WNBA Finals Despite the Injuries!

Yesterday was Game 3 of the WNBA Finals. If you're not familiar with this league, the Finals are a best-of-five series which means you need to win three games (out of five) to be crowned champion. Last year, the Seattle Storm swept the Washington Mystics 3-0.  It was glorious!  Right now, the Washington Mystics are 2-1 ahead of the Connecticut Sun, with Game 4 being held tomorrow night at Mohegan Sun Arena in Connecticut.

Why is this important to me?  First, as the physical therapist for the Seattle Storm, I wish the Storm were playing in the Finals and that I was there to watch.  I love basketball and this really is some of the best basketball you can watch.  Haven't been to a WNBA game?  What are you waiting for?!?! Second, despite being dedicated to the team I work with, I'm also a supporter of the league as a whole and have a long history with the teams currently competing.  The current Head Athletic Trainer for the Sun, Rosemary Ragle, was the UConn Women's Basketball Athletic Trainer while I was in college - and also worked with me on my Grad School thesis.  The current Washington Mystics Head Coach, Mike Thibault, hired me to work for the Connecticut Sun when I was graduating from UConn in 2007.  I worked for him - and the Sun - for four seasons before PT School.  Their assistant coaches include his son, Eric Thibault, and former UConn and Connecticut Sun standout and Olympic Gold Medalist Asjha Jones who were both with the Sun when I worked there.  I can't possibly root for one team over the other - though I have a lot more Connecticut Sun t-shirts in my closet than Mystics attire. 

So I'm following the WNBA Finals, watching teams compete for the highest position in Women's Basketball - perhaps falling only behind the glory of an Olympic Gold Medal or World Championship - and the headlines are riddled with descriptions of injuries these players are experiencing.

Like these tweets:

Alyssa Thomas has a torn labrum in BOTH of her shoulders.

Instead of missing games to have surgery, she modified her shot and played through the pain. 👏#WNBAFinals pic.twitter.com/cVkqss0cQz

— espnW (@espnW) October 2, 2019

The @ConnecticutSun say they'll prepare as if @De11eDonne will play Sunday. The @WashMystics have to prepare as if she won't. The MVP's status for Game 3 of @WNBA Finals expected to be announced Saturday. https://t.co/0Vuwyd1R5m

— Mechelle Voepel (@MechelleV) October 4, 2019

Or this article today in The Guardian:

Elena Delle Donne plays through injury to move Mystics one win from WNBA title

• Washington beat Connecticut Sun 91-81, lead series 2-1
• League MVP has a herniated disk pinching nerve in her back

Associated Press

Sun 6 Oct 2019 18.22 EDT

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 Elena Delle Donne drives the ball to the basket during Sunday’s game. Photograph: David Butler II/USA Today Sports

"Elena Delle Donne put forth a gutsy effort, playing through a back injury, and Washington beat the Connecticut Sun 94-81 on Sunday to move within a victory of winning the franchise’s first title. The league’s MVP has a herniated disk that is pinching a nerve in her back and was questionable to play in Game 3. She finished with 13 points, hitting five of her six shots and played 26 minutes."

I can't help but thinking - what message does this send to the fans, particularly the young ones?  Is this helpful?  What does it all mean, anyways?

First and foremost, a disclaimer. I am not working with either of these athletes.  I do not know what care they are receiving - but I would bet it's excellent from my years interacting with both organizations.  I care about the health practices around the WNBA and have been trying to help improve their standards for several years - so from the research I've done, I can say with confidence that it is highly likely that these basketball players are being well taken care of. 

Additionally, I absolutely 100% believe that the above-mentioned athletes with injuries are experiencing pain.  I read one account that said that Elena Delle Donne could not sit down because it was too painful, so the medical staff and coaching staff had devised a plan to bring her into their locker room when she was subbed out of the game to keep her moving and stretching and to avoid extended periods of sitting time.   This sounds like EXCELLENT collaboration between a medical and coaching staff and is something other teams should take notice of!  (The Storm is good at this, too, in my opinion!)  If an athlete is reporting pain, I believe that they have it.  All pain is real.  Pain is a personal experience that is influenced by many things.  But pain is also a protector and it doesn't necessarily mean these athletes can't be playing.  Here are my thoughts with what I've read and, more importantly, some thoughts on comments from fans who have opinions on the matter.

1) There are HUGE numbers of people with imaging showing torn labrums in their shoulders and disc herniations that DO NOT have pain.  This paper discusses the labrum tears and found that 55-72% of people without shoulder pain had a labrum tear. (The population was a little older than Alyssa Thomas, aged 45-60, but she is an overhead athlete so this presentation for her is not really that surprising).  Want something more specific to athletes?  This blog post from fellow UConn Graduate and well-known strength and conditioning coach with Major League Baseball players, Eric Cressey, presented the research on the same topic.  He quotes: " Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings." This paper looked at a large sample (3110 subjects) without back pain and found on MRI that 30% of 20-year-olds have disc herniations and that the number increases over time.  This is why sometimes people have surgery but it does nothing to correct their pain... because the MRI findings and the surgical correction does not always fit with the pain.  

2) These are elite level athletes so it concerns me when I read that suggest they're "skipping surgery and playing through pain."  Tissue damage DOES NOT correlate with pain, so unless ESPNw was given reports from the teams stating that they had pre-participation MRIs that were normal and then started having pain the correlated with tissue damage (which goes against a lot of the evidence) a surgery may not even come close to fixing these problems.  Another way of looking at this is - why does their body adapt to present with the MRI findings that they have.  For example (hypothetically) is Alyssa Thomas' upper back too stiff for her to get her arms all the way overhead to shoot and rebound?  Because if that's happening, she's effectively cranking on her labrum to get her arms over head and then a shoulder surgery may fix her labrum, but it doesn't actually fix the initial cause of the problem.  She'll still have a stiff upper back, so it'll only be a matter of time until the labrum is reinjured unless the real underlying cause is addressed.  Why does everyone want people to rush straight to surgery, anyways?  That's painful!  As a physical therapist, my number one goal is to help athletes avoid having any surgery at all.  Sure - if it's necessary, such as in the case of Breanna Stewart having an entirely ruptured Achilles tendon, we're talking about something different.  But what if we just let these athletes recover after a grueling season (next week!).  

3) Can we acknowledge the additional stressors of playing in the WNBA Championships?  It is well known that emotional stress contributes to our experience of pain.  Elena Delle Donne was injured during Game 2 of the WNBA Finals.  Anybody else ever get injured at work and need to finish the shift or wake up with a super stiff neck or spasm in their low back and still have to go to their job the next day?  She has a job to do and it's far more in the spotlight than most people's work.  She'll get her symptoms managed and her pain will likely have a bigger impact on her job than on many other peoples' jobs, but she'll also participate in the conversation of whether or not she plays.  Or at least she'll have her agent do it.  Someone will be advocating on behalf of these players to protect their health. 

Many of the comments online were about how she was forced to play.  We don't really know that!  Any chance these commenters considered that she chose to play once the medical providers told her she would be allowed to?  The reality of this situation is that in less than one week the WNBA season ends, the physical and emotional stresses of the season will be reduced, and a period of relative rest (which means  they don't just curl up in a ball in bed) can begin.  What if they have some injuries, but they're also sleep deprived with elevated cortisol levels from their increased stress, not eating as healthy as usual with their family entourage visiting for the Finals and wanting to eat out?  It's so much more complicated than just "an MRI showed some damage." There will be time to stay away from the basketball court coming soon, time to reduce the amount of stress on their bodies and their minds with decreased physical activity including, less jumping, decreased torsion and load on injured anatomy, maybe some extra napping, some gentle swimming or yoga, and globally allowing the nervous system to calm down.  The Playoffs are three straight weeks of sympathetic Fight or Flight Mode... how about a nice parasympathetic Thanksgiving style dinner that puts you into rest and digest recovery mode?  Maybe we'll see that no surgeries will be needed for any of them!  

4) There are definitely circumstances where an injury to an athlete means they should not play their sport because it puts them at risk for further injury.  For example, after experiencing a concussion, it is dangerous to the athlete's health to compete before all symptoms have entirely resolved.  For example, if an athlete has a broken bone, not only could it be extremely painful to compete, but the athlete is at much worse damage with a subsequent injury.  For example, if an athlete cannot control their bowel or bladder or they have muscle weakness or numbness/tingling into their legs or arms - these can suggest a much bigger problem with the spinal cord. 

But there are many circumstances where an injury to an athlete means they will have pain while they do the things they love, but they may be OK to play with certain precautions.  For example, someone who recently sprained their ankle may be able to play while wearing an ankle brace.  The brace can protect from further injury while they are completing their healing.  For example, in many states it is approved for someone wearing a cast with a broken bone to pad the cast and play sports anyways.  The cast will protect the injured athlete from worse injury and the padding protects opponents from being hurt.  A torn labrum of the shoulder may be associated with a lot of pain for Alyssa Thomas, but is she at risk for any sort of red flag event by playing through it?  No.  And, without knowing the details of Elena Delle Donne's injury, I suspect she's experiencing a lot of back pain without the neurological symptoms into her legs that suggest spinal cord problems and that her medical team has determined it is safe to be playing.  She would not be on the court otherwise.

At the end of the day, tomorrow night could be the final game of the 2019 WNBA Season.  If it is, the Mystics go home with a Championship.  If not, they will play one more game.  I personally want to see all the best players on the court at the top of their performance.  So I'll send up some prayers for these two incredible athletes and role models and to all the other WNBA players currently having pain.  And I'll be rooting for the Sun and Mystics medical providers who will soon get a nice rest break, too. 

AASPT Traveling Fellowship

Fellows @ Cincinnati Football

Long before sunrise on the morning of Thursday, September 12, 2019, I boarded a sleepy airplane lightly coated in the typical Pacific Northwest mist heading towards a career-enhancing expedition.  After a brief pit stop in Denver, I continued on to Cincinnati airport, weirdly located across the Ohio River in Northern Kentucky.  Upon arrival at the CVG baggage claim I met two physical therapists who I would spend the next eleven days learning and observing various topics related to sports physical therapy. Rebecca Troulliet from North Oaks Health System in Louisiana and Patrick Barber from University of Rochester in New York joined me for the American Academy of Sports Physical Therapy (AASPT, formerly known as the Sports Section) Traveling Fellowship.  Sponsored by Kevin Wilk, LightForce and DJO Global/DonJoy. We spent about three days each at University of Cincinnati, Mayo Clinic locations in Minneapolis and Rochester, Minnesota, and The Ohio State University. 

What does it mean to be a Fellow?  According to Wikipedia, "a fellowship is a group of people who work together to pursue mutual knowledge or practice."  Though each of us had individual purposes for participation, we are all physical therapists working with athletes and we were all looking for growth in our careers.  Through observation and lecture attendance with more seasoned clinicians, we had exposure to different techniques and clinical approaches than our usual day-to-day experiences.  Now that I've returned to my usual swing of things and seeing my patients at Seattle Children's Hospital, I'm taking this opportunity to reflect on the experience and share why I chose to pursue this Fellowship along with some highlights from our trip. 

First: Why did I want to complete a Fellowship?
In May 2014, when I was completing PT School at the University of Connecticut, my career aspirations were to serve as a team physical therapist in the WNBA.  I had previously worked in a non-medical capacity for the Connecticut Sun for four seasons, but elevating to this new type of position as a new grad PT didn't seem remotely feasible.  Beyond the fact that I was a new clinician,  WNBA teams didn't have physical therapists, then, so this goal seemed unrealistic. (Most teams still don't, which I wrote about here)  I thought my fastest route to working with professional female athletes was to advance my education from PT School through a Sports PT Residency Program. In 2014 there were about twenty of those programs nation-wide, mostly offering one or two slots. I applied to three, including Ohio State, but was not successful in securing a position.  Now there are almost fifty SCS Residency programs with so many more opportunities nationwide! To search Residency programs in any PT Specialty area, click here.

Fortunately, physical therapists have an alternative route to obtaining board certification and specialization in sports physical therapy that does not require participation in a residency program.  You can find the requirements to do so here. As I pursued the alternative route, I also landed a role with the Seattle Storm, and in March 2019 completed my Board Certification Exam.  In our cohort, Pat also took his exam in March following completion of the University of Rochester Residency program and Becca is currently working through the alternative route requirements to specialize in the future.  So because I did not complete a residency program but did pursue specialization, I felt like I lacked some of the mentorship and on-field hours that a residency would have provided, and this fellowship filled some of that gap.  

Second: What was the Fellowship like? 
Each location was very different from the others which helped us gain a broad spectrum of the possible roles and responsibilities for a sports physical therapist.  

Fellows and PT staff @Cincinnati

At the University of Cincinnati, we were hosted by Bob Mangine and Tim Machan and primarily spent our time in their athletic training room with them and on the sideline.  We had the chance to watch game-time coverage, led by Head Athletic Trainer Aaron Himmler and had a sit-down discussion with their concussion program and vision training expert, neuroscientist Dr. Joe Clark. We attended lectures on a variety of topics by members of their staff including wearable technology, use of the ACL-Return to Sport Index Outcome Measure, Neuroplasticity, Prevention of Catastrophic Injuries, and and we each presented our own lectures. My presentation examined the Impact of Fear Avoidance on Return to Sport, Becca discussed Sudden Cardiac Death and Pat outlined Upper Extremity Return to Sport Tests.  

With Timberwolves Robby Sikka and Matt Duhamel

After exploring Cincinnati, the three of us packed our bags to head to Minneapolis for the first half of our visit to the Mayo Clinic.  Our host in Minnesota was Corey Kunzer who is the coordinator of the Mayo Residency program.  The clinic in Minneapolis serves the community as well as having partnerships with the Minnesota Lynx (WNBA), Minnesota Timberwolves (NBA),  and Minnesota Twins (MLB).  Only days before our arrival, the Seattle Storm had knocked the Lynx out of the WNBA playoffs so I felt a little like I was in enemy territory, but I was glad to finally meet Emily Beyer, Lynx Team Physical Therapist as well as Matt Duhamel, Team Physical Therapist/Director of Athletic Therapy for the Timberwolves and Jeff Lahti, PT for the Twins.  We also met Robby Sikka, Timberwolves VP of Basketball Performance and Technology who uses wearable technology with the basketball players to improve their on-court performance.  Their basketball facilities are fantastic and, according to their staff is considered to be the best training site in the NBA. They have practice basketball courts with athletic training rooms and locker rooms for the teams right next to the medical clinics where they have physical therapists, orthopedic surgeons, physicians, athletic trainers, and other specialties who can thoroughly care for the athletes alongside the general public.  Can you imagine being at your PT session and rehabbing alongside (Lynx superstar) Sylvia Fowles or  (Timberwolf and UConn great) Shabazz Napier?! The Mayo providers collaborate with the team providers in their biomechanics lab which includes force plates and multiple angles of cameras for jump-testing and movement assessment as well as for recommendations for optimal care.  It was a really interesting arrangement for sports medicine for all levels of athlete.

Diagnostic Imaging with Dr. Jay Smith @ Mayo

Then we drove down to Rochester, MN, home of the original Mayo Clinic.  Founded in 1889, the Mayo Clinic is basically the entire town of Rochester and the area is spotted with old historical buildings that contain the most beautiful old libraries and intricate marble ceilings that tell the history of medicine in the US along with more contemporary constructions housing the huge variety of specialties that the Mayo Clinic houses.   We learned about Diagnostic Ultrasound from expert Dr. Jay Smith were taken to the Mayo Clinic Biomechanics lab which houses the machine used by Dr. Tim Hewett to extensively study ACL injury, and participated in a golf biomechanics lab.

Coach Tamika (Williams) Jeter @ OSU

After Minnesota we headed to Columbus, Ohio, home of The Ohio State University Buckeyes.  Our host, John Dewitt took us on a tour of their athletics and training facilities where I ran into former UConn and Connecticut Sun basketball player Tamika Williams for a quick reunion.  We attended a discussion on articular cartilage surgical procedures presented by Caroline Brunst and a lecture presented by Dr. Ken Yeager on Building Resiliency observed the nationally recognized Ohio State Marching Band rehearse, attended the marching band Skull Session pep rally and another football game.  We had the chance to meet many of the Ohio State Physical Therapy Residents studying in a wide variety of specialties including performing arts, oncology, sports, orthopedics, women's health, and neurology.  And I got to see some of my Ohio family living nearby, which was the cherry on top of a really awesome collection of learning experiences.

Fellows with John DeWitt @The Ohio State University

I can't recommend this Fellowship highly enough, and would be happy to connect with anyone considering application for future participation.  I'm sure that if you asked Pat and Becca, they would select different portions of our trip as their highlights or what was most impactful based on the differences between our patient populations and professional goals, but I'm so glad I was able to share this impactful experience with them.  Thank you so much, American Academy of Sports Physical Therapy for this opportunity!

Volunteering in Tanzania

Africa was never really on my bucket list. It's SO far away from Seattle and pretty expensive and I didn't see the point in taking so much vacation time to go somewhere that is portrayed the way Africa often is.  And on top of that, why would I take a vacation to work somewhere else for free?  I thought I was going to a very poor place, a desert that would have been all brown, ugly, and dirty, with people who I knew nothing about whose circumstances don't impact my life. I've heard that safaris were amazing, but I despise zoos because they make me sad for the animals and I thought that a safari would feel the same way.  So what reason would I have to put this on my bucket list?

Me and Kristen

A year ago, I met Kristen, my coworker at Seattle Children's Hospital and an East Coast transplant who says Florida like every other New Yorker ("Flaahhrida") and won't eat at a pizza restaurant that doesn't sell by the slice because that isn't the true New York way.  She exudes an incredible passion for life and is a really talented physical therapist.  And she LOVES Tanzania.  LOVES.  She invited me - and several of our coworkers- to go along with her as she supervised a group of PT students from her alma mater, Stony Brook University.  So with the above reasons I had identified not to go, among several others, one key reason on my "yes" list ultimately won: I realized that I wanted to.  It hadn't been on my bucket list because people weren't talking about it, because it's not a top travel destination, because I don't know anyone from Tanzania or even anyone who had ever visited. But I wanted to travel to a new place. I wanted to meet new people, experience new cultures and eat new foods.  I wanted to see an elephant and a giraffe and a zebra in the wild and see that it wasn't like the zoo.  I wanted to connect with my coworker outside our office - because we had already started to become friends - and what better way to really explore a new friendship than spending every minute together for two weeks?  I wanted to give my time to people who needed it more than those I usually give it to.  And I wanted to confirm or dispute all of my preconceived notions.

Mt. Meru

I learned that in many cases I was wrong.  I wasn't in the desert at all.  In fact, Tanzania doesn't have desert.  The Sahara doesn't cover the entire continent of Africa.  Yeesh...There were tons of sunflowers and trees and our hotel had this AWESOME view of Mt. Meru easily visible in the afternoons when the clouds had dissipated.  It even rained despite being the dry season.  The safari animals are truly free.  Lions out in the wild are breathtaking.  There are birds with so many bright colors, they gave Costa Rican parrots and exotic rain forest ornithological creatures a run for their money.  They cooked foods with curry and I didn't really have to eat that much rice, which was good, because I don't really like rice, but for some reason expected to be eating it all the time.  

In some cases I was also right.  I was eaten alive by mosquitoes despite bathing in bug spray and sunscreen.  If you've seen any of my Facebook posts where I'm wearing a bandana or a headband - those weren't for fashion.  They were bathed in permethrin in an effort to reduce my bug bites.  I think it helped - my face didn't suffer nearly as much as my arms and legs did.

Traveling Pharmacy

Our group collectively did need most of the pharmacy that I brought with me.  I exclusively consumed bottled water including for brushing my teeth, but many meals did not agree with  my digestive tract. I got a nasty cut on my finger that required first aid care. Others in my group experienced some illnesses. Plus, the anaphylactic reaction I wrote about here.  

Our work and the things we saw were emotionally intense and left my mind wandering into the wee hours of the night, limiting how much sleep I was getting. (I would never blame late night chats with Kristen for the lack of sleep... ) I over-estimated what was available to the people of Tanzania, and as such, was a bit shocked by what I saw and what I learned.  Now I've been back home for just over two weeks and I'm still processing the experience. When it came up in conversation today at work, a wave of emotions flushed over me, just as it did while I was there.  The number of times "how was your trip" gets asked declines exponentially, but the feeling hasn't changed yet. 

Sandals made from recycled rubber tires

I've really been struggling to write and talk about my experience volunteering in Tanzania.  As much as I have tried to explain it, my words and photos are insufficient.  It's far easier to talk about the animals on safari and pretend like the volunteer work never even happened.  The zebras don't really elicit my emotions.  But talking about my volunteer work sometimes comes out as if I saw a world of poverty, despair, and sadness.  This was not the case.  

The people I met in Tanzania were a wonderful community who prioritize hospitality, traditions, family, and kindness and who happen to live in a place that simply has less.  Less of pretty much everything.  Less material "stuff" available to them than where I come from. Like shoes - where multiple times I saw these sandals made from recycled car tires.  Less money (Tanzania has .03% of the world's wealth averaging $2716 per adult - 2nd from the bottom of this list - compared to the US which has 25% of the world's wealth and $201,319 per adult - 3rd from the top - and consider that we have 607 billionaires in America according to this article averaged in along with the Americans living beneath the poverty line).  Less opportunity.  Less healthcare (269 hospitals in the country for 50 million people over 365,000 square miles (5.38 hospitals per million people) compared to the US 6200 hospitals for a population around 320 million spanning 3.7 million square miles (19.375 hospitals per million people) which just means both countries have areas where people have to travel far for a hospital, but in Tanzania, there are many more people trying to use less facilities.  Shorter life expectancy: 61.8 years compared to the US 79 years. Less schooling for children with disabilities - we learned about every single school for children with disabilities and how many students they accommodate and how many teachers they had in less than 45 minutes.  For all of Tanzania. Less infrastructure.  Less electricity.  Less drinkable water.  Less education (27 universities and 15 colleges versus 4298 higher education institutions in the United States.

Shanga Employee Wheelchair

So they have less... but does that make it bad?  No. And in some cases, cases that really matter, they also have so much more.  They have more family time.  Families live in close proximity with one another and honor their past traditions as they try to be a little bit current while simultaneously adhering to their tribal laws.  They have more respect for their elders - in fact they even have a specific greeting intended to be used with elders rather than for peers. They have more kindness.  They have more generosity.  They have more sharing.  I'm pretty sure they have more work ethic than many of us, working in more labor intensive work than many of us face.  They have more connection to their land and to their animals and to their religion.  They have more healthful food that does not contain the chemicals and processing we add to ours. They have more national holidays.  They have better maternity leave (12 weeks fully paid). They have the same sun, moon, and stars in the sky, but less pollution obstructing your view to see them.  They have the benefit of waking daily to the crow of the rooster, rather than those annoying ring tones installed by Apple set to go off every 9 minutes.  I really started to like waking up to the roosters.

Despite what you may have heard, there may be one planet Earth, but the world is not the same everywhere.  Tanzania is nothing like the United States.  But that does not make the United States better.  It just makes us different.  And, at the end of the day, we're all human beings who bleed red and breathe the same air.

Glass beads made at Shanga

The group of volunteers I went with were four Physical Therapy students from Stony Brook, one of their professors, Kristen, and myself.  Seven Americans split between two facilities volunteering in Tanzania.  One of the facilities was a school for children with disabilities called Step by Step where Kristen supervised two students.  My team was at Shanga which is basically a workshop and store that makes and sells crafts from recycled products and employs people with physical disabilities.  Shanga provides employment and salaries to individuals who would otherwise have much more difficulty finding work  Through sale of their products, visitor donations, and their larger parent company, they can feed their families and have support with access to medical care and equipment.

George teaches group exercise class

At Shanga, we assessed the needs of the employees.  A year before us, they had been visited by Stony Brook students who had developed an exercise program that the staff would participate in about twice per week.  They embraced their new program last year and were eager for some upgrades.  The previous program had some limitations such as a key focus on mobility, but not very much on strength.  We were able to update the program and we taught the leadership team basic concepts of exercise and ways to modify the program to try to give them more ownership and ability to have variety.

We also did one-on-one evaluations of several employees experiencing pain or with mobility issues they were hoping to improve.  There were some employees who had amputations who needed assessments of their prosthetic limbs, something I never do at Seattle Children's but had done on my clinical affiliation in New Mexico during PT school.  Other employees had experienced injury or been having some health issues they wanted checked out like cardiac concerns.  Some had seen last year's PTs and wanted an updated program, as well.

And so, I've described my volunteering experience.  But really, I've tried to explain that the way we view the world from here is through a distorted lens.  I, too, am guilty of this.  It isn't gone now, I'm just a little more aware, now.  Our pre-occupation with money and objects in the United States may be holding us back from some of the other beautiful values seen around the world.  I pray that this experience helps me reflect on what is truly important and embrace those things more in the future.  

Lions and Tigers and Peanuts, Oh My!

I just spent two weeks volunteering in Tanzania, Africa through a company called EDU Africa.  For sure there will be other posts describing the work we did and the impact being in Africa had on me, but I'm just starting to process those thoughts at this point.  Intertwined with our volunteer work were various cultural immersion experiences - learning some traditional African dance, tasting African cuisine, a canoeing trip where we were able to see many of the birds native to East Africa, and we finished our visit with a two-day safari. Who would have thought that after two days on safari where an elephant crossed the street right in front of our tour vehicle and we saw several prides of lions close enough to take my breath away - that a peanut would be the most deadly thing we would encounter on this trip... but alas, it was! This post is about one of my fellow volunteers experiencing an anaphylactic reaction to peanuts on our last night in Tanzania, some stats about anaphylaxis, and what to do if you find yourself in this situation.

Rice, Stew, and Ugali.  Photo: KConn

Prior to our arrival in Africa, the EDU Africa staff gathered each volunteer's dietary concerns.  The company organized almost all of our breakfasts and dinners at our hotel as well as providing us boxed lunches at our volunteer sites each day - interesting meals such as spicy carrot sandwiches and tomato paste coated french fries or cooked meat/vegetable dishes flavored with curry eaten using ugali - a traditional African corn-based dish that reminded me of polenta but that you roll up into a ball and depress a divot into it and basically make yourself a tostito scoop to gather up the stew.  We also had the opportunity to order off menus at a few restaurants which was a constant adventure... I tried to get mozzarella sticks at a restaurant called Bravo Pizza but the mozzarella sticks were basically limp string cheese rolled in dough that was floppy...more like the consistency of soggy fish sticks and were mostly good for a few laughs.  Because there is a high risk of water contamination with parasites, we were strongly advised to avoid consumption of fresh fruit (unless you can peel it like a banana) or any fresh vegetables (because of them being washed in the unsafe water), so there were a lot of carb-heavy meals and cooked vegetables and potatoes and eggs.

With regard to food restrictions, our group of 7 people had several.  For me, I have a strawberry allergy that, to my knowledge, is not very severe - though after this experience, I can guarantee I'll be getting that re-checked.  I also don't eat red meat - but had told them I didn't eat beef, so when pork chops were offered to me, I requested a vegetarian meal along with a fellow volunteer who is a true vegetarian. We had a member with a gluten allergy - try explaining that in Kiswahili - the official language of Tanzania - repeatedly - when they don't know what gluten is.  They use a lot of corn and rice, but to be certain that wheat wasn't in any of the foods was impossible.  And lastly, we traveled with a young woman with a severe nut allergy - who despite her constant efforts and a group of people looking out for her - managed to consume nuts on our last night as they were in a chicken dish with curry that had no evidence of hidden poison.  She had identified her allergy to the hotel, but whether a language barrier was the problem or the serving staff being unaware of what was in the food - it didn't matter. So... we had just finished our second day of African safari and are in the middle of Tanzania in a town I don't know the name of, when we were faced with a potentially awful situation.

Fortunately, there were seven of us PT students and PTs and, after seeing us run out of the dining hall to get closer to her EpiPen and medications, an Australian resident physician joined us and provided her recommendations, which ultimately led to our new friend of two weeks spending the night in a Tanzanian emergency room getting doped up on corticosteroids.  

I'll start with what you should do if you already know you have an allergy to which you have an anaphylactic reaction and you come into contact with the allergen.  In this case, you should have a prescribed EpiPen, which contains epinephrine, also known as adrenaline.  Epinephrine is a medicine that increases your heart rate, helps improve breathing, reduces swelling and hives, and can increase a dropping blood pressure.  Our friend knew she had the allergy but had never had to use an EpiPen because her previous exposure was her first and resulted in a trip to the emergency room home in the USA, ultimately resulting in her carrying an EpiPen and avoiding nuts at all costs.  She hadn't used an EpiPen yet, and there is always risk of having a negative reaction to an EpiPen, in addition to the reaction  you're already having to your allergen.

Our travel buddy had four EpiPens on the trip with her, but only one available while we were on safari, the others packed away in the city with the rest of our luggage.  After she started noticing symptoms, she immediately went to her room and decided to try antihistamines first, wanting to avoid use of the EpiPen.  Truthfully, it delayed the inevitable, though at that time we didn't have our driver on-site yet so it was a good thing that she delayed using it.  About 30 minutes after ingesting the nuts, her symptoms started to get worse.  She threw up her dinner, started breaking out in hives, began to cough and having some difficulty breathing.  Wanna know what happens when you start having trouble breathing?  You panic.  The major problems with anaphylaxis are that it can elicit constriction of your throat, which can be a medical emergency, as well as dropping your blood pressure, which can make you pass out.  Fortunately, our group acted quickly and had initiated the emergency chain to get our driver back to our hotel to be ready to take her to the hospital once things progressed - which they ultimately did - and the hotel manager contacted the nearest hospital to alert them of our situation.  When the Australian medical resident checked her out, and a transport was ready, she was ultimately given the EpiPen and taken to the hospital.  It was a scary situation for about two hours while the rest of the group remained at the hotel waiting for updates on her status, but the end result was a sore arm from weird techniques of placing an IV with a big bolus of corticosteroid making her sore.   Our terrible situation worked out in the best possible way.  Our friend is fine, and now knows what it's like to have to use her EpiPen.

But what if you don't know you have such a severe allergy?  If you find yourself in a situation where you think you have eaten something that could be causing anaphylaxis, the first thing - and also the most difficult - is to try to remain calm.  Panic and increased heart rate don't help if you're experiencing restrictions with your breathing.  Find someone to help you, so you're not alone, and start the emergency chain ASAP.  Either call 911 for an ambulance or get to the hospital quickly.  Anaphylaxis generally does not stop on its own, though it may seem to take a pause and then later return, which can be misleading and cause more trouble if you decide to delay getting medical attention.

According to this website from the American Academy of Allergy, Asthma, and Immunology,
(AAAI) anaphylaxis can be fatal, particularly if there is a decrease in blood pressure, difficulty breathing, or loss of consciousness.  Our friend definitely had difficulty breathing and was coughing by the time she left the hotel to go to the hospital.  We kept an eye on her pulse - but did not have means to check her blood pressure.  The most common causes of anaphylaxis are foods (all different types of nuts, fish, milk, eggs, and preservatives), medications (particularly antibiotics and anti-seizure medications), and insect stings.  In some cases, exercise can induce anaphylaxis, and there is a correlation between those who experience anaphylaxis and those who have asthma, as both tend to present with similar respiratory complications.  The AAAI site advises that if you have a reaction, you should always go to the hospital - even if you feel improvement in symptoms with your EpiPen or another medication.  EpiPen treatment is for emergency response in order to get you to the hospital for appropriate care.  They tend to last around a half an hour, though they may only last ten minutes, so people often carry more than one, particularly if they'll be far away from medical care, so that they can re-administer if symptoms worsen as it weans off.  EpiPen should be administered to the soft outer portion of the thigh and can be done through clothing.  It should be held in place for about 3 seconds and has an indicator on it that changes color to let you know that the medicine is being administered into the body.  Once an EpiPen is used, it cannot be re-used.

And so, the scariest part of my African adventure was a peanut.  Though there are no tigers in Africa, which this article explains, so if I had seen one on this trip, it probably would have scared me quite a bit, too.

The Government is After Me!

Photo Credit: Michelle Vieira at London 2012 Olympics

This morning I have a long layover at JFK airport en route to Africa!  As I've been observing TSA, watching the news sitting in horribly uncomfortable chairs, and seeing what's going on in the world, it got me thinking a little bit about our government. Earlier this year, I was home in Connecticut visiting my family when I received a letter stating that I had been selected for Jury Duty.  In the State of Connecticut.  Where I have not lived for the past 4.5 years.  Fortunately, it was easy for them to verify that I no longer live there and was able to get out of it - but that's my second Jury Duty Selection and some people have never been picked!  How does this happen?  What fortunate - or unfortunate - thing have I done to put me on a list saying I should serve when others have not been chosen?

My first jury duty selection was in the summer of 2004, right after my freshman year of college.  It was a trial where a man had been running in the early morning and he had been struck by a car resulting in severe, long-lasting injuries.  The runner was suing the driver of the car, who happened to be the newspaper delivery guy.  He was also suing the newspaper company and their insurance company.  I spent 5 days in the New Haven County Courthouse listening to testimony, reviewing medical bills and photos of the injuries. This was long before I was a physical therapist, so while I was a bit annoyed to be missing my summer vacation, my job paid me for the time and it was definitely a better learning experience than being at work in the bakery at Everybody's Supermarket would have been.

Anyways, I returned to Seattle after a great snowy East Coast trip and arrived to find a letter from the State of Washington Department of Health that my PT License was being audited and that I needed to show proof of all of my continuing education.  I was certain the government was out to get me!

So... for my fellow PTs - in or out of Washington State, here are a few pointers, should this happen to you, because I found the letter indicating my audit - and the details of what was needed- to be quite lacking.
1) Keep track of your continuing education!  Names of courses and the presenters, dates and locations of where you took them, number of hours, a list of objectives for the course, and keep the copies of the certificates.  My certificates are in a binder and I have a google doc with my annual course titles/hours already, but I didn't have all the required information that was asked of me.  For example, I've talked about the courses I took with Mike Reinold and Lenny Macrina a few times on the blog like here and here, but I couldn't have told you their credentials and didn't have access to written objectives for the two courses I took from them.  Fortunately, their credentials were listed on the certificates and they were more than willing to send me a list of objectives since their classes have been approved by continuing education review boards.  Medbridge also supplies all this information on all of their certificates.
2) Know the rules of your state.  Washington does not require verification of your courses for PT.  Neither does Connecticut.  Three states (Maine, Massachusetts, and South Dakota, which I wrote about here do not require continuing education at all.  But if you practice in those states and then try to switch states, this may cause you some problems in transitioning your license elsewhere. (Also- how are you practicing physical therapy without participating in continuing education?!? My education was great at UConn but seriously- you’re left needing to know so much more!) You may have specific things you need to have specific education for, varying by state. Examples of unique circumstances that some states have for continuing education:

• Suicide prevention training - required in Washington, course is available on Medbridge - probably a really good thing for any physical therapist to have!
• Spine manipulation - can get a special endorsement in the state of Washington, which I hold, and which has its own continuing education requirements. If I had to guess, this is the reason why I was audited... but maybe it's just random.
• Dry Needling - not permitted in Washington, but is allowed in many other states.  My understanding is that dry needling certifications tend to be regulated carefully in some states.
• Somewhat related - if you are a Certified Strength and Conditioning Coach through the NSCA, you cannot use almost any physical therapy courses for your continuing education for your CSCS.  They have a list, here, which includes First Aid/CPR as an option - which we cannot claim for continuing education for our PT licenses.

If you're in Washington, the letter for audit basically says you should read the laws and see what applies to you and submit sufficient information to cover your own requirements.  Here's where you would go to find that information:

1) Physical Therapy Requirements: here for your initial license and here for continuing education requirements

2) Spine Manipulation Endorsement Requirements: here
3) Dry needling is not permitted in the state of Washington under the Physical Therapist practice act,, so we don't have regulations for it. 

I asked a lot of PTs if they've ever been audited... zero coworkers or PT friends have been, but some had friends or family members who've had to submit their information.  Overall, the process wasn't really that difficult because I have all my certificates and track my hours - plus I have more than enough hours for everything I need.

Ultimately, this is my PSA that you should keep track of - at the very least - the minimum requirements you need for your license to remain active - because this is a real thing and to track those things down later would have been much more difficult. 

Abby 2 - Government 0.   See ya in two weeks, America!

Vaccination for Africa!

In just a few days, I’m departing on an adventure, heading to Africa!   I’m headed specifically to Nairobi, Kenya for a day followed by two weeks in Arusha, Tanzania ending with a Safari!!!!  Thanks to my coworker pal Kristen who writes this blog (even more specifically, has several posts from her previous trips to Africa, here)... and we’re joining one of her PT School professors and 7 students from Stony Brook University to do some physical therapy-related work. I don’t have the details of what we’ll be doing yet- so stay tuned for the post-Africa blog posts for that... but the preparations for the trip have been very interesting and I thought I’d write about the medical preparations for the journey - along with some thoughts on vaccination.

From: http://pcwww.liv.ac.uk/epidemics/MAL_geography.htm

Let's talk about medications.  Thanks to Virginia Mason’s Infectious Disease Department- not only was I able to receive the shots and prescriptions I needed, but they also explained many of the possible risks and made recommendations for me. They collected my dates and destinations of travel in advance, prepared a stack of pamphlets for me, and had the shots and prescriptions I needed ready to go.  I now have a whole pharmacy packed based on things that my body might encounter that it doesn't generally experience at home. Specifically- Tanzania is in the malaria belt and Kenya has an escalated risk for contracting yellow fever. And so- I have malaria medications and I had a yellow fever vaccine this week. The provider who organized all my medical care for these travels, Lisa Roberts PA-C was very thorough and presented the options for all the medications - such as discussing my choices for malaria medicines because some of them can be hallucinogenic.

Some interesting facts about these diseases:
Malaria:
1) Link: There are five types of malaria parasites called plasmodium.  One type, Plasmodium Falciparum, can be life threatening and induce liver failure, kidney failure, and coma.  This is generally the type that you take preventive mediation for when traveling.
2) Link: Malaria is transmitted by mosquitos, so using bug repellent containing DEET, long sleeves and pants, and taking preventive medications are all useful preparations. The particular type of mosquito, the Anopheles Mosquito, cannot survive in climates cooler than 68*F, so since central Africa is so warm, this is a common region for the disease.  As global warming continues, the malaria belt is expanding.  Even though the United States has successfully managed to reduce malaria cases, we do house these mosquitos, so there is always the risk that malaria can become a bigger problem here at home.
3) Link: There is a malaria vaccine, but it has a low efficacy and requires four injections... so I'm not immunized, I'm taking preventive medications. The reason for this is that the DNA of that plasmodium reproduces so fast, it can build resistance - just like we've seen with antibiotics resulting in things like methicillin resistant staphylococcus aureus (MRSA - the SuperBug) which, by means of evolution do not respond to the usual medications.  I'm so glad I read "The Origin of Species" by Charles Darwin, and wrote about it here.

Yellow Fever:
1) Link: Yellow Fever is also transmitted by mosquitos.  About 15% of those who are infected will have severe symptoms including shock, organ failure, and possible death.
2) Link:  The vaccine against yellow fever is considered to be life-long protection and 99% effective.  and is a live vaccine, which means that scientists took the actual disease, weakened it, and then it gets injected into you to build up immunity to it. There is also a shortage of the vaccine with limited number of places where you can go to get one - so if you're looking to travel, plan ahead!  You need a specific yellow card marked with your immunization in some cases - for example if you spend time in Kenya before going to Tanzania, like we are, you need the shot.

In addition to malaria and yellow fever, we also discussed risks for hepatitis, rabies, measles, mumps, rubella, influenza, and diphtheria, along with multiple symptoms that could require treatment, particularly related to gastro-intestinal distress which I won't go into detail about but which also included some shots and medicines.

What is a vaccine, anyways?  A vaccine is a medicine used to prepare your immune system to fight a disease in case it ever comes into contact with it.  Our body fights off disease by using a system that requires exposure to something to build up a defense system.  The vaccine is the first exposure to a disease, usually a weakened or dead version of it, so the body can recognize invaders and be prepared to fight.  There is considerable controversy around the country with some parents believing that vaccines are dangerous - or they don't believe in inoculation for a variety of reasons.

While I've been going through these preparations and getting additional immunizations beyond the ones I've had for public schooling, college, graduate school, working on an ambulance and now working in a hospital-based system, Seattle Children's and many other places around the country, have been facing increased episodes of cases of measles. Seattle Children's publicized exposures there here and this article describes the over 1,000 cases identified in the US this year, a considerable increase since measles was considered to be eradicated in 2000.  Measles is a highly contagious disease spread through coughing or sneezing or bodily fluids of infected people and does not have a cure.  A contagious person will likely infect 90% of the non-immunized people they come into contact with.  There is a high risk of fatality from measles because of the complications of the condition - immune compromise and opportunistic infections like pneumonia.  The vaccine is only 97% effective, so even those who are immunized aren't perfectly protected, but because of the high risk, it's essential that people vaccinate their children.  I urge everyone to read about the signs and symptoms of measles, particularly if you are in an area where there has been a spike in cases as it looks like there is a current epidemic occurring or if you are a healthcare provider.

Volunteering Emergency Response in Israel in 2006

Several cases of measles in Washington have been linked back to being at Seattle-Tacoma International Airport, where I'll be headed to depart for Africa in just a few days.  Interestingly, I also found this article looking at the measles epidemic occurring on the east coast, reporting cases in New York in Orthodox Jews who do not inoculate their children and who had recently traveled from Israel (which has been having an outbreak as well).  This article also discusses the Orthodox Jews having this increase in cases.  Having been to Israel several times and lived there as a volunteer EMT in 2006, knowing that they're so advanced in their medical and technological developments, this shocked me!  Over 500 of the cases in the US are in NY in this population, and Washington is 2nd on the list.  As a Jew myself, I can't understand why the Orthodox aren't taking care of this.  It seems that some believe vaccination is against Jewish law, which is of course an interpretation of something, though I'm not sure what, because vaccines obviously did not exist at the time Jewish law was written. What is for certain part of Jewish law is to do anything that may save a life, and since vaccination can save lives, it seems to me that more Jews would support vaccination.

Even the APTA has a position on this.  Physical therapists are in a prime position to encourage families to get their immunizations as part of their regular health care.  The risks of not doing so many times could include fatality - to your own family member or to someone else.  The benefits far outweigh the risks.