Academy Society Spotlight: Experiences in International Volunteer Work
December 2020 Issue
It was my turn to drive. There were nine of us in an oversize grey Chevy Suburban driving along one of the most barren expanses of highway in California. The arid landscape was dotted with scrubby bushes, some twisted trees, and occasional tumbleweeds blowing along. Four lanes, no other cars in sight, and only a straight line of pavement in front and behind. I felt safe and in control at 95 miles per hour. That is, until I checked my rearview mirror and saw the flashing lights of the highway patrol. My initial shock of suddenly seeing the police car was soon replaced by the shock at the hefty fine that the officer presented me with. But first he asked me, "Where are you all headed in such a hurry?" I explained that we were a class of orthotic students from UCLA on our way to a clinic in Calexico on the Mexican border to repair orthopedic braces for children with disabilities. The officer was impressed but still wrote me the biggest traffic ticket I have ever received.
I thought I would never forget that moment, but the whole ride quickly faded in my memory when we entered the makeshift clinic filled with families with children on crutches, in wheelchairs, or being carried by their parents, grandparents, or an older sibling. I was about to begin the most important and life-changing day of work in my life up to that point, and it led me to a career path that has always included international volunteer work.
One of the key aspects that drew me to a career in O&P was the wide variety of possible settings, from small private facilities to large institutions. Once in school, I learned of yet another benefit—the opportunity to do international volunteer work.
After several years of working and gathering experience as a CPO, I began taking time each year for international work. Since then, I have volunteered for Project Hope, the International Executive Service Committee, the Barr Foundation, the World Health Organization, the International Committee of the Red Cross (ICRC), and ProsthetiKa, first as an individual team member, then by organizing projects and recruiting other volunteers. I have organized clinical assistance and training courses in Eastern Europe, Asia, Africa, the Caribbean, Central America, and South America. Some projects stressed direct service and others focused more on training local practitioners. Some included multidisciplinary teams, and some were strictly prosthetists or orthotists. Each successive project provided me additional rewards and insights.
SPOTLIGHT ON TANZANIA
In 2016, I was asked by the ICRC to conduct a two-week multidisciplinary, hands-on training course on the
prosthetic and therapeutic management of patients with upper-limb amputations.
The course was to be given in Dar es Salaam, Tanzania, in East Africa. The trainees were 11 experienced prosthetists who worked in ICRC prosthetic service centers in areas of conflict. They worked in various African countries but periodically traveled to the ICRC training center in Dar es Salaam for continuing education training to advance the quality and/or scope of their skills.
Tanzania is the largest country in East Africa with 47 million people. The official languages are English and Swahili, and the culture is a mix of one-third Christian, one-third Muslim, and one-third various traditional African religions. It is a politically stable country, and therefore lends itself to hosting organized training activities such as the one I was asked to conduct.
OFF-SITE PROJECT PREPARATION
I began by recruiting Lynsay Emmrich, OTR, to join the team. Together we offered expertise as experienced clinicians and teachers. The lead ICRC prosthetist in Tanzania, Zeon DeWitt, is a trained, experienced, and credentialed clinician. He was director of the prosthetic program in Dar es Salaam and served as the local coordinator for our project. He assisted in teaching and administering the course.
Eight months prior to the training, our team worked remotely with Zeon and the ICRC team in Dar es Salaam to agree on the scope of the project, the curriculum, the number of trainees, the number of patients, and the type of prosthetic designs to be used and taught. We also needed to determine the materials and supplies that would be most appropriate to use, and what prosthetic designs would be most appropriate to teach. Supplies and components were ordered and potential patients who needed prostheses were contacted.
Three prosthetists and a therapist from Tanzania, two prosthetists and a therapist from Somalia, and two prosthetists and a therapist from Madagascar made up the trainee group.
Though the training was to take place over two weeks, I arrived one week in advance to prepare. During this time, I met with ICRC staff to finalize the logistics of the training. Tools, equipment, materials, and supplies were checked and organized, and the prospective patients were evaluated by the team. Finally, to assure that the fabrication would go smoothly in the unfamiliar workshop, I worked with Zeon to go through the entire fitting and fabrication process before students arrived by fabricating a body-powered prosthesis and a myoelectric prosthesis for the first patient.
Lectures and demonstrations were given in front of the combined group of prosthetists and therapists. The students were then divided into teams of two prosthetists and one therapist, and each team was assigned a patient. While fabrication was done by prosthetists, pre-prosthetic training, ADL training without a prosthesis, and training in the use of the prosthesis were done by therapists. When there was a particular challenge of interest to the full group, the combined class was brought together to discuss the problem and possible solutions. Finally, results and outcomes were presented and discussed among the full group.
As a multidisciplinary team, all individual assessments and treatment planning were patient-needs-centered rather than assuming every solution involved a prosthesis. With that in mind, patients were taught to perform selected tasks without a prosthesis when that seemed to be more appropriate. Some ADLs were taught both with and without a prosthesis. For example, some patients received therapy aids such as elastic straps to allow them to hold a spoon or a toothbrush on the residual limb to forgo a prosthesis. Individual needs were met with individual solutions. This was considered a significant benefit of a multidisciplinary course.
SELECTION OF APPROPRIATE MATERIALS AND TECHNOLOGY
During our assessment, we learned that all ICRC workshops in which the trainees work utilize thermoplastic fabrication techniques rather than lamination. They have access to polypropylene and have the equipment to vacuum form. We further concluded that the thermoplastic material met the selection criteria of being locally available and affordable. We therefore elected to use only thermoplastic materials during the course. We also determined that, to train in best practices, we would teach, demonstrate, and have the trainees use clear diagnostic sockets on all patients.
ICRC has designed its own components for their projects in developing countries. All prosthetists and technicians working in ICRC workshops are accustomed to using ICRC components for body-powered devices. We felt it was important to teach using the
components the trainees are likely to use, so we used the ICRC components for the body-powered prostheses in
Myoelectric components were also purchased from India and met the goal of being affordable and accessible. These were very basic myoelectric systems that allowed opening and closing using two electrode sites.
Through my experiences, feedback, evaluation of outcomes, and the advice and example of respected colleagues, I have concluded that to provide long-term benefits from a short-term project, the most effective O&P assistance plan should incorporate the following principles:
1. Work with a local partner organization that has a sustainable structure
2. Assure that the local partner organization has expressed a need and desire for our help
3. Assure that a project involving direct patient service also includes training for local clinicians to carry on services after the end of the project
4. Precede each project with a formal assessment of the needs, resources, and capabilities of the personnel, the locally available materials, the type, quantity, and quality of tools and equipment already in place, and the goals of the local organization
5. Include the local partner organization in assessment, planning, and implementation of the project
6. Assure that the content of the course is multidisciplinary, and that trainers and trainees consist of an appropriate multidisciplinary group to teach, model, and encourage cooperation and involvement
7. Measure the success of the project by the information and skills transferred and by enhancement of local capacity rather than only by the number of disabled clients that are directly served during the project
8. Attempt to utilize locally available and affordable materials, tools, and supplies to ensure sustainability and to avoid creating dependence. Locally available does not mean the materials used must be locally produced, though they may be in some instances. Rather, it means that the community has the logistics and resources to acquire the materials.
9. Teach and demonstrate best practice standards of care and outcomes and focus on achieving these standards with locally appropriate designs and locally available materials
In a well-conceived project, the ultimate benefit is to people with disabilities who receive services they would otherwise have not received. In addition, if local practitioners or technicians are trained during the project, the amputees benefit further because there will be improvement in the local resources available.
Local and visiting clinicians inevitably gain mutual understanding and respect for each other, and value the team approach as better for the patient. It is most gratifying to experience how working side by side in meaningful work transcends political, religious, and cultural differences. Philanthropic work in O&P has a positive impact on the giver as well as on the receiver.
Jon Batzdorff, CPO, FAAOP, practices in Santa Rosa, California. He is past president of the US Member Society of the International Society of Prosthetics & Orthotics.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.