who teach the next patient’s family
how to care for their loved one. Nurses administer IV’s and treat
wounds. Therapists “do” exercises and modalities. But it’s the
experienced family members who teach the new-comers on the ward how to
move and feed and bathe their own disabled son or husband. They’re the
ones who are teaching each other how to transfer and position their
patients. They’re the ones that are trading feeding tips and helping
each other when another set of hands is needed. Winning over these
dedicated family members and establishing, through them, new practice on
the ward bears fruit. Not only will they be better able to care for
their own family members, but they will teach the next group of
families. We are establishing what could be called “institutional
memory”.
The truth is, my most enthusiastic students are the family members of
the patients. In second place are the affiliating physical therapy
students from the Da Nang Medical School who, by now, have heard of me
from the previous graduating class. Least enthusiastic are some of the
physical therapists themselves. It’s not easy, changing old habits.
It’s slow going but, with administrative support, persistence and a few
“miracle cures,” we are starting to help Vietnamese PTs realize how
rewarding and how FUN it can be to be an engaged and effective physical
therapist.
Dave and I decided we needed to convince these guys that they had real
talent—even though they lacked art school diplomas. So we commissioned
Hien to create some pencil sketches for Steady Footsteps greeting cards
and we purchased two of Phuong’s wonderful paper mosaics. As Hien began
painting in watercolors and--later--acrylics, we bought some of his
paintings as well. And every time we had a foreign visitor at the
hospital, we took them by Hien and Phuong’s room, which was gradually
evolving into a cross between a hospital ward and an art studio.
All of the visitors exclaimed over the art work and some took the
opportunity to purchase pieces to hang in their homes in Germany,
America and Australia. At our suggestion, the proprietors of three
local shops: Reaching Out Handicraft Shop of Hoi An; Tam’s Pub and Surf Shop
near China Beach; and the Bach Mai Art Gallery at 12 Trung Nu Vuong
Street (just across the street from Da Nang's famous Cham Museum) all
agreed to carry and sell Hien and Phuong’s work without charging any
mark-up.
