Guatemalan Journal : Cari Muschler

Guatemala Journal : Cari Muschler

Journal Entry 1 : Pastores, Miguel :  Guatemala

Cari Muschler : Physical Therapy student at Sacret Heart University, CT
Well we just got done with our first day.  We had an assessment session at the church where all the congragation came in and we took their medical histories, blood pressure, HR and screened for any illnesses.  I met two amazing patients.  One women was 32 and 5 weeks pregnant and having pain urinating.  She also had back pain and diabetic radiculopathy.  This was her third pregnancy, all of her past pregnancies were delivered by C-section, which apparently is how they deliver all of the babies here.  But, it was interesting working with the nursing staff, as they were convinced that all of her pain was coming from her diabetes and her UTI, but after questioning her some more I was able to find out that she had some SI disfunction due to her pregnancies and we were able to give her some exercises to help with the pain. 

The next patient I worked with was a 53 year old man who worked at the church.  He had 5 kids and had a wife who had a bacterial infection in her mouth, which requires her to get all of her teeth pulled, but he cant afford the extractions, so he was praying for the Lord to heal her.  When I was questioning about his health he said he was in fair condition, but was just so upbeat and happy.  He ended up having a fungal infection in both of his feet as well as experiencing some eye problems which caused dizziness. We discovered a piece of skin growing over the outside of his eye (which we unfortunately could do nothing about), and was having OA pain in both of his knees.  It was hard because there was very little I could do with no treatment table or even a floor to show him exercises on.  I suggested that he get some inserts to put in his work shoes as he said wearing tennis shoes decreased his pain.  I was able to find a table at the church to show him some hip strengthening exercises.

It's a whole different ballgame out here, we pretty much have to forget everything we learned about what to give patients for treatment and really be creative.  We can't put people up on a table and manipulate them or work on their tissue, because we have no treatment tables and because one treatment really won't be affective.  We can't give them any exercises that require them being on the floor because they all have dirt floors and we can't give them anything that requires any equipment, because they have none.

So I think what I figured out today, is that we should focus on function, trying to figure out what is causing the pain, making sure that it is musculoskeletal pain and not something systemic, and teaching proper body mechanics in walking, lifting and sitting.  But I'm off to bed to get some rest for a full day at a Mayan clinic tomorrow, so Ill check in with you then.

Entry 2

Wow, I don't even know where to start...
Today the team took off from Antigua and drove 30 minutes out of the city and set up a clinic an elementary school for all of the people in the outskirts of town to get medical help.   We broke off into teams of 2-4 with an RN and a PT at each station to make sure that we were covering all of our bases. In total my group and I saw 12 patients.  We treated everything from fungal infections - parasites - headaches - neck pain and stroke enduced dysphasia from alcohol withdrawal that resulted in a stroke.  The beginning of the day was difficult trying to figure out what we could really do to help these patients, but after seeing a few patients with similar problems I was able to get in a groove and know what I could give them with what little resources we had. 

The problems that we could help solve as PTs were primarily cervical and lumbar pain.  There were multiple women who came in with headaches, shoulder and elbow pain due to cervical and postural problems that we were able to address.  We gave them some exercises and postural education and hope that they will share this knowledge with others.  These women carry around their children until they are 4 years old while balancing everything on their head as they walk the hour to Antigua and back to sell their merchandise.  

We saw a lot of poor pelvic control that was leading to low back pain that radiated down their legs and was preventing them from working.  We sent them home with some exercises and were able to pick up some lumbar stability belts here in town to bring back to them tomorrow.  

There were three stories that really stuck out in my mind today though.  The first was a 97 year old woman who reminded me of my Grandma Cari who passed away at 101 a few years ago.  She was sharp as a tack, so thankful and wise.   She kept hugging us and kissing us on the cheek telling us "God is going to repay you 15x over for all the help you have given us".  She had very progressed cataracts that we unfortunately couldn't do anything about and also had ankle pain from a fracture that she has had for the past 10 years.  I was able to give her some pain medication and some instructions on how to keep the swelling down.  Although we were not able to do a lot for her, I have never seen anyone more grateful. 

But off to bed for another long rewarding day!

Entry 3

My youngest patient today was a 4 year old who had groin and knee pain for 2 years.   My first thought was that he could possibly have hip dysplasia or slipped capitol femoral epiphysis where weakened growth plate of the hip during growth spurts basically collapses and can cause bone death as one side had worse pain than the other and he was showing classic pain presentations of SCFE.  So I checked his strength, which was normal (at least I think it was as I'm not used to working with 4 year olds, but good enough) and I checked his range of motion and decided that he did not have SCFE luckily and that he had some minor dysplasia.  I wish I could have sent him to get an Xray and be able to see him again for follow up but all I could really do was instruct his mom in how he can strengthen his hips by having him do a lot of squatting down to pick up toys off the floor.  Hopefully that will stabilize his hips enough to decrease the pain.  

Two other patients really touched me today.  One was a 53 year old woman who had epilepsy.  She told us that she has these fits at night where she would go stiff and black out and wake up dizzy with foam at her mouth.  She had been having these fits for 10 years and her husband actually left her for another woman because of these fits, so now she was living on the street.  She also had hand, neck pain and headaches that after about a half an hour of examining her I discovered was due to a median nerve entrapment (probably from having the seizures) and I was able to give her some nerve glide exercises, neck stretches and postural education to help alleviate her symptoms.  She was just so grateful for helping her that she went around and gave everyone in the room a huge hug and a kiss before she left with a huge smile on her face.

Finally, I was presented with a 55 year old man, who looked like he could be 80 with severe arthritis in all of his joints.  He had the biggest nodules I have ever seen in every digit of his fingers, and his knees looked like they were the size of melons.  Despite the severity of his arthritis the only thing he complained about was knee pain and difficulty with his vision, even though I knew he had to have pain in every other joint in his body.  First I decided to tackle the easier problem, which was to find him a pair of glasses.  After checking his eyesight and finding out which ones to give him, he put the glasses on and his face lit up.  He was so ecstatic that he could actually see up close, it was truly amazing how such a little thing could make such a big difference to this man.  Then I was able to work through a knee exam and found that he had a huge amount of atrophy in both his quads and his calves, which were both just shriveled down to the size of a small child's, making his joints look that much bigger.  Since squatting was very painful, me and the resident were able to come up with an exercise he could do in sitting with a theraband for some resistance to strengthen his quads.  We then were able to show him some calf raises to not only strengthen his calves, but also his hips to help decrease the amount of stress at his knees.  Although this could only do so much, he was just so happy to have someone give him something that would help.  He too went around to everyone in the room before he left, gave all the girls a big kiss on the cheek and hugged all the guys, blessing us all for being there and helping him and the rest of his people.  

OMG I almost forgot Carlos! This man was amazing.  I had seen Carlos yesterday for back pain that was radiating down both of his legs and was causing him so much pain that he was unable to work as a farmer.  Yesterday I had given him a few exercises but knew I needed to give him more so I told him to come back today.  Last night I went into town to get him a lumbar stability belt to help him retrain his abdominals to helps support his back so that he could go back to work.  When he came in he was all smiles, and so happy to see me again.  I took him through another exam and found a position that elevated his pain. Finding this, I was able to give him some exercises to encourage the movement to help centralize his pain.  I also gave him some abdominal strengthening exercises, postural education and his belt.  He too gave us all a huge hug and kiss and blessed us and thanked us a 100x over and left.  Four hours later Justine, one of the other PT students, came over to me to tell me that Carlos was back sitting in line to be seen again.  I assumed that he had come with his wife as there was a woman with him, or someone else in his family who needed to be seen, so I went back to work.  Then 2 hours later it was standing in the PT room and in walks Carlos giving everyone hugs and thanking them 100x over again! He had come back and waited in line for 2 hours just so that he could come thank us all individually again.  I'm getting teary just thinking about it.  All of these people amaze me.  They are the most patient people I have ever seen.  They will wait patiently for hours just to be seen and think nothing over waiting, and then they are just so thankful for the smallest gestures.  

If only they knew how much they taught me today about patience, giving and love.

Entry 4

Today was our first day at Santa Maria de Jesus, a mayan village outside of Antigua. In the morning all I knew was that we were going outside of Antigua, and when we showed up at the base of a volcano at a school I had no idea what to expect.  We walked in and kids were playing in the courtyard.  As we entered we got bombarded by smiling children who ran towards us with open arms and gave us the biggest hugs I have ever gotten, it was amazing.  After setting up we were able to play with the kids for a while and take some pictures.  They LOVED getting their pictures taken, they thought it was so funny being able to see themselves on the camera.  When the kids had to go back to class we set up shop and started treating some of the teachers at the school.

We saw some with carpal tunnel, others with knee osteo arthritis and a lot of neck pain.  It was different treating these women who were so educated and really understood what we wanted them to do, it was great.  We were able to treat some kids throughout the day as well with sprained ankles, rib bruises from falling and some growing pains.

But the case that broke our hearts was this family who came in with their 2 month old daughter with spina bifida who had just had her surgery.  The nurses told us to come over to take a look at her, but when they saw her they were afraid for her life.  The little girl was so pale and dehydrated they thought she was going to die.  They were able to talk to the parents and collect enough money from the group that we were able to drive them to the nearest hospital, as we did not have the equipment to give her the treatment she needed.  When she left, one of the nurses who was collecting the money came up to me and said “I don’t know if she is going to make it, in my entire profession, I have never seen a baby in such bad condition before”.  We all had to struggle holding back tears, but were able to with hope, continue with our treatment for the rest of the day.  The parents had been instructed to bring their daughter back tomorrow.

Entry 5

Today was an amazing last day of treating here in Guatemala.  We were able to go back to the school a second day and had so many patients, as the word had spread through the village that we were there.  In total we saw 100 patients, including the little girl from the day before who was in such bad shape we didn’t know if she would make it.  She came back looking a lot better and the PT team was able to work with the parents to try and address some of the neuromuscular concerns.  She had a lot of tone in her legs and we were able to give the parents instructions on how they could help her in here movement development, strengthening her upper body, as she will never have full control over her lower extremities, but also working to decrease her tone so she could be as functional as possible.  The nurses still said she was not out of the clear yet and together we collected some money to help the family make sure they keep her fed with formula, so we are hoping for the best.

At the same time she was being seen, we were also working with a little boy named Kevin.  Kevin is a 1 year 10 month old boy with microcephaly who came in with his rightfully concerned mother.  Due to his microcephally, Kevin's head was very small for his age, but he was a ball of rambunctious joy.  It was amazing to see that he had reachd all his motor milestones, running, climbing, throwing, screwing on and off the bubble caps, falling and getting up, even hitting a few of us, all with a great big smile on his face.  His mother was concerned though that his head had not grown much in the past few times he was checked and he had not started to talk yet.  We tried to see if he was able to make any noises yet and although it took a while, we were able to get him to make out some sort of word/sound, so that was promising.  We were able to tell the worried mom that Kevin was doing great motor skill wise, and he was only a few months behind on language, but we were concerned that his head had not grown at all and decided that we would need to follow up with him.   We are going to try to raise funds to get him to a specialist.  If he doesn’t go he may begin to digress developmentally if he maintains this head size.    In the mean time we were able to tell the mother where he should be next with motor development and encouraged her to play catch with him, and work on double limb jumping.

We also told her to give him cereal to work on his fine motor skills and his speech development, as playing with foods in his mouth can help him develop the motor skills he needs to talk.  His mother was relieved and was very receptive to the recommendations, and I am anxious to see what we can do for him.

After Kevin, Lucus, another little boy who was 6 came in with his mother.  Nursing had referred him to us as he said he was having leg pain due to a recent fall.  Lucus was a little shy, but after letting him pick out a stuffed animal that was donated he opened up a bit.  After talking with him and his mom it turned out that his leg pain had not started with the fall but started 4 years ago when he was bit in the side of his chest by a dog.  His mother told us that at the time of the bite she had tried to treat the wound herself by putting various herbs and cloths on it as she could not afford to bring him to the hospital.  After a few days though the wound was severely infected.  She told us that once she brought him to the hospital the doctors there scolded her and were very upset that she had not brought him in earlier.  But honestly what could she do.  It is hard to see these loving mothers who truly care about there kids struggle and be blamed for the conditions of their kids when they really do not have the resources to give them everything they want to give them.  The wound eventually healed but Lucus was left with constant leg pain that went down the front of his thigh for 4 years.  After checking Lucus out was he was fairly strong, had normal range of motion but lacked muscle bulk in his right thigh, and his pain increased when testing the cutaneous nerve.  What had happened is his cutaneous nerve that goes down the side and front of the thigh had been restricted due to the scar tissue from the dog bite, causing the leg pain.  This didn’t help with the leg pain he was having below the knee though that started getting worse at the end of the day after getting a little more history from him.  When I started moving his knee and ankle around I noticed his shoes, they were 3 inches too big for him.  His foot barely fit in them.  Because kids grow and constantly need new shoes his mother, not having enough money to keep up with his growing feet had bought him shoes to grow into.  However, the poor kids could barely walk correctly and had to work his legs so much to keep the shoes on his feet that they were causing him to have constant shin splints.  We were able to tell his mother this, who giggled a bit embarrassingly.  As she could obviously not go out and buy him new shoes we decided to trace his foot so we could go into town and get him the right size to send up with the next group.  We were also able to give Lucus some exercises to help mobilize his nerve and increase his strength in that side of his leg, and hopefully both his pains should go away. Lucus left with a smile on his face.  These kids are so resilient.  It is truly amazing how stoic they are.  80% of the children were malnourished, had parasites, were sick and some had been in pain serious pain for a long time, and yet they come in with smiling faces, greeting us every day with a huge hug, laughing, smiling and not wanting to let go.  Some of them may eat a few tortillas a day, have to drink coffee (2 kids I found were having 8 cups of coffee a day because they could not afford water and coffee was cheaper).  All of them are underhydrated and really they have nothing but their families.  They all have jobs, helping their families sell things to tourists on the street after school or on the weekends.  They are robbed of a childhood, but you look in their eyes and you see old souls but pure joy.  I still haven’t been able to wrap my head around it, I can’t even describe the amount of strength these children have.  Their laughs are infectious and their smiles are so pure and you would never know that this is the life that they are living because it does not show in their faces.   These kids really touched me and I really don’t know how I can stop thinking about them.


Entry 6

At the end of the day we drove back to Antigua, exhausted emotionally and physically from a rewarding but tiring day.  We were able to get some fuel at the Church with a nice dinner then decided to head out to help the homeless.  One of the missionary families goes out multiple times a week, driving around to various spots to stop to feed the homeless with a pot of soup in their trunk and freshly made tortillas.  We had come on the trip all donated sockes, shoes and shirts to pass out as well.  Our first stop on the rout was a “shelter” which was literally just an outdoor cement block with a metal overhang, where homeless families and people could pay 1 Q to stay the night protected from the rain.  We got there and there were probably 20 people all huddled throughout the side of the building, most of which were drunk on rubbing alcohol or high off of glue.  There were 3 and 6 year old lids walking around, families, a lot of young men, and a lady in her 20s barely able to walk, grabbing in the air out of her mind.  It was a sight I will never forget.  We handed out soups and tortillas to everyone, and started handing out shirts and soup.  Things got a little crazy as competition for the goods with the drunk and high homeless as we wanted to give some more things to the families, but we got out unharmed.  We got in the van and drove to the next stop along the side of one of the buildings of Antigua where about 12 homeless men and one woman were huddled against a building along the sidewalk block, again all high and drunk off glue and some form of alcohol.  The 18 year old care taker/leader of this group of homeless men and women named _______ was there and greeted us.   We started handing out the soup and tortillas, and the shirts.  We checked to see if everyone had shoes and the one woman was wearing sandles.  With the rainy season approaching in 2 months we wanted to make sure that everyone had shoes, socks and an extra dry shirt.  We approached the one woman with sandles with a pair of shoes and socks. As she was a little out of it she was confused as we put the socks on her feet.  We started putting the shoes on and she started wimpering like a little kid, shaking her hands and tearing.  Apparently the sock needed to be readjusted and we laced up her shoes.  When she was able to make it to standing up, suddenly emerged the biggest smile and her face lit up like a little kid on Christmas morning.  She started walking around and stuttering what I think was thank you.  As we were starting to say goodbye and go she came up to us smiling and looking down at her feet, and started doing a little jig.  I jumped in and started dancing with her with her and her new shoes.  I loved my new dancing buddy with her new shoes, and so did she.  She ended our little dance with a big hug and a smile.  Dios Le Bendiga “God bless you” she said.  After our little jig one of my classmates and now my Guatemala family was talking with _____ who he had seen earlier that week on a homeless run.  _____ had pointed to him and another classmate saying I remember you, you were here earlier this week, I talked to you and you helped me with my legs (which they also had done).  He started telling them how by talking with them and it was because of them that he has hope.  He told them his whole story of how he had been homeless since he was 6 years old and how he was still there.  This man although drunk was so soulful and lovable.  He was just so sweat and kept saying, it is because of you I have hope, I want to walk to mexico and I want to go to America, and I want to learn English.  Dios le bendiga, he kept saying throughout the story, god be with you, and we replied dios le bendega back, as it was so hard hearing his hopes and wanting so bad for them to be true, but in the back of my head all I could think of is look at where this poor man is and how hopeful he is and how although I hope, I know that he will probably die there.  I will continue to pray for him and my dancing buddy, and I hope that they can make it off that corner and go to mexico, and America and learn English, but again look where they are….look what they have.  They are addicts, but they are sweat soulful kind loving people at the same time.  They were so thankful…dios le bendiga….and they said it with such honesty. …dios le bendiga…

Day 5:

It was strange waking up with no clinic to go to and no kids with smiling faced to hug and play with, but it was time for a mental and emotional break.  The team decided to wake up and hike up ____volcano.  We got in a van and took the hour treck up to the entrance.  Our guide jumped in and introduced himself. Caezar, but pronounced “che-char” was a smiling confident guy.  He told us that …..

As we started driving out of Antigua, I was surprised by how much I had seen and done this week.  It feels like in 7 days I did more and learned more than I have in 5 years.  I have been touched by these people.  These amazing people who have nothing but their families, who live with pain every day, work harder than I have ever seen anybody work, and still are gracious and hopeful and you know how you always want to be the best person you can be…well that’s how I can describe them….they truly are the best people that they can be or anyone could be.   Leaving them with only a sliver of help to only 200 out of thousands who need it is hard.  But I think, as one of the professors in our group said so eloquently as we drove out of Antigua is…you have one moment to make a difference in this one persons life in front of you.  You don’t know when that moment will come but you have to be ready.  As we leave looking back on the week, all we can hope is that just one action we did or just one thing we said stuck and made of difference in someones life….and that’s all we can hope for….dios le bendiga…


We pull up back to Sacred Heart and unload the bus.  Everyone else from the team leaves but us 6 PTs, and we all feel torn.  We want desperately to go home to our comfy beds, our homes and our families, and yet it feels like we are leaving our new little family and don’t know how to say goodbye even though we will see each other in 1 day.  But leaving each other means this mission is over, but it feels like there is so much more to do.

I pick up my dog and drive up my driveway, leaving my suitcase in the car.  Im not ready to unpack. I lie in bed, staring at my remote to my TV and feel almost like I am a stranger in my own room.  I don’t know what to do with myself.  There is so much that has happened in these past few days and I feel unprepared for the adjustment that is taking place, coming back to my realitiy and knowing the reality that lies with my new friends and patients back in Guatemala.  I cant help that a part of me feels like I have abandoned them, but I have to remind myself that im not.  I am going to follow through with what I have found and make sure I can touch a few lives because I can not think of anyone else that deserves being touched than the people of Guatemala as they have touched my heart.