WINSTON CHURCHILL MEMORIAL TRUST TRAVEL FELLOWSHIP

REPORT

REHABILITATION IN THE MILITARY POPULATION

FROM TWO DIFFERENT PERSPECTIVES

BY

MAJOR JAYNE McLENAGHAN

Acknowledgements

I would like to thank the following for their help and support during this fellowship.

I wish to sincerely thank The Winston Churchill Memorial Trust for allowing me this

fabulous opportunity to travel to the USA and Sierra Leone to research and learn. It has been

a wonderful experience from which I have grown and developed and will continue to

reflect upon for a long time to come.

Major Terry Fee PT US Army Centre for the Intrepid, Colonel Jennifer Menetrez MD, Ryan

Blanck, Johhny Owens PT at BAMC and CFI.

Bambino Suma (Prosthetics Outreach foundation- Sierra Leone).

DMRC Headley Court for the wonderful support they have given me to complete this study

period.

I would like to thank my (now) Husband Andy for supporting me in my often mad ideas to

do this, and worrying about me when I ended up in a few scrapes along the way.

CONTENTS

Page 3-6 Background and Methodology of Operations

Page 6-9 Introduction to the American trip

Page 10-14 Limb Salvage

Page 14-15 Multi Disciplinary Working

Page 15-18 Prosthetics

Page 18-19 Alternative Forms of Transport and Outcome Measures

Page 19-22 Aquatherapy

Page 22-27 Adaptive Sports

Page 27-29 Occupational Therapy

Page 30-32 Research and Development

Page 32 Sports Psychology

Page 33 Presenting to my US colleagues

Page 33-34 America at the end

Page 35 Washington DC

Page 36 Sierra Leone

Page 37 Sierra Leonean Rehabilitation Initiative

Page 38 Country background

Page 39 The adventure starts

Page 40-41 The Sierra Leone POF centre

Page 42-46 Working in the Clinic

Page 46-48 Cases

Page 49 Club foot project

Page 49-50 Amputee camps

Page 51-52 Equipment

Page 53 What did I learn?

Page 54-56 Goals achieved

Page 56 Conclusion

Introduction and Background

I have worked as a Physiotherapist at the Defence Medical Rehabilitation Centre

(DMRC) Headley Court for the past 9 years. During this time, the country has been

engaged in two theatres of war in Iraq and Afghanistan. The type of patients that I

encounter on a daily basis has changed dramatically from when I first started at

Defence Medical Rehabilitation Centre ( DMRC) Headley Court.

The wars in Iraq and Afghanistan have the lowest mortality rates of any modern

major conflict. However, the numbers of patients who now have life changing poly

trauma have increased to a level where they are the majority of the case load I now

hold. The scale of this type of trauma has never been seen in the UK and this

number of complicated cases of multiple amputation and polytrauma have also never

been rehabilitated or treated by physiotherapists. Along with these multiple

amputations, I am also seeing a substantial number of patients with soft tissue

damage which inevitably accompanies complex fractures to both the upper and

lower extremities.

I started this fellowship with a desire to learn and develop my existing skills and pass

on my new found knowledge to those in the same field within DMRC.

Personal Objectives

My personal objectives from the fellowship were as follows: -

To give and receive – to offer myself as a resource to those I met and worked

with on my travels and to share my experiences with those I work with at

home.

To expand my knowledge and that of the people I work with.

To look, listen and learn from others; to share in their experiences and take on

board any new ideas that they had to offer.

To take a „step outside‟ of my normal world and working environment, and

look into the world of others and the way that they work.

To absorb and assess all the information and introduce any new ideas into my

work place if appropriate.

Methodology of Operation

My methodology of operation was that I made substantial notes wherever I went. I

noted conversations, things that I had seen, ideas that came to me and moments of

divine inspiration. These notes were then written up in my hotel room or on a plane

as I moved from one place to the next. I took time to reflect on my experiences

during these times and continue to reflect to this day.

Before starting to plan my trip or filling in any of the application forms for the

fellowship, I had an idea of what I would want to do if I were lucky enough to be

selected and given the opportunity to travel. I would look to my colleagues in the

USA for new ideas, as they were no doubt experiencing the same type of patients

with the same injuries as I was seeing daily at DMRC. The US has more money to

deal with their injured servicemen and women and thus would have more resources

available to them as well as a brand new facility in the Centre for the Intrepid. I also

wanted to look at the opposite end of the spectrum where there was no money

available, like the African war torn countries. While being able to throw money at a

problem helps, some times money is not always the answer – this is where clever

ideas and treatment strategies come into their own. I also wanted to step away from

my normal life and day to day work to give me new ideas and refresh my energies to

enable me to continue to treat the difficult and demanding, yet inspirational group of

individuals who pass through the DMRC Headley Court.

INTRODUCTION

Fig 1 - The symbol of a broken ring, cracked but still intact, marks the entrance to the new Centre for the Intrepid, a 65,000-square-foot rehabilitation centre next to Brooke Army Medical Centre in San Antonio, Texas.

The first location that I really wanted to visit was “The Centre for the Intrepid”.

Named after an aircraft carrier of the same name that sparked the spirits of a nation

following the devastating attack on Pearl Harbour during the dark, early days of

World War II and which has become the namesake of the world's most

technologically advanced rehabilitation centre for amputees and burn victims.

The Centre for the Intrepid is a four-storey, 65,000 square-foot facility, adjacent to

Brooke Army Medical Centre in San Antonio, Texas. It was built by the „Intrepid

Fallen Heroes Fund‟. This $50 million 'state-of-the-world' physical rehabilitation

centre - all privately funded - was the largest single private contribution to the US

wounded warriors in the history of the country.

The centre provides traumatic amputee patients, burn patients requiring advanced

rehabilitation and those requiring limb salvage efforts with techniques and training to

help them regain their ability to live and work productively.

The Centre comprises of the following main departments: the Military Performance

Laboratory, Occupational Therapy, Physical Therapy, Prosthetics, Case

Management and Behavioural Medicine. Much of the technology found in the new

centre can't be found anywhere else in the world and it was this that attracted me to

the facility and is what convinced me to make it my first place to visit. What

physiotherapist wouldn‟t be excited about a Gait Lab which is fitted with 24 cameras

on an automated truss and which uses infrared light to analyze human motion? Or a

computer assisted environment, called CAREN, which is a 21-foot simulated dome

with a 300-degree screen that immerses patients using sensors and high-speed

infrared cameras and a moving platform that reacts to the patients' movements?

The third floor of the Centre provides patients with prosthetic fitting, physical therapy

and a gym, all within the same area. "If this was a civilian facility, a patient would be

fitted with a prosthetic device at site, go to physical therapy at another location, work

out in a gym and return to the get the prosthesis adjusted. Here it's all done on one

floor."

In the Occupational Therapy department, the focus is on restoring health and

function following serious injury or illness. At the Centre for the Intrepid, this is

assisted by a fully furnished apartment which has been created to give patients a

real-world environment to practice every day life skills.

According to Capt. Florie Gonzales, an occupational therapist at the centre, the

apartment is equipped with a computer workstation with state-of-the-art voice

recognition, a fully equipped kitchen and bath and a comfortable living room that

completely takes the patients out of the hospital environment.

In addition to the living apartment, patients have access to a virtual driving simulator

that helps them learn to adjust to driving without limbs in a virtual setting that mirrors

real driving experiences.

Patients can also hone their military shooting skills using a Firearms Training

Simulator that puts them on a 'virtual range' with 9 mm pistols and M-4 rifle replicas.

Other 'state-of-the-world' strengthening and physical therapy tools include a tread

wall, a 21-foot climbing tower, a mini running track, and a basket ball court and a

six-lane swimming pool. There is also a „Flow-Rider‟ machine which is similar to a

wave machine and helps promote balance, strength, motivation as well as giving the

users confidence in coping with their new injuries.

More than anything I went to the Centre for the Intrepid to meet the staff and see

how they cope with the same type of patients and treat the same type of injuries that

we see at DMRC Headley Court every day. These patients and their injuries create

a common bond between the two Centres which is probably not replicated anywhere

else in the world.

Limb Salvage

Over recent years, efforts aimed at limb salvage and the use of the external fixators,

such as Taylor spatial frames have increased across the world. Despite these

increased efforts, little in the way of research into the rehabilitation of these patients

has occurred and most of the progress that has been achieved has been in the UK

and the USA. I was fortunate enough to get the opportunity to spend two days in the

Brook Army Medical Centre (BAMC) with Johnny Owens, an American Physical

Therapist who has a special interest in limb salvage. Back at home in the UK, staff

at the DMRC have been pushing our patients to be weight bearing and be as

functional as possible as soon as possible, which is something that our American

counterparts are doing to great effect at BAMC also. They use a sports medicine

approach with a heavy emphasis on functional rehabilitation as well as aggressive

early management and restoration of Range of movement (ROM), strength training,

and integration into functional movement. This type of rehabilitation plan is based on

an algorithm of the functional assessment protocol which some therapists in the

United States have attended training courses for. However this is very time

consuming in its assessment and labour intensive in working out the plans. This

protocol has some exercises which are of interest, but on the whole I would believe it

is of limited in its application within our patient group.

The restoration of ankle ROM to allow enough plantar flexion to walk when the

cumbersome frame comes off has been a constant battle that the DMRC therapists

have been working hard on. In BAMC they have started to use foot plates to stop

the worst of this battle for ROM being lost. The aggressive use of Taylor frames on

the foot has stopped the progressive loss of foot dorsiflexion. The use of pins

through the toes to keep the soft tissue from shortening has proved invaluable in the

battle to keep the foot functional throughout the rehabilitation process.

Fig 2 – Taylor Spatial frame external fixator with foot place as used at the Brook Army Medical Centre.

The use of closed-chain functional exercises and corrective positional exercises is

something that we will increase in our programmes at DMRC, for these type of

patients. Constant correction to normal patterns and normal movement technique

helps with gait outcomes when they eventually come out of the external frames.

I have seen the use of progressive patterning exercises which we will be able to

integrate into our programmes, to encourage limb salvage and preservation.

Strength and core stability are emphasised along the course of the entire limb,

proximal hip control and balance work in non weight bearing, and early balance work

on some equipment which is new to me called “Proprio”, (PROPRIO Reactive

Balance System (Perry Dynamics, Decatur, Inc., IL, USA) which makes the patient

use their Foot and Ankle strategies and ROM whilst controlling their core movement.

I have learned a great deal of techniques and heard alot of experiences from Johnny

Owens PT, which have aided me in the ability to now plan further for the treatment

protocols for our limb salvage patients. However I had hoped that they would have

some outcome measures which I could draw from, but they are as limited in this as

we are in the UK. A lack of researchers and time and money means that there is little

outcome measuring tools, other than a return to running and passing a fitness

running test ( 2 miles). They do test strength testing with isokinetics, stability testing

by the way of the side jump tests and ability to perform a controlled single leg squat

from a 12 inch height. Lots of great work is being done on Amputee Outcome

Measures and this work will aid us in the UK to measure our progress and outcomes

for these patients.

In the US they have developed one wonderful prosthetic/orthotic device which has

revolutionised the rehab of calcaneal and lower limb trauma. The wonderful

prosthetist Ryan Blanck and inspirational PT Johnny Owens have developed an

orthotic which ensures that the weight bearing in a limb is taken off the foot and onto

the tibial condyles, such as in a prosthetic limb would. This has revolutionised CFI

and BAMCs‟ ability to progress these patients and get them to a stage where they

are able to run with calcaneal and lower limb damage. They are teaching running re-

education to encourage mid foot strike and lessen impact on the calcaneum, and the

use of a rhythmical metronome to gain rhythm and confidence was a great idea,

(which I have stolen and used in our patient group). Constant pendulum exercises

for the arms and legs to increase speed and consistency and accuracy, teaching the

patients linear and multi directional exercises to allow different type of movements,

allowing them to take part in a number of different challenging and dynamic sports

and activities.

Scarring and Soft Tissue Injury

Scarring which is a secondary problem

encountered in our patient group is also

seen by the team in BAMC, however they

are not offering any further or different

treatments than the myofascial release,

pressure garments, silicone and massage. I believe in the UK we are providing more

man hours of soft tissue work per patient in this field than is being offered in the US

centre, however I am uncertain, as there is no research to show if the outcomes are

any better if more soft tissue work is done.

A key difference noted at the CFI, was that there is a pressure garment company

on-site to provide a permanent measuring service, funded by the Veterans

Administration. This professional service takes away the need for therapist time in

measuring for these garments, and leaves more therapy time available.

In BAMC they are trying hard to convince and motivate patients to engage with their

limb salvage rehab programme and not go down the route of elective amputation. I

have gained information in how they do this including a video which they supply to

the patients to show what can be achieved by the limb salvage rehabilitation team.

I have learned that they are having the same problems in the USA rehab facilities as

we are in the UK, however I have gained great ideas to develop protocols and

problem solving with our own patients.

Multi- disciplinary team working

Much like our team at DMRC, CFI and BAMC work as Multi disciplinary Team

(MDT) delivering care. In this team they are lead by a Medical physician, who has a

team of Physical therapists, case managers, prosthetists, Occupational therapists, a

team from the Veterans Association (VA), physicians‟ assistants, dieticians,

orthopaedic surgeons and a Clinical psychologist nurse specialist. Although the

medical language is very different ,like us they use a lot of three word abbreviations

the ethos is the same and the delivery care excellent and planning superb.

During these MDT team meetings patients are discussed in depth and joint decisions

are made about the length of stay, social problems, psychology, and medication.

Many discussions are made when as to when patients should go to Medical board

and about their prognosis and futures. It is a very open forum and the team are well

gelled and talk easily putting their opinion forward without holding back. I learned a

great deal about the processes that are in place to manage these patients both

clinically and from a case management point of you. I was impressed with their team

playing and of the leadership that the Main physician in physical medicine showed

with the rest of the team. There was a great deal of respect within the team for each

other professions. I also saw the way they have the same difficulty getting some

patients to engage in rehab as our team in the UK do, and they have no more

answers than we have, just talking and explaining and being compassionate with the

patient is all they have to offer. I have seen some great examples of team work for

the best patient scare within the US system.

Each patient is allocated a case manager and at CFI they have a team of 5 case

managers who manage about 10 patients each, which are active and about a further

30 that are no longer in the active programme. These case managers are a

wonderful group of nurse specialists which means they know all aspects of care and

medical procedures and help co-ordinate care, surgical interventions, appointments

and the use of the VA facilities. This ability to understand the whole medical need of

the patient and the family position is a skill all of its own and they are the true key to

the development of the whole procedure of rehab in this setting.

Prosthetics

The prosthetics department takes up the whole of the second floor of the CFI

building and is a vast department, all purpose built and supplying a wonderful facility.

At CFI they have 4 full time prosthetists and a further 6 technicians who do the

fabrication of the limbs. All the fabrication is very similar to that in DMRC and time

scales are similar as well. The number of the limbs for each patient that is produced

can be up to 5 limbs. They have some great equipment to produce the limbs

however most of the production has the same problems as we have in the UK with

the increase in hard to fit patients because of length of residual limb and the increase

in heterotrophic ossification (HO). At CFI they have a great deal more emphasis on

the cosmetic appearance of their upper limb and have some great production of the

covers that are used on the upper limbs, looking like real skin and exact colour

matching. The myoelectric prostheses i-Limb and ProDigits (Touch Bionics,

Livingston, UK) provide an artificial functional hand or fingers respectively that can

be controlled by myoelectric signals. The prostheses also do not provide any

proprioception or sensation so the user does not have an idea of how hard or lightly

they are gripping the item, the amount of pressure has to be controlled by visual

contact. iLimbs are being used and researched more in this environment as are

myoelectric arms and hands. This is mainly in part to the expertise that they have at

this and the wonderful prosthetists who have made many of these, as they have

many more upper limb amputees than we have in DMRC.

In the Lower limb- C-Legs are used widely on bilateral above knee amputees,

however most single above knee amputees are given a mechanical knee. Trails for

the new generation C-leg are underway in the research facility at CFI to evaluate the

cost vs. functional usefulness of the knee. Phantom limb pain is dealt with in a

separate clinic- a specialist pain clinic where they also use acupuncture as well as

drugs to control these often debilitating pains.

In alternatives to traditional prosthetics other things are being tried. The trials for

oseointergration are ongoing in BAMC and at present they are testing the cellular

level work which is hoped will lead to great things in the future. However this is a

long way from a practical application for everyone, but the work continues to be

trailed for the future..

Alternative forms of transports

Wheelchairs are supplied by The Veterans Agency, and these are very similar to the

ones supplied in the UK, however they do have the ability to supply something much

more exciting and mobile- a Sedway. These are single personal carriers. Electric

two wheeled vehicles the patient can get supplied by a charity to allow them freedom

to get about. The main benefits of these are that they are smooth and exciting to run

in and they are great for bilateral amputees allowing them to go up to 27 miles in

them! They can do a flat out speed of 12 miles an hour and are a work out using

them as they require balance, core control and co-ordination to use. It offers a great

alternative to wheelchairs, and the patients love it!

Outcome measures

After much searching at Headley court we are trying to develop outcome measures

for patients with Amputations which are in line with the level of function we see in our

population group. We have been unable to find an outcome measure that is

suitable, and I had hoped that the CFI had something already in place to measure

their outcomes. They are not any further on than we are and are trying to develop a

measure called the Champ outcome measure, being developed by Dr Robert Galiey.

However it had not been published and I look forward to reading it and using it within

our population. In the mean time they are using 6 minute walk tests and heart rate

monitoring and recovering 1 minute heart rate and stair climbing 4 flights of stairs.

CFI do benefit from having an indoor running track, making this possible in all

weathers. They are struggling in the same way we are for a way to prove outcome

and are developing with their research department a gait lab solution to prove

outcomes in improving gait in amputees and lower limb trauma patients. They are

also using video fluoscopy to show fit and movement within sockets to improve gait

and walking efficiency in the amputee population. The OT department use a series

of outcome measures for hand function to test strength and activities of daily living,

which is invaluable within their treatment.

Aquatherapy

Aquatherapy is high on the agenda at the CFI, and they work through two phases of

aquatherapy, delivering 1/3 aquatic exercise, 1/3 adaptive swimming and then 1/3

flow- rider. They progress through a period of rehab every day until they are capable

of doing their own programme. The difference in our population and the US

population is that there is more than 50 % of the US forces who are unable to swim.

Therefore they spend a great deal of time teaching adaptive swimming. The CFI

when built had a “Flow Rider” installed and the principles as well as the “wow” factor-

was to work core, balance, and to encourage the patients to do adventurous

challenging activity. The noise of the “Flow Rider” is overwhelming, let alone the

movement and speed that the water moves (28 miles an hour)!! Which takes the

patient out of their comfort zone. I had the great pleasure of having a go on the

“Flow rider”, and enjoyed the experience and can see why the patients would benefit

from this type of therapy.

Aquatherapy is a great adjunct to treatment and the programmes that they have

developed will be a great source of inspiration for or development of a programme of

our new pool at DMRC. The equipment which they have and used has given me

great ideas of which equipment will work in our practice. They have adapted much of

the equipment for the amputees making fins that will fit on stumps and paddles that

will fit on upper limb stumps, giving ideas for adaptive sports.

I have spent a great deal of time with their aqua therapist talking about the nitty gritty

parts to running a pool and the clinical and technical problems that she has had.

She is the pool manager and programme manager and an amputee herself! A true

inspiration and the patients are able to relate to her and be inspired by her ability to

overcome difficulty. I have looked at their documentation and procedures to help us

with a plan to implement a new aqua therapy treatment plan. I have talked to them

about every aspect of pools maintenance, equipment care, testing, and pool training.

It has given me insight into what needs to be implemented with the new pool that is

being built and the procedures we have for our hydrotherapy pool. The use of the

patients as life guards (once trained up) was inspired and they find worth and

meaning in having a job with in the centre whilst still being able to take part in their

rehab.

Adaptive Sports

I have had the pleasure of seeing and trying some of the adaptive sports and look at

the way that they are implemented in this group. The most impressive of which was

sledge ice hockey which I have never seen before. This contact sport involves

balance, control and core stability and mostly guts and aerobic ability. I went to an

ice hockey practice and watched amputees, spinal cord injuries and combat injuries

of all types get on the ice and compete on a level field. It was inspiring to see guys

who have been really badly injured really enjoy a team sport again; in fact they were

travelling to Chicago the next weekend to compete.

The centre has a wonderful outdoor basket ball court, surrounded by enormous fans

because of the heat in the summer, and they practice once a week under the

supervision and guidance of one of the PTAs.

I have experienced kayaking in the indoor pool in preparation for the river and have

seen the skills that can be developed to benefit the rehab of patients. The skills of

Olympic level athels are being used to educate this group in kayaking so they can

participate in rapid

running and white

water. Teaching them

first to roll in the pool

and basic paddling.

I have even seen judo and self defence classes from “Challenge Athletes”,

amputees in action. I have watched “Challenge athletes” and “Operation Comfort”

display their wonderful programmes and seen the profound effects they can have on

rehab. The use of a recreational programme manager is inspired. Heather is a very

well qualified woman with a MSc in recreation management and psychology in her

background as well. This educational background is vital in understanding the use

and power of recreational therapy, you can see this well planned use of therapy in

the way that Heather works and engages with the patients. She even writes in their

therapy notes and runs the weekly community meetings. The patients enter into a

contract and goal setting when they go on an outing or a sporting trip. The patients

deciding what the goals of the exercise are themselves and ask the rest of the

therapy staff to sign off on their plan and goals. The other therapy staff – PT and OT

staff engages with a different type of sport and then attend if the patients have a

rehab goal. All new activities and places visited are assessed by a therapist.

Patients are asked to request what they do on the Friday afternoon activity and they

are classed in different levels of difficulty and social impact. This enables the

continuity of care and a feeling of community. The OTs even do the “Concealed

hand gun courses”- This just shows you the cultural difference between the two

countries. Not a single one of our patients in the UK are likely to have a firearms

licence.

This is an example of the activities time table they have in operation-

Monday- Kayaking in the pool, Running practice.

Tuesday- Golf at a local course, Equine therapy and Equine management course.

Wednesday- Wheelchair basketball, sledge hockey practice

Thursday-River Kayaking

Friday-Cycling in the evening, afternoon lunch/ bowling/cinema/mini golf activity.

Sat- Skydiving, abseiling and climbing, and rowing.

Sunday- Sledge hockey- on ice practice.

The Centre also offers partnerships with the Paralympics training teams and

“Challenge Athletes”, and get involved in big local events- such as mini triathlons and

the “Baton Death March” in Mexico just across the border.

One of the most fun things I did see was “Tyre Water polo” this allowed patients with

even the worst injuries to play on a level playing field in the water on the adapted

tyres!

In the UK we now have most of these activities available to our patient groups, the

culture differences in sporting interests are apparent in the patients choice, however

are excellent “Battle Back” team supply a great deal of choice to our groups of

patients.

Occupational Therapy

I have been able to spend some time with the OT team at CFI and have been able to

gain a great deal of information about the way they practice and seen the differences

and similarities between the way the two centres work. I had been given 4 pages of

questions from our OT team and have been able to get answer to these questions

and a great deal of insight for my own practice. They have wonderful activities of

daily living flat which has no adaptations at all to push patients to work in a difficult

environment- to challenge them. One of the best pieces of equipment is a car built in

the OT department with reality 2-D screens to try the patients coping strategies and

ability to get in and out of a car. This is most important in Texas as all the trucks are

HUGE! I have gained some great working partners in the US OT team and will be

able to work together in the future. The car allows practice with different distraction

techniques to get the patient used to the ways of the road before they start on the

real thing.

I also have had an opportunity to use the indoor simulated range to test my weapon

skills and watch the patients with injuries get used to weapons and firing again.

One treatment technique which they are using on both sides of the water is the use

of Mirror therapy for the treatment of phantom limb pain and sensation and the OTs

in the US are seeing great results with the use of this technique. Wheel chairs in the

USA are supplied by the Veterans agency (VA) and the OTs have very little to do

with this process as an expert from the VA does all the measuring and prescription.

The manual therapy treatments for burns patients and restricted joints are all very

similar to the treatments used by our staff in the UK, and they are delivered by both

OTs and PTs depending on the area of the body affected. I have picked up some

great ideas for equipment that could help us in our practice, and these could be

easily made by our workshop department in Headley Court, everything from

desensitisation equipment to assessment tools. I plan to feed back all the things I

have learned from the OTs in the US to our group in the UK.

Research and Development

I had the privilege of spending a day with the 12 strong research team working in

CFI. I had a chance to talk to them about the research that they were doing and how

they have worked it towards the clinical need of the patients who are seen in CFI.

They have a myriad of wonderful research equipment, including a top of the range

gait lab and a virtual reality system –CAREN. CAREN control software suite

provides real-time data streams between many types of integrated hardware. It

creates a situation where a human subject is immersed in a real-time feedback-loop

where his motions and behaviour are considered an input and output of this

feedback-loop having the system respond to the motions of the subject and the

subject motions to the system.

I had the opportunity to be immersed in this

virtual reality system and try out the clinical

applications for this piece of equipment and

discuss how the use of this has made clinical

improvements with patients. It is a very

expensive piece of equipment and we would be

unlikely ever to able to buy something like this,

but the virtual reality cheaper things like Wii

could be something we could use more in our

practice and it has given me some great ideas.

of some things to try.

I was able to see the use of the gait lab and the trial of some new C-leg systems

which we may use in our clinic. It is a massive lab that takes so many people to use

and run and it is right in their clinical practice area. The interface between their

clinicians and research team needs some work to make this more clinical in its

implementation, and this is always a problem in a situation like this. It is staffed by a

wonderful team who are both forward thinking and dynamic.

They are currently studying dynamic balance and visual fields, the effect of vacuum

assisted limb suspension sockets on stability, reaction timing on mild traumatic brain

injury, and the effect of walking speed and surface on dynamic stability. All of these

projects are relevant to our practice at Headley Court.

It has inspired me to try some different techniques and keep in touch with the

research team in CFI so see the results of the current research projects so we are

able to put in practice some of the techniques which may work in this population

group.

The current projects include-

Trans-tibial amputations- reliability of kinetic and video fluorscopic

assessment on veterans. This work is assessing the displacement of the

stump in the socket, and how vacuum sockets help with the energy efficiency

of the limb and the proprioception and time to recovery in balance of the

residual limb. This is tested by walking speed on an uneven surface,

increasing speed and making the under surface more unstable.

Dynamic stability walking during platform and visual field disturbance. This

exciting piece of research is looking at the reliance of the visual field in the

walking pattern.

Reaction time in concussion and mild traumatic brain injury.

Longevity study of outcomes of amputees at 0, 2, 4,6,12 months and then at 2

years. They are testing the gait pattern in the gait lab, the metabolic

efficiency.

Distraction and walking- testing if patients are able to multi task and walk on

the prosthetic limb. To improve the ability to cope in the real world of busy

pavements and crowds.

There are so many implications for us in the results of the work that they are

doing and I wait in anticipation of the results of the studies to inspire our practice.

It has also inspired me to use some of the techniques they use in the research

facility in my own practice.

Psychology and the Sport Medicine

I had hoped that CFI would inspire me to use more psychology in my treatment but I

have seen very little use of psychology techniques in day to day treatment. It may be

that because their psychologist is at another site that I missed some of the input the

patients would receive. I feel that in the UK we are using more relaxation, Cognitive

behavioural therapy, imagery, goal setting and positive thinking in our treatment

process. I think that it is something our patients benefit from. They do have facilities

on the main base for main stream sports psychology which they use with sports

psychology but I feel that they have not integrated it into this programme or trained

their therapists in the use of this great intervention. I have spoken to both OTs and

PTs about their thoughts and they are shocked by the amount of time and efforts we

use in our practices dealing with psychology issues and relaxation techniques-

maybe their patients are much more laid back about their situation and rehab where

we find our patients both angry and frustrated by the process, and by their injuries.

I have also found that psychology has been used in the welfare of the staff. They

have done some research on the “Compassion fatigue of the care givers” and found

that 50 % of staff who cared for combat casualties had compassion fatigue and 38 %

had burn out. This may be something I will research in our staff as I feel some may

be suffering in silence from compassion fatigue. In Headley Court we use

psychology in the treatment of our chronic fatigue patients, with our OTs using

cognitive behavioural therapy and pain management strategies which I saw no

evidence of their usage in the US.

Presenting to my colleagues in the USA

I had been invited by my US colleagues to present how we work at DMRC, and

about my fellowship. I had an opportunity to present to about 40 people and enjoyed

the experience even if some of my English humour was not enjoyed! I enjoyed

speaking about my opportunity and the fellowship and about what the trust has

offered to me by way of help and support. I spoke about my work and the work of the

team at DMRC, the Help for Heroes charity, the WCMT and our battle Back

programme. I got a great response and some additional offers of help with cross

Atlantic adventurous programmes.

America at an end

My American colleagues have been inquisitive and engaging and have been a

constant source of education and humour. It has been a great experience to both

my cultural and educational side, and has given me moments of divine inspiration

and a renewed regard for my own profession. What I have found is that although we

are countries who both speak English and you would think similar values, we could

not be more different in a lot of respects. They way care is delivered in a cultural

context would not work on all British forces patients. The type of patients that DMRC

receive are culturally very different from Americans and alot of the way that the

process work in the USA would not translate well in the UK, due to our cultural

differences . This is mainly to do with the way our forces think, act and behave and

the way in which family and “home” is regarded culturally in the UK . DMRC

patients want to be with their friends and family and not stay with us unless they

have to. They are unwilling to change their lives once disabled, and the family home

and area they come from is very important to them. Here I learned a lot of very

useful ways of working and have gained a wealth of knowledge some of which could

not translate due to culture, values and financial reasons to UK rehab. It is just a

matter of taking those things that can be translated and using them to improve my

practice.

The great thing about the USA is the attitude towards their forces and those injured.

I have seen great improvements in the attitude and way the UK has got behind our

Forces over the last few years, however the US public is constantly aware of the

sacrifices that these people have made for their “freedom”. It is very evident in

talking to the public and watching the TV of the attitude towards the injured and how

much money they have invested in the facilities which have been provided. On

attending the Ice Hockey match I watched in awe as the whole stadium got to their

feet for the sledge hockey team and showed such respect for the serving members

who were also attending the match. This level of respect and love for their country

and freedom is a rare site as is the true patriotism that they show from an early age

and in every day life. The way that every man has a true love for their country and

shows it is the singing of the national anthem and the understanding of what freedom

means is something that may be watered down in our own country.

Washington D.C.

Life has not been all work and I had been told by the Trust to enjoy the experience

and do some things that were “out of the box” and enjoy travelling and expand my

life knowledge. So on my way back to the UK I was able to stop for a few days in

Washington DC to stay with some friends who kindly put me up so I could drink in

some more American culture. Texas sure was big, but DC was something all

together different. It gave me a chance to see what effect Britain had on America

and in everywhere I went I was reminded how much influence the UK has had on

history and how influential Winston Churchill was on the US during the war. I went to

the White house and saw pictures of our great leader meeting Franklin D Roosevelt

and drinking tea on the lawns outside the White House. I went to museums and

followed the USAs‟ slant on the wars both present and past and on how Winston

Churchill had a huge effect on how the US participated in the Second World War. I

also had the overwhelming experience of going to Arlington National Cemetery and

watched from afar as they buried a soldier who had been killed 8 weeks ago in

Afghanistan when I had been serving there. It brought in to perspective the war and

the loss and how things had been full circle for me to witness the injured and the

dead during my tour of Afghanistan and then see the “home” side to it back in the

USA. A sad and poignant end to my stay in Washington DC. The Capital city is a

credit to them and all things capitalistic and democratic. They have a nation who has

a culture so different in every aspect from the British, and never a moment passed

whilst I was there that I did not feel very different and VERY British.

Sierra Leone

When I started to think about what I wanted to gain from the chance I had been

given to do anything I liked- to study and travel, I wanted to give something back. As

with a lot of things, we take for granted what we can do, what we know and the

knowledge we have, with no real thought for those who do not have and cannot do. I

wanted to give myself the tools to be useful in the future to implement some

regeneration work in Iraq and Afghanistan when the opportunity comes and the

countries are more stable.

I looked to other countries who had had recent conflicts and who were now

rebuilding. One of those countries was Sierra Leone (SL) in Western Africa. Having

emerged from the end of a bloody civil war where the country and its people had

been devastated by a conflict so gruesome that it left thousands of people without

limbs, it was rebuilding itself and trying to now treat its wounded.

I found a charity based in Settle in the USA who supported a project to enable locals

to treat and enable their amputee population. Called “Prosthetic Outreach

Foundation” (POF) they provide the funds to run a rehab facility in Makeni, 3 hours

east of Freetown- the capital. It was inspiring to read their web pages and see the

difference they were making with very little money and staff in countries that had

been ravaged by war. Having watched the Americans spend alot of money on a

project this was my way of seeing how the “rest of the world do it”. Helped by Rye

Pye of POF in the USA I planned the trip. I think in hindsight I did not know what I

was letting myself in for! I had been in Africa several times and knew what to expect

from an African country. The one thing I did not expect was the worried look on

everyone‟s face when I said that I was going to SL- on my own! I read some books-

some of which made me feel better (some worse) about what I was going to find. I

spent some time persuading my poor “other half “that it would be fine, and a few

interesting conversations with a travel agent to get me to where I wanted to go. A lot

of reading of guidebooks and novels helped me in the practical aspects like money -

it was somewhat of a shock to realise that I could not use my bank card anywhere in

the country, money was difficult and I could not get any Leones in the UK, I had to

wait until I got there. A long way from the wealthy and easy USA! Safety was my

main concern and the charity that I had planned to travel to was able to make me

feel a little bit better, however it was a long way from my comfort zone!

Sierra Leonean Rehabilitation Initiative

In 2005, Prosthetics Outreach Foundation launched an

exciting new program in the West African nation of Sierra

Leone. This rehabilitation initiative is bringing modern

prosthetic care and rehabilitation services to children and

adults throughout Sierra Leone's Northern Province, a

region hit particularly hard by

the recent civil war. As the

only local or international

group providing similar

services in northern Sierra

Leone, POF is filling a critical

need and contributing to the rebuilding of this war-

torn area.

Country Background

A devastating civil war gripped Sierra Leone throughout the 1990s and into the turn of

the century. Rebels gruesomely amputated the hands and feet of men, women and

children, both to terrorize the population and to deter them from supporting the

government.

When the war ended, tens of thousands of people had lost their lives and more than

two million individuals were displaced, living in large, anonymous, government-

sponsored refugee camps. Today, families struggle to regain some semblance of a

normal life in a world where friends and relatives have vanished, where there is little

remaining economic infrastructure, and where both emotional and physical scars run

deep. On March 23, 1991, rebel forces led by Sankoh crossed into Sierra Leone from

neighbouring Liberia with the stated objective of toppling the corrupt government.

However, their first targets were the country‟s lucrative diamond fields and any

villagers caught in their path. Once in command of the country‟s mining sector, the

RUF became a fearsome and seemingly intractable force. Using income from rough

diamonds smuggled across the border into Liberia and Guinea, the RUF purchased

weapons and financed their hit-and-run military operations.

For over a decade, RUF forces wreaked havoc on the country, directing the brunt of

their terror on civilians. Government forces, weakened by corruption, in-fighting, and

lack of funds, proved incapable of protecting communities from RUF atrocities, which

included mass rapes and murders, child abductions, and indiscriminate amputations of

non-combatants‟ hands, arms, feet, and legs. Only with the successive interventions of

a multi-national African army followed by a UN peacekeeping force was the chaos

finally quelled in May 2001.

The adventure starts!

So the adventure started- with a six hour delay at Heathrow, a flight that landed in

the dark when it should have been light, a thousand people pestering me to help me,

and a lack of a guide who had forgotten to pick me up from the airport. The trip had

started pretty much as I had expected- expect the worse and then it will only get

better.-I was rescued by the Immigration Officer- who I have to say to this day was

the kindest person have met in the whole of Africa. You are not allowed to enter into

SL without someone to met you and guarantee your safety if you are foreign visitor.

When my guide did turn up (24 hours late!)- I felt much better!

The trip to Makeni was interesting- first a taxi ride, a deep wade into the sea- a boat

ride and a 3 hour 4x wheeled drive, and a wonderful host in Mr Bambino Suma- the

prosthestist who works for POF as he was guaranteeing my safety!

The country is colourful and very African, with a wealth of different types of scenery

on the way, from flat grass land to jungle. No mains electric power exists in Makeni

as they are waiting for their Hydro Dam to be finished in a few weeks. Everyone

either has a generator or makes do

with candles or lanterns at night.

People take their mobile phones to the

shops to charge them for a fee. In fact

nearly everyone has a phone and no

one has electric to run it off! The

country is a strange mix of odd values and standards and odd infrastructure. With a

very limited health care system they have a low life expectancy and live life to the

full. This involves dancing, loud music, a locally brewed alcohol from palm trees

called palm wine, having more than one girl friend and driving like a lunatic, with very

little thought for tomorrow. It makes them a great, warm and often very aggressive

people, who live hand to mouth and have to struggle every day to stay alive. Poverty

is everywhere- even the houses that do look ok, are nowhere to the standard that

you would expect even in a developing country. I was met with a strange curious,

suspicious attitude by all, who quickly changed their attitude when you are warm and

friendly to them. When they know why you are here they are even better.

I was the only white face in town and kids stared and ran after you like you see on

the TV, just to look at me and my white skin and light hair. There are no tourists

here, only aid workers and missionaries. They were only about 3 NGOs in the whole

town as most are based up in the Capital -Freetown.

The POF Centre is based in the new hospital grounds and has been in operation for

the last 4 years doing out reach and prosthetic clinics in villages in the north of the

country where the worst of the war fighting occurred- and hence most of the

amputations. They have locally employed staff, who are made up of a prosthetist,

and several technicians

who make the

components and the

legs, two physiotherapy

assistants (PTAs), and

several support staff.

The PTAs were who I was really interested in helping, and some of the prosthetic

components that they were making and fitting. There is not a single qualified

physiotherapist in the whole country of 6 million people-that would be the same as

half of London not having any physio cover! The two PTAs which they did have, had

little to no training. One PTA had a two week course which he had been on in

Freetown, and the other had a massage course- of a few days. The prosthetics had

been training them on the very basics, but they knew so little in most aspects of

health that I was a little horrified at first. At least they were trying! Which more than

anyone else was doing. The rest of the country where doing without physiotherapy

and rehabiliation. The PTAs had the ability to learn and this was the main thing, and

they were bright and enthusitic. What they lacked in knowledge, they made up for in

eagerness to do the best by the patients.

I started the week with a plan to teach them all

sorts of stuff, only to discover that I would be

teaching the very basics- how to get a patient

out of a chair was the first thing! They looked at

things from a different way of thinking, life was

slow and disorganised here and no one is in a

hurry, it makes treating any number of patients

hard as they have a different approach to work and life than we in the west do. I had

gone from seeing one of the most highly organised and well run clinics in the world-

to utter disorganisation, from hundreds of policies and plans- to few plans and no

policy. However I felt more at home and welcomed here than anywhere I have ever

been.

The centre is severally underfunded like everything in SL, and they are mainly

working with Charity money for the payment of wages and fuel and products. They

are surviving on donations and volunteers, on a monthly income of $1500. We could

not pay one physiotherapist this sum. But labour is cheap and the cost of living low,

but all of the staff live hand to mouth and therefore the level of work you get out of

them are varied . A centre in the western world could not do what they do. However

conditions are very harsh- there is no running water, they have a generator which

sometimes gives power and frequently lets them down, this makes work grind to a

halt in the work shop and the fans go off making the treatment of patients

exhausting. Without a doubt higher temperatures reduce productivity.

Equipment as is happens is one thing they have- but they lack the basics- with no

walking sticks and no crutches, I had to get the patients to get a carpenter to make

some sticks, and hope that some stock would be renewed. The one thing we had no

problem with was DNAs (did not attend clinics) as patients waited asleep in the

waiting room on the floor to be seen. Children asleep sprawled out on the floor,

trying to get cool, waiting for us to fix something or see them for an assessment.

Working at the Clinic

I had the opportunity to work every morning in the clinic with the Physio assistants

and then in the afternoon teach them for about 2-3 hours. I was able to help design

some braces and help with assessment and treatment of the patients.

The way they work is very different, and they are dispensing drugs, giving injections,

and doing things that is well above my scope of practice in the UK, however they are

doing this with little knowledge and understanding of the meaning or application of it.

But in reality if they do not get help and advice here there is little hope for them

elsewhere. You can buy all sorts of drugs over the counter with no prescription-

including pain killers, antibiotics and all type of lotions and potions too. I see no real

problem with then doing this as long as they have some grasp about health as their

options are few and if it helps a little then who is to say they should not have it.

Ethically I do have issues with it as it devalues education and encourages people to

practice well out of the scope of ability putting lives in danger. People get well and

take advice well, and they respect the health service as they feel grateful to have it. I

wondered as I saw cases of Rickets, amputations, Strokes and high blood pressure

whether I should be advising these people, and if I had been practicing in the UK I

would have not, but suddenly you are the only person with a good medical

understanding and was it right to ignore or give advice?, just because you do not

normally practice in this field.

In the afternoons I taught the PTAs all sorts of subject matter, starting with basic

health and diet, obesity (yes some people are overweight)! Psychology of rehab-

how to get the most from the patients and motivate them. Then how to instruct- how

to behave with patients, how to listen, how to write notes... the list went on. The

most interesting thing to teach them was ethics. Being from a good Christian

background made it alot easier to teach this as I was able to draw some similarities

from the teaching they knew in Scripture, as they were all religious. Teaching

confidentiality was hard, teaching fairness was easy!

The basic knowledge of health and things like cleanliness was not there- they had

never really been taught, as very few clinical staff had ever been there from the

western countries. The manager of the project in Seattle is an engineer so he can

give them no guidance on things like this. I was horrified to see the hand washing

facilities, after coming from a centre which is obsessed with it. They have no running

water and they use water out of a bucket to wash hands, in an old sink which would

not pass any hand washing audit. But the patients I think are resistant to alot of the

infections we would not be! They let their kids do whatever they want in the ground

outside-the kids are dirty all day long! I did manage to persuade them to not use the

same hand towel for months on end and it was better to just drip dry hands.

The list of subjects taught to the PTAs was driven by them and the prosthetist who

normally teaches them clinical matters. The things they wanted to know where

about exercise, assessment and ideas of how to make things more interesting for the

patients. The lack of basic knowledge about anatomy, biology and health is

necessary to have to learn the more complex details of exercise, and lets‟ face it

there is no point in teaching about VO2 MAX testing if they do not understand why

anyone would want to get out of breath in the first place.

I had to translate everything into local reality, talking about how much energy you

use when you do the laundry, or sweep the house. Exercise is an unnecessary part

of life here, just living is hard enough, working out how you are going to feed

yourself, and not starve.

Teaching gait was challenging and once they understood it was like a penny

dropping, putting all the techniques, assessment tools and treatments into place will

not be easy. It involves more of a complicated thought process than I had

appreciated, being able to multi task, assess, come up with a plan and then be able

to deliver is beyond the ability of the PTAs, unless they have more time spent on

their training. However if they deliver some advice, some care and some treatment

it will be better than nothing. There is no way that my strict “best clinical guidelines”

would work here. To do this you need staff, structure, and training in vast quantity,

and this is expensive and unsustainable. Trying to modify everything to fit SL ways

is hard and has been an excellent lesson to me to be inventive, imaginative and

creative with in limiting circumstances. I could forget my policy writing and best

practice guidelines as there was no way that they could implement it or would even

read the thing! I would not know even where to start. To put in place policy for

rehab would take years and maybe show very little outcome in an environment like

this.

It is amazing when you start a discussion about eating and diet that they have

never heard of anorexia or any eating disorders and they could not get their head

around any of this pressure to look thin or vain... they just had no understanding or

contemplation of why someone would starve them self. When you have to worry

everyday if you will have enough to eat then it is an alien concept.

To see other Health care facilities I visited the Government run Hospital in Makeni

and to say that it was basic would be kind to it! Levels of hygiene and care where

basic, and I hope that when they move to their new buildings they will improve their

standards in the New Hospital. In perspective the nurses get paid $50 a month, and

the Drs maybe $350, and the patients walk for days to get here.

Cases

During working in the clinic I have seen a vast array of conditions- some common but

a few that I have never seen except in books. “Rickets” being one of them. A set of

twins with the worst rickets that I have ever seen presented to the clinic -a boy and a

girl came to have serial plastering/splinting done and at the age of 8 I wondered how

they had managed so far with the disabilities that they had. One telling fact is that

they had never been in school and had been teased endlessly by other children. I

assisted them to serial plaster their legs- one at a time with a plan to recast in 4

weeks after the changes had been made to the malleable bones, also provide them

with vitamins and supplements to their daily food.

Strokes or CVA appear very common and I saw many cases of stroke, with speech

problems and physical disability. I have been lucky enough to give guidance to the

PTAs of what programmes to do with these patients. The provision of walking sticks

and other orthotics enable these patients to improve just a little bit in their activities of

daily living. Making simple shoe raises on the soles of flip flops made a considerable

difference to the patients gait and function. Making a cervical collar for a child with

hydrocephalus, to enable him to hold his head up. Due to weight of the child‟s head

he was unable to sit without the head dragging the body to the side. Once the collar

was applied the child at least was able to sit leaning back and this would allow him to

engage with others and not have to lie down constantly. A small thing, being able to

make a big difference. I sat sewing the collar by hand, as yet again the generator

had failed – so no sewing machine- hoping my GCSE “home economics” stitching

would hold together and not get the child down.

Amputee camps

I met a wonderful group of people- on my visit, all below the age of 25 who where

here working for various NGOs, one of whom Dan-himself an amputee from

America, was doing advocacy projects for POF and others. He works with the

Amputee camps to help them start a school. The Amputee camps had been built by

a Norwegian charity and they donated one house to each amputee and their family

after the war to settle and allow them to live in a protected way and start them out in

life. Other projects exist to help them get work etc.

The

school

had just

been set

up and we

went to visit as the school teachers needed to set up a bank account and Dan was

helping to organise this. They need guidance for everything including how to set up

a bank account and how to run a school and how to gain funds etc. The amputees

some time wheel themselves for up to one and half hours to get to town to a

meeting. I met the elders in the village- all amputees and some of the kids who

where all in school when I was there- impressive seeing 200 little kids all paying

attention to their teacher! Unheard of in the UK.

Club foot Project

Children pulled at every heart string I ever had and as we started to do some out-

reach for a club foot project, I would see many children who tugged the strings.

Smart kids, often educated and able to speak to me in English (and ignore my really

bad spoken “Crio”) crowded around us everywhere we went, as we instantly created

the entertainment for the day! For some it was the first time they had seen a white

woman‟s face in a while, so I was a constant source of amusement. The club foot

project work is in its infancy and although in other parts of the world it is running well,

in this part of Africa it is just coming to the front of the NGOs minds and funds. I

have seen a wide variety of cases- from abscesses on the soles of feet to tendonitis

and rickets. Life would never be boring in this clinic if you hung around for a few

days. Word was out as well that there was a new Dr in town, who was a “bone

Specialist” so a few more people visited... it‟s hard to explain that I am not a Dr, they

think anyone from The UK who is medical must be a Dr, and with never having heard

or physiotherapy there is some times little point it trying to make a big long

explanation of what you do for a living.

Equipment

The centre itself has alot of the same techniques and equipment that they have in

our own centre. The casting techniques are the same for the prosthetic limbs, the

plastic even come from the same British company as we buy ours. The other

components are very different as they try and make a new mould to prepare a block

to put below the socket and the shaft.

They are using a prosthetic knee that was developed for this type of project in the

USA. It is robust, cheap and easy to fit, however these type of components would

never be able to be make in this country and all this material will always be imported

making it a costly procedure. The workshop is well equipped and yet again they are

let down by one fundamental thing that we take for granted- power! The centre has

a generator which powers the workshop and it is a well maintained and well loved

piece of equipment. For some this is the only power they will see in the day as none

of the staff, except the boss had electric. So when patients came here for treatment

they were unwilling to go after the session was over- mainly because they were

waiting for their mobile phone to charge as they plugged it in the physio treatment

room.

The supplies are there, it is the skill to use both the tools and the equipment that is

needed. The workshop men have all had great training at the hands of the

Prosthestist, and could turn their hands to most things- sewing things by hand was

not one of their favourite things.

The main problem was physio equipment. Without even a physio matt to do floor

exercises and little on the way of weights, or resistive equipment they would need to

use their imagination alot. The problem about using imagination is that you have to

start with a good background knowledge of exercise physiology and antomy, and I

think I had not appreciated how teaching exercise would be so complicated it you

had no idea of muscle groups and their actions. In fact I had to start from the very

beginning and teach them the basics of anatomy and physiology – only the big

muscles names and actions. Bones- the same, there was nothing to be gained from

teaching origins and insertions or complex structure as they would not use it or gain

from it unless they could put it in context.

To use equipment effectively you have to understand what happens when you get on

a piece of equipment and how it will improve or do harm to a patient. They did have

parallel bars which were great and many patients benefited from them and the short

flight of steps that they had made locally. They were making a good job with the few

weights that they had. Inspiration was what was lacking, but if no one has ever

showed you how to progress and regress exercises and how to make balance

exercise fun, then how could you ever know how to do it.

What did I learn?

I learnt that the Western society was not built in a day and that Sierra Leone

and its ways will not be changed in a day, or by one physiotherapist. Even if I

changed a small amount for the clinic and the people I saw I would be happy.

If I left behind some knowledge to enlighten them this would make things a

small better.

A week is not long enough- but I could not stay long term. It is a harsh

environment with soaring heat and baking sun. Food is a big problem as

there are limitations in a large way as to what there is available to eat, I eat

everything but I was largely limited as it just was not available. Fibre is

nonexistent in their diet, and if you like rice, you will be fine, it‟s what is eaten

every meal. They eat a surprising amount of white rice and white bread, and

alot of them suffer from constipation- no wonder.

Never try and impose your values on a system that cannot change to adapt to

them- it will not work. It will take decades to improve quality of life for the

people of Sierra Leone and a serious change in attitude towards corruption.

Knowledge and training is power, you can have all the equipment in the world

and no idea how to use it and it will be useless to you. You also must be

flexible with your knowledge to teach in an environment such as this.

Expect the unexpected! Expect little and you will never be disappointed. This

is best applied to every aspect of life except friendship and warmth in this

country. The country is underdeveloped, full or idiosyncrasies, corruption,

and has had a loss of more than a decade of development due to the war.

What was a country on the brink before the war has been put back further

behind its more Western neighbours.

People are generally good! I had expected to get hassled to death- but I left

the country with my wallet, my passport, all my luggage and had not been

stolen from, only given to. Unlike some others going home on my flight, I had

a safe trip. Mainly in part to my wits, my wonderful guide and my paranoia.

For most this is a country I would advise would not be a tourist destination-

and if I am wrong in ten years I will be happy to say I am sorry I got it wrong.

If you want to go and help it‟s a great project, if you want to have a challenge

then go. Want an easy life? Want some where different to go for a week- pick

somewhere else- for now anyway!

Did I make a difference?- I hope so, even if I made a small change it was worth it- it

has to be – it‟s a long way and alot of stress and heart ache and challenge if I have

had no impact and taught nothing, and learned nothing. I think at the very least I

learned alot.

I made some great friends and in truth my faith in human nature has been restored

by going to Sierra Leone. I left with a journal of mad “happenings”, funny stories,

photos, newly made friends and enough stories to tell until I am 50. I plan to go back

some day, just let me get over this trip first. It may take some time!!

Did I achieve my goals?

� To give and receive – to offer myself as a resource to those I met and worked

With on my travels; to share my experiences to those I work with at home, and

expand my knowledge and those I work with.

� To listen and learn from others; to share in their experiences and take on board

ideas that they had to offer.

� To look, see and learn – just to take a ‘step outside’ of my normal world and work,

as I was privileged to look into the world of others and they way that they work.

� To absorb all the information gleaned and use it in my work place.

Conclusion

I have been fortunate along my way to met the most receptive people and feel I have

been an advocate for my profession and my country. I have taught and learnt and

gained in a way that I would not normally get the opportunity to. I have been inspired

beyond boundaries and cannot wait to go back to work with a new zeal for life armed

with what I have learnt and what I have to offer. The ideas and tips I have picked up

will be great in my job. I have learnt alot about myself and how blessed I am to live

in a wonderful country with all it has to offer. Sometimes, if everything is taken away

and you have only the basics do you then start to understand that having knowledge,

education and an imagination and using them are worth more than any multi-million

dollar rehab facility.

To stop and take a step away from your life and go outside your normal comfort zone

is inspiring and has given me a much needed chance to let my ideas develop and

think in a different productive way.

I have given and received a vast amount, and now I hope to expand the knowledge

of those I work with.

I can never thank the WCMT enough for the chances I have had, and to those who

have allowed me the time off work, the gift of their experience and have taken the

time to teach me, look after me and most of all inspire me.