Catching up

These last four months have been a roller coaster of emotions, loneliness, culture shock, busyness, and adventure. I don’t think I’ll ever say that this trip has been easy, but I will always say I’m glad we did it, that we have learned a lot, and have had a great time! We are over halfway…only 2 more months to go…there’s so much to be done, as Duane begins some intensive training sessions at the Center, and as he starts to fade himself out of work there. This transition period will be incredibly challenging for him and for the staff at the Center.

Not much has been said about what is happening there recently, mostly having to do with the fact that any spare time Duane has is filled up with teaching prep and mind preoccupation. About a month ago the Center hired a new prosthetist…Sergio. He has been a real gift, and is eager to learn. He is 26 years old, is a trained physiotherapist (which is such a great skill to have when working with people who are re-learning how to walk), and has never done any prosthetics in his life. He is literally starting from the beginning. At least he knows anatomy, and has an understanding of the body, so I guess he’s not starting completely at zero. There has also been a bit of an overhaul of the entire staff at the Center. One of the prosthetists quit quite early after our arrival and the other main prosthetist lives part-time in another city about 5 hours away so he’s not always here. Sergio is likely going to be the main guy. We’ve also hired a full-time office staff to deal with patient files and other general office type stuff. These big changes at the Center have been both good, and challenging! Certain expectations have had to be changed as a result of dealing with a different culture that does things a different way. The North American time structure is one of the major ideals we have had to change…for anyone who has traveled, you will know what I’m speaking of. When you’re on vacation, a more relaxed way of life is welcoming…you can come when you want, leave when you want and have no time constraints…BUT, when you’re in a work environment trying to accomplish certain tasks for people who are in need, it’s difficult to adjust. I don’t think we need to toss it all out the window…there is a certain level of professionalism and excellence that can and should be expected, but we have to meet somewhere in the middle.

Language has been coming slowly, but well for us both. Duane knows everything having to do with legs and how to build legs, and can get everything he needs around the city. This is his first time learning a language and it’s so fun watching him communicate! He has improved dramatically in the last two weeks. I am a slow, but steady language machine, but have found it difficult to balance learning with being a mom. I just don’t have the time I would like to put into it. Those who have said that Spanish is easy were quite misleading. There are so many different and difficult tenses that are hard to keep track of and there are many irregular verbs…pure memorization is the only way to remember how to conjugate them. In some ways, Thai is much easier. Amelia has learned a little bit…not as much as we perhaps initially hoped, but I am amazed with her. I think the thing that impresses me the most is simply her understanding that another language exists. I can now ask her, “What is the Spanish word for ‘ball’?” and she will answer, “Pelota”. She has her own made up language as well, I think because she hears us speaking something different, and so she thinks she should as well. She fascinates me.

I have begun teaching English at an all boys’ school once a week. It is a whirlwind morning where I teach four classes an hour and a half each. The boys love having a foreigner in class and are intrigued by my height, as I stand at least 2-3 inches taller than any of them. This is their first experience with learning English through the communication method and it’s a challenge to get them into a communicative mindset. They believe they can’t speak, and so they don’t try, and of course there are the general pressures surrounding high school aged kids to never look dumb. Unfortunately, having confidence and taking chances fascilitate learning a language. We have some work to do.

We definitely feel that our time here is coming to a close. We can’t believe how quickly and how slowly it has all passed. Please keep Duane in your thoughts for these last 2 months as he is feeling the mounting pressure to instruct and guide the guys at the Center to autonomy. This is a difficult task, one that he is doing masterfully, but the pressure still remains.

Thanks for following us on our journey!

Fun with Plastic

 We've been really busy at the Center and realizing you can do everything with 3mm and 5mm Copoly plastic :)

Patellar tendon bearing prosthesis for a terrible chopart amputation with a chronic ulcer on the distal end.

 Clam shell design allows for donning of the prosthesis. Otherwise the patient's ankle is too large to pass through the smaller proximal circumference.

   

Flexible AFO to provide medial-lateral ankle stability for a patient with a longitudinal partial foot amputation.

 "Stove-pipe" design prosthesis for Symes amputation. This is the right foot of the same patient using the AFO shown above, on his left foot.

We'll be doing a hip prosthesis in the near future and many "normal" trans-tibials and trans-femorals.

Raising Kids Abroad

I’m not going to say that my experiences are the same as all of those traveling and living abroad with kids, but I do think that perhaps some of you might be able to identify with me.

My level of flexibility had to go from novice to yogi overnight. In La Paz it is very difficult to find healthy foods for your kids…people are eating ice cream and lollipops at 9am, and there is evidence of this consumption all over the playground. This has been incredibly difficult for Amelia, as it seems to her that her parents are cruel and are withholding the best things in life from her. I have definitely had to relax in the “healthy eating” department as people love to give her treats, and I have had to be creative in the kitchen to provide nutritious meals for my family.

In the developed world we are sleep obsessed. We have sleep consultants, we schedule when our kids sleep and it is our goal to get our kids to sleep through the night as quickly as possible. One of the questions I heard the most after Amelia was born was, “Does she sleep through the night?”. Nobody asks me that here. Kids are not scheduled…in fact, I don’t think children even have naps. They sleep when they are tired which ends up being on the bus, or in their parents arms wherever they may be at that moment. I seriously see kids sleeping everywhere here. Also, kids don’t have a scheduled bedtime. They are up very late, but seem to function just fine. Many do not understand our scheduled sleep routines and I have had to relax a bit in this department as well.

I did not think that a 2 year old would have a difficult time adjusting to another culture…I was wrong. We went through a month or more of difficult transition, with Amelia missing her friends and really not liking the attention she receives here. I wasn’t prepared for the difficulties facing an introverted child in a country where kids don’t get the luxury to be so. Children are passed around from day one, and get used to many hands and many faces. On numerous occasions I have had to decline the outstretched arms of a vendor at the market who wants to hold Amelia (as she desperately clings to me). The people are so sweet here and love our blonde little girl, but unfortunately she does not reciprocate their affection. The other day, Amelia and I were walking down the street and a woman walked up, picked Amelia up, swung her around and said, “You are an airplane” in Spanish. Amelia’s stunned expression said it all. Just as quickly as it began, it was over and Amelia was back on the ground asking, “What happened?”. If this had been 2 months ago, her reaction just wouldn’t have been as impassive. She has developed coping mechanisms, and has adapted to the way that things are done here. That’s not to say that she has accepted the attention she receives, but we’ve come miles from where we started.

I am perhaps the one who still needs to change. I think of the big, open fields in our cities, our spacious yards, our public libraries, recreational activities and I feel like parenting is easier at home. I miss the consistent friends for Amelia, and I feel like I’m not able to provide her with what she needs…but this is only my conception of her actual needs. Truly, all of the things I have listed are luxuries that are a part of our daily lives at home…things that I took for granted. I am aware that we are now at our halfway point in our adventure and culture shock is more a reality now then it was at the beginning of our trip. I am trying to seize everyday.

Just to be clear, this is not a criticism of how other cultures (specifically this one) parent…not in the least. Bolivians deeply care for their children and more often than not, provide safe and loving homes for them. Weekends are for families. It says something positive about the family construct when you see teenage girls still holding their mother’s hands. This is more a reflection on the difficulties of culture change and how that has affected me, my child, and my ideas of parenting. Ultimately, it has been such a positive experience, and being stretched and challenged in the way one does things can’t ever be bad!  

Nuestra Casa

Ok...so we have officially as of today, been in our "new" house for a full month. I cannot even begin to express how this place has changed our existence here in Bolivia. This is our third place in 3 months, and by far the best. Amelia's entire demeanour changed when we moved into this house (which may be a result of our renewed emotional state) and we immediately felt like we were home.

One of our living rooms...the previous renter bought the couch set at El Alto and the taxi driver strapped all of them to the top of his car.

The other living room where we spend most of our time...hippy living. Amelia loves sitting on the floor. 

Dining room.

Hallway lit with skylights. 

Our kitchen...it's rare to see a full-sized fridge.

The office. This is the warmest and cosiest room in the house.

Our bedroom.

Amelia's bedroom.

We took this place over from a couple from Spain. It is spacious, completely furnished, shares a garden with another Spanish family (who have kids), is incredibly quiet, private and safe, and has fruit trees ripe for the picking. When it rains, the beautiful aroma of the citronella tree wafts through the yard. The entire house is lit with natural light due to the skylights that run the length of the flat. Being that we are in rainy season, we have the pleasure of daily listening to the drops hit the plastic skylights, creating a cosy, romantic feel. We are a mere 4 blocks from the Centre, live directly across the street from a convenience store (and when I say convenient, I mean convenient...toilet paper, eggs, wine, beer, diapers that you can buy individually, chips, noodles, the best banana bread...EVERYTHING), live next door to a Salteñ
aria, and a place that sells "almuerzo familiar" (familiar lunch...for 10Bs ($2) you get soup, meat and rice, and a dessert).

Plums. I made plum jam out of them. I don't think Bolivians have ever tried it. They were very surprised when I told them. 

The garden. Our house is on the right.

Cherries. 

Purple plums. 

Tumbo. Looks like passionfruit on the inside, but tastes like nothing I've ever had before. Really sour...used mostly for juice. 

Anyone want to come over? We'd be happy to have you!

Next Time Your Boss Tells You to Clean Up

Several weeks, or maybe months ago (yeesh, we've been here a long time already!) I had the privilege of visiting "the other" prosthetics clinic in La Paz. This clinic is in a fascinating old building and truly is the most memorable clinic I have ever seen. If was founded many decades ago by a German who shipped EVERYTHING OttoBock over on a big ship. The amount of money spent on machinery and fabrication equipment, let alone the shipping costs to get it here, would have been astronomical. I'm sure in its beginnings it would have been quite a beautiful place. The interesting thing is that it appears nothing has changed during the decades that passed, I mean nothing. No desks have been cleared, no corners swept, no walls washed, no squeaky hinges oiled, no clocks wound back up....this place is one-of-a-kind. 

Next time your boss tells you to clean up the plaster room, just remember this one, and tell her it can wait :)

This clinic is different than the one I work at, in that each patient who goes here must pay for their prosthesis. Due to the high cost of prosthetic components and the low income of most Bolivians, this is usually unattainable. Centro de Miembros Artificiales, where I volunteer, is able to provide prostheses for low cost, or no cost.

The prosthetists here were really keen guys and will likely join us for a few of my teaching sessions in the coming months.

Things you Need to Know Before Visiting La Paz

• You will not find a clean wall, gate, or fence anywhere in the city. They are all covered with varying quality of graffiti.
• If you want to go out for supper, think again. It is difficult to find anything open before 7 or 8pm. If traveling with a toddler who’s bedtime is 8:30pm, this proves to be a bit of a challenge.
• Their big meal of the day is lunch and may leave you feeling full for days. Lunch includes soup, bread, a small salad, the second plate (which is usually some sort of meat and potato, or meat and rice), and finally you end the meal with a piece of fruit or pastry. Bolivians make some seriously delicious soup! 
• In addition to feeling full, you WILL feel sick at some point. It’s best just to prepare yourself mentally and emotionally for that inevitability. Also, there is a strong likelihood that going to the bathroom will be abnormal probably 70% of the time.
• When cooking for yourself you need to adjust all recipes for the altitude or you’ll end up with flat, squishy chocolate cake, or pancakes that just don’t hold together. There are many websites that can help you with this.
• You will not completely adjust to this altitude. You will likely find yourself panting and/or partially blacking out a few times a day.
• The altitude (and the monster hills you climb everyday) will make you lose weight. Depending on your size at the start, this could be a good or bad thing.
• There are very few strollers here. Most people just carry their kids in their arms, sans baby-carrier. I challenge anyone to an arm wrestle when we get back…or a baby carrying competition.
• You will find amazing coffee for cheap!
• People don’t really care that you’re here. You aren’t an anomaly, and you aren’t special because you are white. It’s nice. You are free to carry on without any celebrity status.
• Even though people don’t care that you’re here, they are very nice and are willing to help at a moment’s notice. They are even willing to put up with your terrible attempt at Spanish.
• Most travelers and tourists seem to already speak Spanish. If you don’t, you are probably stupid and are definitely in a minority.
• Language classes are cheap, so you don’t have any excuse to not learn!
• People in La Paz, and perhaps Bolivia, speak Spanish with little to no accent, in comparison with their neighboring countries, so they are easy to understand. This also aids in language learning. 
• You never know what is going to be open and when. So when you leave your house on a mission, be prepared to be disappointed. Perhaps it’s best to have an alternate plan, and be ready for that to fail too.
• Speaking of open...this city seems like it is on social lockdown. All gates and fences are 8 feet tall, and are topped with broken glass or barbed wire. I don't know who my neighbours are and I'm not sure how to figure that out, short of ringing them at their gate. Also, little neighbourhood shops that are open midday are only kind of open. You aren't able to enter them...you have to look from the door and point at what you want. Either there is a high level of distrust here, or a high level of threat. 
• The Internet doesn’t always work. This is good for those of us who are used to having it all the time. You can’t stream anything quickly. In fact Facebook friends, could you please stop posting videos? I can only see the thumbnail.
• The stray dogs are not scary like Thailand stray dogs. They are not aggressive, and keep to themselves.
• People here seem to love dogs. There are dog grooming places everywhere, and no end to places where you can purchase dog clothes, dog shoes, and puppy paraphernalia. Around Christmas there were Santa dogs a-plenty.
• Christmas is at midnight…so when someone asks you over to their house for turkey at 1, they don’t mean 1 in the afternoon. They mean 1am. Don’t show up to their house midday (that may or may not have happened).
• It is incredibly easy to get around the city. Transportation is cheap and accessible, as long as you know where you are going. It’s best not to travel around 6pm or else you may be hanging out the door of the bus just to get a spot.
• There are very few single occupancy vehicles. This pleases me.
• There are even fewer bikes. Although, I don't blame them...I don't want to cycle up these hills either.
• If you're a small kid in Canada, don't worry...you'll be the same size as other kids your age here.
• If you are a kid, and you’re blonde, and you don’t like being touched or looked at, it’s best to learn the art of closing your eyes, or putting your head down early. In all likelihood you’ll eventually adjust or learn how to cope with the attention, just like a little someone I know did. 

Well, I hope that helps with any future plans of visiting La Paz. This place is spectacular, wild, and wonderful all at once. These observations are just the small ways in which we have needed to change or modify our own outlook as we learn how to live here. Some things have been hilariously different, and other things have been tremendously hard, but we are thankful for the opportunity to live here and discover how other people exist.

Up and Running, and Walking

I’m pleased to say that the Center (clinic) is up and running and so are some new patients! Before Christmas we were able to complete three new prostheses and have started work on several others.

The Center invested greatly in a commercial quality convection oven and although we flopped a chocolate cake, the oven is doing a fine job of baking copolymer polypropelene :) For those that don’t know, one way to fabricate prosthetic limbs is called plastic thermoforming. A flat piece of plastic sheet (usually 3 or 5mm thick) is cooked on a teflon sheet at high temperature until chemical bonds are altered and the plastic can flow. The fluid plastic is quickly handled with gloved hands and placed over a modified plaster model of a residual limb. The plastic is sealed to a vacuum system and thus precisely thermoformed into the three-dimensional limb shape and left 24 hrs to cool.

Designing, fabricating, and fitting prostheses is an extremely rewarding craft, and the stories of success do not get much better than what is happening here at Centro de Miembres Artificiales. Meet A-----o:

A-----o is a young man born the same year as my middle brother. This makes him 36 yrs old. TWELVE years ago he lost his right leg above the knee in a traumatic accident, otherwise he is completely healthy. Since then he has used this contraption to restore body image and assist in standing. 

The inside of the prosthetic interface is peppered with metal staples that previously fixed some type of foam or plastic in place :(

He used lots of fabric from an old sweatshirt to pad the interface and help make the oversized and mis-shaped socket wearable. The prosthesis was suspended using a simple belt. The knee is some kind of outside hinge joint and the foot is broken. Everything is held together with some rubber strips. The unit weighs close to 10 lbs.

In comparison A-----o’s new custom made ischial containment socket fits so intimately to his limb that it is suspended solely with suction, aided by a one-way expulsion valve . The copolymer plastic is smooth and strong, yet allows some flex to aid in comfort. Below the copolymer socket is a new polycentric knee made in-house of delrin plastic and designed by Limbs International. The polycentric joint allows mechanical stability in the stance phase of gait and knee flexion in swing to provide normal (-ish) biomechanics and improved ground clearance. Below the knee is a Shape and Roll foot also made in-house of copolymer plastic. The total prosthesis weighs half of what his old one did.

Less than an hour after fitting the prosthesis A----o was walking independently without aids. That is a special thing to watch :) He walked home and left his old “prosthesis” for our museum.