KNOCK KNOCK… WHO’S THERE?

The Ministers of Health, Education and Social Protection!

Thursday, September 24, 2009… Wow! What an incredible day was had by our team!  We had meetings with the Minister of Education and the Minister of Health (one day prior to his official appointment), and we were introduced to the Minister of Social Protection.  As we have previously reported, this is a time of change in Moldova and we were on the ground level as the country is building its infrastructure.  The team this year has worked with people, programs and policies.

We’ll begin with our morning activities… a round table discussion held around a long rectangular table.  Beverly Kropp, special educator, and Cyndi Robinson, team leader, met with representatives from the Ministry of Education, heads of various government education agencies, as well as administrators and clinicians from the Rehabilitation Center for Children to discuss implementation of the new governmental regulation for inclusion of children with disabilities in the public school system.  Flash back to the early 1970’s in the US when children with disabilities were often institutionalized and did not attend public schools.  Beverly, our very humble team member, offered “what she could,” which included her perspective based on her experience in special education as a teacher, administrator and collaborator over almost 4 decades in the state of Oregon.  She expressed that inclusion is an evolutionary process which requires changes in attitudes and systems including teacher education, curriculum development, architectural changes, etc.  Equally, the people from Moldova offered perspectives from their respective agencies.  They described what has been done, as well as the future challenges they perceive.  Following this meeting, the top administrators present at the meeting expressed that the information provided by Beverly opened the first discussions between these Moldovan agencies.

Flash forward to the late afternoon…  Cyndi Robinson, Meryl Gersh, PT and Margaret Miller, OT were summoned from their clinical sites to a meeting with the soon to be appointed Minister of Health.  Dr. Vladimir Hotineanu opened the meeting with a brief commentary about the April elections in Moldova which were followed by public rioting.  The outcome of the subsequent “re-do” of the election held in late July presents an opportunity for change in Moldova by a more consensus driven government.  Cyndi, Meryl and Margaret identified opportunities to improve rehabilitation services in Moldova on a systems level.  Recommendations included development of a rehabilitation center, individualized rehabilitation programs, early intervention, multidisciplinary team management, and support for training of in-country specialists.  The Minister engaged us in conversation and demonstrated a genuine understanding and interest in the proposed ideas.  The Minister demonstrated a good grasp of interdisciplinary rehabilitation and shared a focus on reducing disability and improving participation.  He acknowledged the need for international consultation in order to develop the Moldovan health care system to international standards.  Dr. Hotineanu was officially appointed to the office of Minister of Health on Friday, September 25, 2009.

There is the old saying, “Sometimes it is not what you know in life, but who you know.”  We are fortunate to be aided by our in-country hosts and by the professional relationships developed since Cyndi first traveled on a team to Moldova in 2003.

Today was our final day working in the clinics… for now.  I have to say that I am thrilled and amazed by the accomplishments our team experienced this year.  Physical rehabilitation is being provided in ICU and acute care settings.  Dramatic changes to the system of rehabilitation are being considered at institutional and governmental levels.  Planning for the inclusion of children with disabilities in schools is taking place at a multi-institution level.  And we have been invited to teach in the Physical Therapy Curriculum in Chisinau.  During wrap-up meetings, I met with each of the clinic directors in the facilities where we worked to outline teaching topics for 2010.  I look forward to returning to Moldova in July and September of 2010!  Cyndi

Now it is late and all the team has gone to bed.  We are happy, satisfied, and tired! 

Napta buna…

The Cat in Shoes (alias “Puss n Boots”) – 9/22/2009

Often image is everything; sometimes it’s the only thing.

Cyndi Robinson and Meryl Gersh visited the National University of Physical Education and Sport of Moldova this morning and met the University Administration (Vice Chancellor or President, Vice Chancellor of Science, the Dean of the Faculty of Physical Therapy and Dr. Elena Caun, the head of the Faculty (Department) of Physical Therapy.  We were warmly welcomed and “official pictures” were taken in front of a wall of trophies and awards.  The main building of the Sport University is a magnificent structure – new, clean, up to date, with unbelievable sports, gymnastic, and fitness facilities, as well as state-of-the-art smart classrooms with the latest audiovisual technology.  Several saunas rivaled any spa in the U.S. and Cyndi and I decided we wanted to move right in.  This incredible structure is home to many of the academic sport programs at the University.  Unfortunately, the program in physical therapy is not one of them.

We were then escorted to the Physical Therapy Department, located in an old building “out back,” in disrepair, with none of the modern conveniences of the newer building.  Classrooms are small with no capacity for audiovisual support.  Students are taught from handmade posters and drawings, whose yellowing paper backgrounds indicate the age of both the poster and the science of practice on it.  We had to request to see the “lab” where students practice interventions three times, and were then shown a small room with three treatment tables.  Such austere facilities have even more of an impact when one learns that close to 125 physical therapy students comprise each class (learning teams of 25 students each).  With three treatment tables, how much practice time could each student possibly get?  We were assured that students also have some access to the facilities in the new building but we were never sure quite how much.  Fortunately, a new building (or full renovation of the old one, we’re not clear which) is scheduled for this coming year, so hopefully the physical therapy department will have a proper home in the future.

We met with the Dean and Department Head of Physical Therapy who were most welcoming to us and very interested in physical therapy education in the U.S.  They openly shared their curriculum, which on paper, resembles ours pretty closely, with foundational courses in anatomy, biomechanics, massage, procedures, and professional ethics, followed by systems courses in orthopedics, neurology, cardiopulmonary, and other topics.   Of course, it is difficult to know the content within each of these courses.  Dr. Caun was eager to collaborate with us in education and research and we were able to share some educational standards and outcome assessments with her.  We hope to be able to embark on some collaborative efforts in the future.

Meryl and Cyndi rubbing elbows with the President of Sport University

On another note, chaos reigned at the Neurology Institute later in the afternoon as Meryl tried to conduct an electrotherapy lab around a small table with 12 PT’s and 3 devices in the “occupational therapy” room.  There was much interest, many questions, everyone talking at once and our dear interpreter, Elena, trying to sort through the comments, questions, laughter, and “shocked” expressions.  The physical therapists (kinetotherapists) had never been exposed to electrotherapy before, and now have just two of Meryl’s lessons under their belts.  Still, they are an incredibly bright and dedicated group who also know how to have fun with their patients, each other, and visitors like us.  They’re looking forward to another lab tomorrow (we left after 6 p.m. and these guys work into the night!).

The first electrical stimulation lab

Other team members continue to do great work.  Margaret had a huge teaching day today.  35 people attended her seminar about developmental feeding skills.  She also taught a team how to administer the B and O, a developmental motor test for school-aged children.  Bev worked with a massage therapist at Republic Children’s Hospital, trading massage secrets.  She joined Margaret for the feeding seminar in the afternoon.  Sheri continues her important work, treating patients at the pediatric and adult burn units.  And the students, Janine and Irina, are our invaluable “tech support team.”  If we have any computer or equipment issues, they are right on top of things.  They fixed a computer glitch of Meryl’s on the fly during a lecture, and were able to fix a piece of equipment at the Neurology Institute and teach the PT’s how to program it.  They are learning a lot and are a terrific support to the team as a whole.

We laugh hard and share our stories around the dinner table each night, tasting and testing the wines of Moldova (some from wineries, some home-made – a scary thought!)  In fact, Meryl was offered a taste of home-made “Bailey’s Irish Cream” at the clinic this afternoon.  Actually, it wasn’t close to Bailey’s but, like all the “interesting patients” we see, this was one interesting beverage!

If you see pictures accompanying this blog entry, you know I had the tech support of Irina or Janine.  We are excited about the work, the terrific therapists and other folks, the highly motivated patients, and always grateful for the caring support of our interpreters, and Rodica and Vova, our MTI hosts.

La revedere (see you tomorrow – roughly),

Meryl Gersh

When Opportunity Knocks…

Greetings friends and colleagues!  Today’s post is coming from Cyndi Robinson, PT, MS, team leader.

This is my 8th trip to Moldova, my 4th in a leadership role.  I have had the opportunity to develop professional relationships and friendships here in Moldova.  I have learned about the health care system, the facilities, equipment and supplies available, and the knowledge and skills of the local professionals.  I have collaborated with our in-country hosts and the clinic directors while here in country and also by email and skype from half a world away.  I have been challenged to identify the best methods to bring change to those professionals who seek it but may be limited by government regulations and administrative directives and to help others to recognize the benefits of change to patient care outcomes.  Previous teams have been chipping away at a mountain, and this year we are experiencing a land slide!

As has been mentioned in previous posts, this is a time of change in Moldova.  There was a controversial government election in April that resulted in violence in the capitol city of Chisinau, our “headquarters”.  A new election in July resulted in the Communist Party losing the majority rule in the country.  As in a US election, this also means that many new government officials will be appointed.  Key to our work, we are hoping for the appointment of the new Minister of Health before the end of this week.  The individual who our local colleagues expect to be appointed is known to be a progressive thinker.  They are eagerly awaiting news… as they are hopeful for changes that will advance the quality of health care they can provide.  This is the opportunity I alluded to in today’s title.

Here are a few of the incredible highlights!

1. Meryl Gersh, PT, PhD facilitated the first treatment provided by a local PT in the intensive care unit setting.
2. Irina Lyamin, SPT and Janine Sing, SPT presented a seminar entitled “Timing and Intensity of Stroke Rehabilitation”.  The information they provided is expected to be instrumental in developing a plan for major changes to the model of rehabilitation in the country, including early intervention and more ongoing rehabilitation in the early weeks/months following stroke (and other illnesses and injuries).  The Minister of Health just modified practice regulations to allow rehabilitation in the acute care setting in late 2007!
3. Cyndi Robinson and Meryl Gersh will meet with the Vice Chancellor (president) of the Sport University in Chisinua, Moldova to discuss Physical Therapist education in the US and to discuss curricular development at the University.  I will also be exploring musculoskeletal teaching opportunities for 2010.
4. Margaret Miller, OTR/L and Beverly Kropp, LMT and special educator will be meeting with the Minister of Education, other high ranking officials from the Ministry and pediatric rehabilitation clinic directors to discuss inclusion of children with disabilities in the public schools.  This request is in response to a new government regulation.
5. Sherri Matson, PTA, has been working closely with the kinetotherapists on the pediatric burn unit to model changes to their clinical practice, particularly techniques for contracture prevention in the days and weeks immediately following burn injury.  Given the 2007 regulation allowing rehabilitation in the acute care setting, this is a new area of practice for our colleagues.

I have to admit that I have been in awe of my team members this year and also of the opportunities being made available to us and the accomplishments of the team.  I can’t believe what we have accomplished in one week… or what lies ahead this week… and for the future.  (Teams will be traveling to Moldova in July 2010 and September 2010).

Despite the hard work and late evenings of preparation, we have been doing our best to soak in the culture of Moldova.  Moldova’s primary industry is farming, of which wine is the main producer and export.  So, while you may have thought our winery tour and tasting was indulgent… it is a very important component of the Moldovan economy.  This past Saturday, we traveled about 100 kilometers from Chisinau to visit a monastery that is etched into the cliffs of a natural land formation.  As a bonus, we were treated to a motor cycle rally as a large group completed their monastery visit as we were arriving.  I particularly enjoyed the leather jackets representing multiple riding clubs from Moldova, Russia, Romania and the Ukraine!  I took photos so I will have time to sound out the words on their jackets written in the Cyrillic alphabet!

Moldovan Motorcyclists

Matryoshka doll and the countryside at the monastery

The rest of the team has headed off to bed.  I also better get my rest in preparation for another day.

La revedere, napta buna, buna seara, spa-koy-nay-no-chay… meaning good night!

Stay tuned for more exciting news!
Cyndi

Presenting Early Intervention in Stroke Rehabilitation

Irina Lyamin and Janine Sing, 3rd year students from the University of Washington, presented today on the topic of early rehabilitation for patients after stroke. They provided evidence from the literature supporting early rehabilitation for improving impairments, functional limitations, and participation, using the ICF model as the framework for their presentation. The Medical Director of the Institute of Neurology and Neurosurgery (INN), the Secretary of Education, and Chief of the Neuro-rehab Medicine at the INN were all in attendance. This was especially important since early intervention is not practiced in many/most Moldovian hospitals and acute centers. In order to make a change, these influential leaders must implement current, up-to-date, and evidence-based methods.

A quick background on some rehab methods in Moldova: in most hospitals in Moldova, with the exception of the INN, rehab is started in the acute center WEEKS after a stroke. Research suggests that early intervention (rehab as soon as the patient is medically stable) is not only safe but also important because most recovery after stroke is made within the first month. The presentation also facilitated a good discussion amongst various health care professionals  about how rehabilitation is structured in the United States.  We hope that the PTs and the influential leaders in attendance today will be able to have a strong impact on regulations of rehabilitation in the surrounding hospitals.

The remainder of the day was spent working with patients with various disorders, such as stroke, Guillain-Barre, and Devic’s syndrome. We are continuing to work with patients from the intensive care unit and are excited to see the PTs become more confident with working  with patients in this type of setting.

La reverdere!

The team at the Institute for Neurology and Neurosurgery

Working with a kinetotherapist (PT) and a patient with hemiparesis

-Irina Lyamin and Janine Sing

History made in Moldova: Physical Therapists provide the first PT treatment session in intensive care unit!!!!

Meryl Gersh, Professor of Physical Therapy from Eastern Washington University, and Irina Lyamin, a third year DPT student from the University of Washington worked with Dr. Oleg Pascal and physical therapists from the Institute of Neurology and Neurosurgery (INN) in Chisinau, Moldova to assist a patient in the ICU in gaining range of motion and mobility for the first time in an intensive care environment in  Moldovan medical history. Physical therapists in Moldova only recently received approval to work with patients in the acute care environment, and today was their first experience.  Dr. Gersh presented a talk on rehabilitation considerations in acute care to 50 physical therapists, physicians, nurses, ICU personnel as well as the Director of the Physical Therapy program from the Sport University in Chisinau.  Meryl and Irina were warmly welcomed by staff and patients at the INN.  Following the presentation, they instructed physical therapists in a hands-on clinical experience in the ICU, working with a 32 year old man who was diagnosed with Guillain Barre Syndrome.  The physical therapists were excited to learn how they could monitor the patient’s physiologic response to changes in position and even minimal levels of activity through the regular taking of heart rate and blood pressure.  We all look forward excitedly to this patient’s improvement in function through daily visits over the next two weeks.  Could sitting bedside be next?

Margaret Miller, MSOTR/L, an occupational therapist from Sacred Heart Medical Center in Spokane, WA, Beverly Kropp, LMT, a licensed massage therapist and special educator, and Janine Sing, a third year DPT student at the University of Washington worked in a pediatric outpatient setting with a young boy with arthrogryposis, and sensory hypersensitivity, which affected his tolerance to touch and facilitated movement.  They provided insight and treatment suggestions to the community clinicians and his mother on site.  Beverly offered guidance on structuring the home environment for cognitive development.  This team is also serving patients and clinicians at two other pediatric sites, a state-of-the-art pediatric rehabilitation center and a community youth center that supports recreational activities for youth with psychological and physical disabilities as well as healthy young people.  This team also toured a residential school for students with developmental delay.  They are excited to share their expertise and ideas in these settings over the next two weeks.

Sheri Mattson, PTA from Providence St. Vincent’s Hospital in Portland, OR and Cindy Robinson, PT MS, a faculty member at the University of Washington inventoried rehabilitation equipment that has been donated and shipped by container to Moldova during the past year.  As a result of their efforts, many of the facilities that we are working with will receive much needed equipment and supplies to their ability to deliver care.  In addition, they worked with a 2 ½ year old girl who sustained burns over 65% of her body in a house fire.  Her brother and sister were similarly injured.  The girl had spent 2 ½ months positioned prone on a mesh hammock in a crib at Republic Children’s Hospital and had undergone multiple debridement and skin grafting procedures.  Understandably, she suffers from severe scarring and contractures across most of her joints.  Cindy and Sheri instructed the parents, who are with her most of the time, in range of motion and therapeutic play activities.  They are excited about working with her similarly injured 1 ½ year old sister in the coming days.

All-in-all, it has been an exciting and most rewarding first day in our volunteer experience in Moldova through Medical Teams International. We are all looking forward to the development of lasting collegial collaboration and friendships here.  It has not been all work and no play, however.  We all enjoyed an excursion to Milisti Mici Winery on Monday afternoon. According to the Guiness Book of World Records, this winery houses the largest underground storage of wine the world – at this time almost 2 million bottles (and three ex-tourists from 2004) are stored along 55 km of underground tunnels.  Of course, we all had a great time.  Nothing like 7 women bonding underground over wine!

Hope you’ve enjoyed this update.  We’ll be back in touch soon.

Treating a patient in the ICU

Meryl and friends

Our Work Begins Tomorrow…

Our team of seven rehab professionals from Washington and Oregon arrived to Chishinau, Moldova about two days ago. Everything went smoothly with traveling. We took our day of rest on Sunday, and today we toured the various clinics where we will work. For most of us, the Moldovan culture is very much a whole new experience. As with all trips, it’s important to go with an open mind, not to have expectations. Most people live in very basic living conditions: apartments that have not seen renovations for years, overgrown streets and sidewalks, deep holes in sidewalks for sewage, etc. People work hard, try to live and provide for their families, and seem to enjoy the community around them. It’s a tight-knit, yet large community of elderly, families, and young people. It’s a developing country, doing it’s best to transition away from Soviet influence to claim it own identity, language , and way of life. It’s a beautiful culture with a rich history and the people are warm and hospitable.

Our work in Moldova will be quite influential. Currently the country is in a new political transition, with a new minister of health to be appointed. New laws and regulations will be put into affect soon. In particular, regulations surrounding physical therapy practice will be heavily influenced by the presentations and trainings we will be providing. An example is early intervention for stroke rehab. Currently in Moldova, patients are not mobilized during the first week post stroke.  Intensive rehabilitation may not take place for several months after stroke. We will be presenting evidence for early intervention,  aiming to get the Minister of Health, primary academic personel, and doctors to hop on the bandwagon for early intervention. Some of us will be presenting evidence on stroke, pediatrics, and psychosocial factors affecting stroke patients. We start working tomorrowing morning, with Meryl paving the foundation for early intervention in her first of a series of lectures. Others from the team will disperse into other clinics (neuro, pediatrics, acute). There’s lots to do, lots to plan, and lots of work to do. Will get back to you as plans progess…

Our Moldova Rehab team!

We made it to Chisinau, Moldova!

until next year….

A few weeks ago, our team of 8 transitioned to life in Moldova… and now we have transitioned back to life at home here in Washington where we will reassess our values, belongings, goals…  When we arrived in Moldvoa, it may have seemed sparse, antiquated, and in disrepair in many ways.  Then hospitality and familiarity took over.  We were embraced by our in-country coordinator, Rodica, as well as by the professional staff, patients and familes at the facilities where we worked. 

I have had the fortune of experiencing change in Moldova since 2003.  The rusted construction cranes are gone and new buildings stand in their places.  In the summer of 2007, the Minister of Health approved the provision of rehabilitation services in the acute care setting, making early rehabilitation following new onset of stroke and other diseases and injuries a possibility.  I worked in the newly constructed Rehabilitation Center for Children this September where professionals from multiple facilities gathered to attend seminars and training sessions offered by our team. 

What does the future hold for Moldova?  None of us can be certain what the future holds.  I believe an important thing for the future of rehabilitation medicine in Moldova is the unity that I observed among the professionals this year.  In the past, we have worked with the staff from individual facilities.  This year, professionals from a number of facilities shared our proposed teaching topics in advance of our arrival and identified a facility that could host a large audience.  As a result, we presented seminars to audiences of up to 55 professionals of different disciplines from a variety of clinical settings.  This unity will allow them to work together to implement information and techniques that were presented.  More importantly, I believe this unity will carry over into efforts to change the rules governing the education programs and services provided in rehabilitation medicine in Moldova.  Similar to our State Practice Act, changes in Moldova must be approved by the Minister of Health.

What does the future hold for our Rehabilitation Development Team?  We hope that we can continue to facilitate and support the changes needed in Moldova in order to enhance the quality of rehabilitation services.  Barb Ingram and I plan to lead another team to Moldova next September.  We also hope to facilitate additional teams to meet focused needs: pediatric (rehab and medical), stroke, and orthopedic.  If you are interested to participate as a team member, or supporting the efforts of travelling team members, please feel free to contact me (cyndirob@u.washington.edu) or Barb Ingram (uneedam@aol.com).  We would be happy to share our knowledge, enthusiasm, and fondness for Moldova.

Sincerely,
Cyndi Robinson, PT

Moldovan Happenings

• Well, the days continue to pass quickly.  The Moldovan health care professionals have been very receptive to seminars we have provided:
  International Classification of Functioning, Disability and Health as a Framework for Rehabilitation and Research
  Outcome Measures for the Assessment of Balance and Walking Following Stroke
  Research Study Presentation: Physical and Environmental Factors Associated with Recovery of Community Walking Following Stroke
  Burn Rehabilitation in Intensive Care and Acute Care Settings
  Benefits of Exercise in the Acute Care Setting
  Objectives of and Suggestions for Home Visits
  Role of Therapeutic Recreation in Acute, Rehabilitation and Outpatient Pediatric and Adult Settings
  Dependent Transfer Training
  PROM Techniques in Patients with Spasticity

We have been provided access to a conference room in the newly renovated pediatric facility for the majority of these presentations.  Professionals from several facilities have been gathering for these presentations… notworking we have not experienced in the past.  Yeah!!  Progress.  They are coming together to facilitate change!

Well, I have just been called away to a team meeting.  More later….

Thanks to all who are supporting our team!
Cyndi

Only a few days left

The end of our trip is rapidly approaching. While I’m looking forward to returning home (regular hot showers, normal sewer systems, no mosquitoes, and being able to easily communicate with those around me), I will also miss Moldova – the generosity of people, the adventure of something other, the food, the city and the country…… It has been a great clerkship, and a great international experience. I have learned a lot, and want to excel in my upcoming clinicals and future work so that I can come back here and help the health care professionals here achieve what they desire and are capable of. It will require a lot of change on their part, and change can come slow but Cyndi and Barbara have seen change over the past 7+ years. This is my last blog post here as I have work to get done for a patient and we have a project to work on. Thank you for those who have supported us one way or another. Paka, David

(oh, and the Moldovan dancers last night were AMAZING!!!!!!)

burns, peds, and me

Many know that I want to work with older adults (while peds wasn’t my favorite class, I didn’t mind it – I just knew that peds isn’t my kind of thing).  And of course, after you sit through a burn lecture who wants to work with burns?  Well, it has been enjoyable to work with peds patients with burns.  Getting them up and walking (3 teens with burns on their legs/feet), seeing progress as they learn to deal with a little bit of pain to increase their range of motion by quite a bit, using toys to get them to play and use the range of motion a bit more…. wow, it has been great!  Toddlers, adolescents, teens – all wonderful.  Of course, bandage change is another issue (more empathy than being sick to my stomach).

The health care system here and the training are very interesting.  They are 17 years out from independence, and started as the richest of the former Soviet bloc countries (now the poorest in all of Europe).  Unfortunately the system and training seem to be stuck in the past, which makes translation and working with professionals challenging, but it looks like attitudes are changing gradually.  I hope that we can come back again on a future team and see further changes here.

I could write about a lot more (inaccessibility or hazards such as missing manhole covers, the drivers, the beauty of the city and the country even though they are poor, the incredible generosity, the church, etc), but I must go to a “Moldovan Concert” (sponsored by the Cardiology Association or something)!  Paka, David