Rehabilitation - from A to Z

Cheri Blauwet, MD
PGY-3, Physical Medicine and Rehabilitation

St. Marc, Haiti
Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

I am now one week into my rotation in Global Health/Physical Medicine and Rehabilitation with the Zanmi Lasante Rehabilitation Team and in partnership with my residency program at Spaulding Rehabilitation Hospital. In considering the lessons most poignantly learned over the past 7 days, the ability to care for spinal cord injury (SCI) patients through the continuum of their care remains a highlight of my experience thus far.

Last Saturday our colleague from the Emergency Department called to ask if we could come see a patient for lower extremity parasthesias/weakness after involvement in a motor vehicle accident. It had already been approximately 12 hours since the time of injury, however his exam was clearly consistent with spinal cord injury at approximately the L2/L3 level, to include a palpable step-off sign as well as the flaccidity and decreased reflexes associated with spinal shock. The next several hours involved no less than 50 calls to surgical facilities throughout Haiti in an attempt to obtain the appropriate neurosurgical management for his acute SCI. He was ultimately transported to Port au Prince and admitted to a facility with the capacity for CT imaging as well as surgical management. There, he was diagnosed with an L2 burst fracture and in most recent discussion, he remains on strict spinal precautions while awaiting surgical decompression/fusion until a neurosurgeon is available within the next few days.

Only a few days later, I had the opportunity to go on home visits to see spinal cord injury patients within the Artibonite region and to more fully understand the manner in which care can be provided in the community. Observing the work of the St. Boniface Hospital Rehabilitation Team (a organization whose mission is closely aligned with our own), I was exceptionally impressed with the commitment and resourcefulness that enabled individuals with SCI to live full, healthy lives in their own home environments as opposed to within institutions. To provide an example, we visited one woman with a C7 SCI (and therefore tetraplegia) who was discharged from the inpatient setting only 2 months ago. Immediately after her SCI, she had developed Stage IV decubitus ulcers prior to receiving appropriate care, and these were still in various stages of healing. The Team had contracted with a layperson in the community for purpose of dressing changes two times a day given the lack of hands-on nursing care in her rural community. A cadre of “community integration technicians” had visited her home and widened the doorway of her small, brick home in order to allow her wheelchair to enter. The Rehabilitation Team had brought a small but reasonable monthly supply of supplies not available in her community, such as urinary catheters, wound care supplies, and medications frequently useful to the SCI population such as Gabapentin for neuropathic pain. In this setting, she was doing quite well and appeared to be moving forward, both physically and emotionally, despite having a diagnosis that would likely have been considered end-stage only a few years ago prior to the implementation of community based rehabilitation.

                         On a home visit near Verrettes, Haiti (permission given to post)

                           An example of home modifications (door widened, sidewalk from 

                                        street created with small ramp into home)

This series of events brought home to me the possibilities inherent within the process of rehabilitation, from managing high acuity injuries to ultimately considering issues of community reintegration as a portion of our role as physiatrists. This true continuum of care is what heavily attracted me to this field, and it is what keeps me “hooked” at the end of the day.