The Return of the Rebel Without A Cause

THE LONG GOODBYE

2021-01-26T23:28:00.002-05:00

Jim can feel his heart beating fast. He is sitting in his car, hands on the steering wheel shaking. He looks up at the traffic light, red light. He can feel the sweat trickle down from his brow, down to his left cheek. He quickly brushes it away. He looks around him. Cars everywhere. His breath becomes shallow and ragged. The buildings and the scenery seem like he has been here before. They look familiar but somehow, at the same time, they don't.

A loud honk from the vehicle behind him caused him to jump in his seat. Jim is terrified now. The light has turned green. But Jim remained frozen in place. He doesn't know what to do. His eyes widened in bewilderment. The honking kept on, and he can hear the muffled shouts of the drivers around him from his closed window. His heart is racing faster. He glanced at his rearview mirror and see the flashing lights of a police car. He watched from his driver side mirror as the officer stepped off of the vehicle and walk towards his door. The officer signaled for him to roll his window down.

"Are you okay, sir?"

"I... I don't know...", replied Jim between sobs. "I don't know where I am. Where's Nancy? I don't know where I am". He buried his face on his hands and wept.

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Jim first met Nancy in science class. She was new in town and quite shy. To Jim, she looked very plain looking, with her dark brown hair and wide brown eyes. She was not someone he would ask for dates. You see, Jim was the school's basketball star. He won MVP as a sophomore when the school won the state championships last year. He was quite popular with the ladies, dirty blonde hair, green eyes, and small dimples on each cheek. Nancy sat a couple of chairs to the front and to the left. She was plain-looking alright, but there was something about her that intrigues him. He doesn't know what it is but there was something there. Maybe it's the small lady bug hairclip she wore on her hair.

He started casually talking to her between classes and found her quite charming. She had an infectious smile and a cute little laugh. However, Jim has to keep up with appearances. Everybody knows that the prettiest girl in class, Tina, was interested in him. And his friends have been pushing him to date her. His friends don't think to much of Nancy. To them, she is but a wallflower in class, totally unremarkable. So her kept his friendship with her low key.

Prom came and was surprised to find himself thinking of Nancy. Thinking of Nancy in her nice bright colored dresses, her lady bug hairclip, her shy smile. He asked Nancy to go with him. She hesitated at first, but said yes at the end. He felt giddy with excitement. Two days later, while he was out walking with friends on campus, Tina walked up to him and asked him straightforwardly, "So, Jim, when are you going to ask me to the prom?". Jim froze. His friends were already hollering and giving each other high fives. They were expecting that Jim and Tina would make King and Queen, they were such a beautiful pair. Jim felt that he could not turn Tina down in front of his friends. So he asked her to go with him. He felt torn deep inside. He doesn't have the heart to tell Nancy. And he'd be embarrassed to reject the prettiest girl in class in front of his friends.

On the day of prom, he simply didn't show up at Nancy's house to pick her up. He stood her up without explanation. He and Tina walked in much to the admiration of the crowd. On his arm is the most popular girl in school, they were like a Hollywood power couple, and yet he did not feel happy. Sometime later, he saw Nancy dancing and laughing on the dance floor with her best friend Beth and her date John. Nancy looked so happy, so full of life, without him and in spite of him ditching her on prom night.

It was a that moment that he knew in his heart, he had to win her back. He must win her back. Nancy is such an extraordinary woman.

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Alzheimer's disease is the most prevalent form of dementia in the United States accounting for 60-80% of all documented dementia cases. It is a progressive brain disease that results in the loss of brain neurons resulting to a decline in mental capacity and performance, loss of memory, and a reduction of behavior and social skills that eventually leads to a person losing functional independence. As many as 6 million Americans are affected by this disease and this number is expected to triple in the next 4 decades. It is the 6th leading cause of deaths annually in the United States and is the only one, arguably, that cannot be slowed, prevented, or stopped. The total cost of dementia care in the United States in 2018 was at $290B, excluding unpaid care. It is expected to climb to $1.1T in the next 30 years. Given the rapidly aging population of Western countries including the US, the social and economic costs of dementia continues to steepen as the years go by.

Dementia by itself is an umbrella term for conditions that result in a progressive decline in mental function and memory. There are dozens of types of dementia with Alzheimer's being the most prevalent and most known. The disease progresses thru 7 stages. The first two stages feature symptoms that are almost undetectable. Personality changes start in the 3rd and 4th stages where family members start to notice symptoms and work becomes interrupted. Note that the patient may expire without completing the stages but as the disease progresses, cognition and mental function worsen until the affected individual becomes fully incapacitated. Dementia is often touted as the Disease of a Long Goodbye because families lose their loved ones slowly and it is painful to see their heroes fade, eventually not remembering who they are.

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Nancy found Jim obnoxious but quite attractive at the same time. He was the school jock that all the other girls swooned over. It came as a shock when he started to talking to her. Being new in town, with few friends, it was comforting to talk to Jim. She eventually found him quite charming, awkward, and despite being popular, he was down to earth. She found herself thinking about him quite often, and soon enough his name found its way to her diary.

Her heart leapt to her throat when Jim asked her to the prom. She felt something off. This was something she wanted all along but somehow, at the back of her mind, something didn't feel right. When Jim saw her hesitate, he wavered and said nervously, "You don't have to say yes if you don't want to. It's okay." She paused, and finally, she said yes.

The days leading to the prom went by like a whirl. The nagging feeling at the back of her head never left. She felt that something might happen at prom, that it might not be as nice and as magical as she thought it would be. Will Jim break her heart?

She found a light yellow dress with frills. She put a ribbon in her hair and wore her laced up Sunday shoes. She sprayed light fruity cologne on her self. Her parents told her she was glowing. She sat on the sofa, nervousness and excitement trying to win over each other, and waited for Jim.

He never came. She was in Mama's embrace when the phone rang. Beth, her best friend, called her from the school. Beth and her date, John, didn't see her at the school gym where the prom is being held. Between sobs, she told Beth that Jim stood her up. Beth told her to wait there and hung up. Fifteen minutes later, the doorbell rang. Beth and John were outside. Before she can say another word, Beth pulled her upstairs to the bedroom, fixed her make up, and told her "To hell with Jim! We are gonna go out there and we are gonna have a good time!".

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It was the perfect May wedding one could wish for. The blue skies were littered by light feathery clouds, and spring bird songs filled the air. Beth, her maid of honor, squeezed her hand and giggled. John, her husband, stood to the side taking pictures. Jim was standing beside her, looking as dashing as ever did. They dated for three years, engaged for one more before they decided on a wedding date. As the saying goes, her cup runneth over with love. It was the happiest day of her life.

They built a home and a family. Two girls, two boys. Time flew fast and soon the kids, one by one, started leaving the nest. Jim had the same beautiful green eyes, the same disarming smile. He now had a soft belly, and where once were sinewy arms, now hold some flabby wrinkled skin. But, my gosh, he still sweeps her off her feet.

She saw the first sign two weeks after they spent a holiday in Mexico for their 42nd wedding anniversary. She received a notice of disconnection from the electric company. She thought it was very odd. Jim always pays the bills on time. All this time that they have been married, he has never missed a single payment. She called the electric company, ready to give them an earful. They told her that their account has not been paid in the past two months. When she finally hung up, she had more questions than she had answers. She found Jim sweeping the garage floor. She asked him about the electric bill. He casually replied, "Oh, I must have forgotten. Can you please just sign a check for me, dear?".

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The incident at the traffic light was the last straw. This time, the whole family gathered together to plan out what to do with Dad. It was clear that Dad was no longer safe to drive. He has gotten more irritable lately, and snaps every time the subject about driving is brought up. He insists that he is fine and that he is a "grown man who knows what he is doing".

In moments of clarity, he sounds and acts just like how he's always been. But there have been brief moments of outbursts, confusion, sometimes downright hostility. The incidences have become more frequent as days went by. The children seldom see this, granted, they don't live in the same roof as Jim and Nancy. Jim hasn't been sleeping well lately and has been napping at different random intervals throughout the day. He has been asking the same questions over and over again. When Nancy tells him that he has asked that question just a few minutes ago, Jim sulks and insists that he hasn't. He also has seemed more withdrawn and has shown no interest in what he used to love doing before. He hasn't tinkered with his projects in the garage, or worked on his garden, or read his books.

To Nancy's eyes, Jim is fading. She feels a myriad of emotions, generally negative, but mostly it is just hopelessness. And isolation. When Jim's doctor finally sent him to a neurologist who did a battery of tests on him, Nancy dreaded the findings. Please don't let it be what I think it is, she prayed. But her prayer wasn't realized, Alzheimer's, they said, advanced Alzheimer's disease. The shock ripped Nancy's heart out. Jim quickly stood up from his chair and pointed at the doctor furiously: "You're lying!" The rage in Jim's eyes was something that she has never seen before. And that's when she knew that the doctor was right.

Jim's mood became unpredictable and he eventually started lashing out at other people, defensively trying to cover the fact that his mental faculties were deteriorating. They soon had to quit going to church. Church friends promised to come and visit, and they did, for a time. And then the visits became more sparse as time went on. Soon, people just stopped inviting them to parties, events, social gatherings. People assumed that they were unavailable anyway. In light of all of these, never had Nancy ever felt so lonely, desperate, and alone.

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There are a lot of medical articles that delve on the subject of Alzheimer's disease and dementia but the topic of focus is the disease itself and the afflicted, and very rarely is the impact on familial caregivers. Caregiver burnout is prevalent in Alzheimer's patients just like it is in many progressive, incurable diseases like ALS, and Parkinson's disease. Caregiver burnout is characterized by three dimensions: emotional exhaustion, cynicism, and reduced personal accomplishment. A Japanese study revealed that dementia symptoms that most commonly result to caregiver burnout are aggression, irritability, abnormal motor behavior, and hallucinations.

The emotional banks of caregivers of Alzheimer's victims can get exhausted steadily. The routine is mind numbing, the emotional toll grinds towards hopelessness, and the isolation is draining. The schedule, the doctor appointments, the medications, the mundane day to day tasks-- they all are physically and mentally taxing. Throughout all of these, society tends to just forget about the caregivers: out of sight, out of mind. Dementia patients and their caregivers become unintentional social pariahs, relegated to an endless spiral of despair that can only be severed by inevitable death.

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Today is a good day. Jim has been lucid. He took his medicine today without fighting with Nancy and allowed her to help him wash up in the shower. He asked her about the grandchildren and wondered aloud where the photo albums were placed. Nancy got them for him and they sat in the sofa flipping thru the pages of the picture book, rekindling memories, talking about family, reminiscing happier times. Many times Jim would ask about who the people were in the picture, and Nancy obliged him, ever so patient with explaining who they were and what event it was in the picture.

In moments like this, Nancy feels that Jim has returned to her. The fleeting moments of lucidity, full of promise and love. The only man she had ever loved all her life is holding her hand again, his kind eyes knowing her again -- a recognition that this person is valuable, precious, endearing.

Jim gently closed the picture book and yawned. He placed his head on her chest, and soon Nancy can feel his gentle purr of a snore. The soft rise and fall of her chest as she breathes soothes the husband as it did the children when they were very small. Jim's right hand was softly clasping something. She pulled his fingers carefully to see what it was.

And from his hand fell a small ladybug hairclip.

********** END **********

THE FLAGBEARER

2020-07-04T14:00:00.007-04:00

He stared into the gray cold waters of the Chesapeake Bay. Today is February 29, on a leap year. Today is also his birthday, he just turned 16. The chilly spindrift of the Atlantic ocean washes over his face. Virginia winters are mild, and snow is scant even during the winter time. Fridays are busier than most days on the docks. His master has him working here helping to board cotton and dried tobacco on steamships to Baltimore. He has lived here his whole life, in the city of Norfolk, embraced by the Chesapeake Bay.

His skin is the color of ebony. He was born into a family of slaves. In the springtime, he will be back in the fields, painstakingly planting and growing tobacco plants in his master's plantation. Summer is when they harvest the crop, then they dry it under the sun. Acres upon acres of tobacco fields is where he toils, day after day after day. He looks forward to Sunday, the only day of the week where they are not forced to work. His greatest fear, is to live out his life in insignificance.

He looks forward to Sundays because it is a day of rest and a day of prayer. Oh, how he loves his Bible and his church. He loves to listen to his mother's soulful rendition of Amazing Grace during Sunday service at St John's Church, the only church for colored people like him in the city. He loves his church, and the Gospel comforts him. He closes his eyes to feel the cool breeze on his face once more. His daydreaming is broken by the shouts of James Rigby, a heavy built balding white man his master hired as one of his enforcers. His master has hired more of these enforcers; slaves have been disappearing here in the ports of Norfolk, and missing slaves is a big dent on the business. There has been whispers of an underground railroad that these slaves apparently use, but the master couldn't confirm its veracity. James Rigby holds a musket with one hand, and his other hand points directly at his direction: What are you standing around there, boy? Best be moving now!

Under his breath, he recites his favorite Psalm: The Lord gives strength to his people; the Lord blesses his people with peace. He takes a deep breath once, and walks back into the ship.

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It has been almost two years since that fateful night when his father disappeared like smoke. It was like he just vanished into thin air. They lived is a small house, and had scant belongings. But they had love for one another and have faith in God. Things will get better, his parents always said, we just need to have faith. The night before his father vanished, he overheard his mother and father talking in hushed tones. He caught a few words here and there. Words like: secret passage, Baltimore, Philadelphia, and Massachusetts. With daybreak, as they got ready for another day of work at the ports, his father gave him a tight hug and told him to look after his mother and sister, and that his father "will see them again". He did not understand what he meant. That was the last time he spoke to his father. That night, his father did not return home.

The next day, he worked the stables while his mother and sister worked at the plantation. His mother came home that night with bruises and a left eye that was swollen shut. The master beat her to find out where her husband was. She said she did not know. This infuriated the master and more blows landed on her. The master told then told her that she owed him money for her husband escape. She just nodded her head and wept.

Leading to his 16th birthday, the master became more stringent with the slaves to reduce the risk of them escaping. The northern states and Canada has been too strong of a pull for slaves to risk their lives and escape their masters. Virginia is too close to these states who have outlawed slavery. The master didn't want to risk it. So he hired more people like James Rigby to quash their dreams of running away.

A few weeks after his 17th birthday, his mother gathered him and his sister before they retired for the night. In hushed tones, she told them that she has heard from their father at last. She told them to never speak of what she was about to tell them, ever. The message was not sent in a traditional way like through a letter. Instead, it was passed on along the vines of the extensive and secretive Underground Railroad. The Underground Railroad is a metaphorical network of secret routes and safe passages for enslaved people who want to escape to the free states and Canada. The message told of his father having reached the safety of New Bedford, Massachusetts. His father is doing well and is saving everything he can scrimp on to buy his family out of slavery.

He knew that the literal price of freedom is too high for the three of them. And so he plotted his escape. Everything has to run perfectly. One mistake could mean death or an actual sale to any of the lower Southern states that would make it an impossibility to be free from bondage. He planned meticulously. It took months and months of timing, and preparation. He worked so hard at the docks that James Rigby eventually let his guard down on him. He kept his head low enough that he became invisible, indistinct from the other slaves and indentured servants. He spoke to no one of his plan. All the while, he kept his eyes peeled and his ears open for any clues that could lead him to the Underground Railroad. He was getting ready.

A few months before his 19th birthday, he, too, vanished from the face of the earth.

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In the dark of night, he landed as a stowaway in a Baltimore bound steamship who brought cotton and wool from the port of Norfolk to one of the biggest ports in the world, the city of Baltimore. The captain of the ship is a sympathizer for the abolitionists and feigned knowledge of his presence in the ship. The next few weeks went by like a blur. There were many different people, all faceless and nameless, fair or dark skinned, that guided him from town to town, city to city, as they moved him from Baltimore to Philadelphia and to his final destination in New Bedford, MA. With his own eyes, he saw how people with the same skin complexion as he, working and living side by side with those whose skin color look like his master's. He felt a pang of sadness. After all, his mother and sister are still down there at Norfolk. And yet, a sliver of hope continued to find a home in his heart, and a few days before his 19th birthday, he was reunited with his father.

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His love for the Gospel and for church never wavered so he pursued his education in ecclesiastical studies in the hopes of eventually becoming a pastor. By this time, he and his father were able to save enough to buy out his mother and his sister from slavery. The Civil War has begun, and pressure has been mounting on men to pick which side of history they want to be a part of. The war has started its bloodletting as the Union and the Confederate armies clashed. Then, on New Years Day, the 3rd yr into the bloody war, President Lincoln issued the Emancipation Proclamation, declaring that all slaves, henceforth, are free men.

He knew in his heart that God's call to service is not confined to the lectern of a church. He himself is a witness to the joy brought on by liberation from slavery, that he as a black man, can get to enjoy the freedoms guaranteed in the Constitution. As the Emancipation Proclamation allowed for the enlisting of African-American men into the service of the Union army, he joined the 54th Massachusetts Infantry Regimen, an all-black infantry unit that received strong recognition for their bravery and courage throughout the war. He is now 23 yrs of age at this time, and due to his education level, he was promoted to sergeant. The commander of this infantry unit is Colonel Robert Gould Shaw, young and only 3 yrs his senior. Colonel Shaw was the son of a wealthy and influential abolitionist up in Boston.

The 54th Massachusetts Infantry Regimen was commanded to move south and help break down the formidable defenses of Charleston Harbor in South Carolina. The Union Navy was sent ahead to take Fort Wagner down. Fort Wagner is located at Morris Island, almost a thousand miles away from New Bedford, MA. The fort is daunting to say the least with its 9 meter earth and sand filled wall. So intimidating was this fort, that the Union Navy was not able to penetrate its defenses. In an act of courage, Colonel Shaw volunteered to lead the assault on the heavily fortified fort. He listened as Colonel Shaw rallied the unit and prepare for battle.

He could not get himself to sleep that night. He knew that at daylight, blood will be spilled. From the beach, he can see the heavily fortified defenses facing them. It sent shivers down his spine. He has one foot in the grave now, and the looming possibility of death is now palpable. While he is lying in his cot, he can feel his knees trembling. Fear has crept in, now if only sleep could be as forgiving.

He awoke to the loud call to arms of Colonel Shaw. Today is the 18th of July, 1863. The attack on Fort Wagner was imminent. He fell in line of his company's formation. Colonel Shaw's commanding presence washes over them. Colonel Shaw sits high on his battle horse. The company's color guard stands tall in the middle of the battalion, holding the flag of the United States of America, 35 stars, red, white, and blue. In many sense, the color guard carries the reputation of the whole Union Army. Seizing an enemy's flag is great honor, and on the flip side, losing a flag is a tragic dishonor. Hence, the color guard is a primary target of the enemy. Only the bravest of the brave take on the responsibility of being the color guard. It is almost a self-imposed death sentence. He wipes the sweat off of his brow. He closes his eyes and mutter a short prayer. The subdued tension enveloping the morning air is broken by guttural scream of Colonel Shaw: Charge!

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He could hear himself shouting alongside the members of his infantry division as they muster up the courage and strength to charge up the fort. He hears several loud booms as cannons are fired by the enemy from the fort's parapet. The sound of muskets firing peppered thru the air in between the firing of the loud cannons. He can feel his heart pounding with adrenaline, and his breath has been fast and shallow. He runs along the other soldiers charging forward. He slows down briefly to touch his face. He felt a splattering of liquid on his right cheek as he saw an infantry member to the right of him fall down with a bullet to the head. He looks at his hand, it is red, but darker, much darker than the color of the flag waving to rally them forward. He marches on towards the fort. Boom! A cannon ball explodes to the front and left of him, instantly killing a few of his fellow soldiers. He can see Colonel Shaw on his horse waving his hand and screaming at the top of his lungs for his men to rush forward. He felt the zing of bullet graze his left cheek, as he dives into a shallow ditch to take aim. Bang! His aim was true, as the lifeless body of a Confederate soldier falls over the parapet. As he reloads his rifle, he looks back at the rest of his company. The ground was already littered with bodies of the fallen. Another soldier slumps beside him in his shallow dug out, bleeding out of his right ear but still alive. At a distance, he can see Colonel Shaw getting closer to the walls of the parapet, the color guard to the right and back of him along with other soldiers. Colonel Shaw was desperately calling on his men to rally forward. Then as he gets up and out of the ditch to continue the charge, he saw Colonel Shaw hold his own neck as blood poured through his fingers. Colonel Shaw slumps forward and his now lifeless body falls of the horse. He rushes towards the fallen commander and as he gets closer, from the corner of his eye, he sees the color guard go down on his knees as the color guard takes several bullets to the body. He changes course and runs towards the color guard. He grabs the pole holding the flag tightly between his hands ensuring that the flag never touches the ground. Between his hands, he is holding the color of the United States of America. He waves the flag to rally the remaining troops. In his loudest voice, he calls on his fellow soldiers to continue charging. For the Union, charge! For freedom, charge!

The flag waves gently as he struggles to climb up the steep earth of the fort. Lord, let me get up there. One foot in front of the other. Yes, that's it. Keep going. Just a little more, a little more. Thud. He felt the air leave his lungs as the impact of a bullet hits him in right breast. He can feel himself bleed. He gasps for air. This is nothing. Keep going. Just a little more, a little more. He trudges on, with his right arm getting weak from the gunshot wound, the weight of the flag gets a little heavier. But he keeps going. Zing! Another bullet grazes his temple. Breathe, come on, breathe. Keep going. Thud. Searing heat on his right arm just right above the elbow. Another bullet. His right arm goes limp and he is forced to hold the flag pole between his left arm and his chest. The pain is unbearable, O Lord, help me. Keep going. Keep going, he tells himself. He can see the other Union soldiers climb up to the fort. I can do this. Just a little more, a little more. And so he marches on, securing the flag with his left arm wrapped around the pole and close to his chest. He keeps going up, up to the fort, up to the fort. Boom! Another cannonball lands in front of him, instantly killing and maiming a half dozen men. The impact sent shrapnel flying everywhere. One of them shatters the bones of his lower left leg just above the ankles. He can barely breathe. The pain and exhaustion is taking a toll on his body. Just keep going, a little more, a little more. And so he drags his left leg behind him, limping in pain and exhaustion. He holds the flag high, clutching it like a dragon would his treasures. Under heavy gunfire, he plants the flag at the top of the parapet. At the sight of the flag of the United States of America flying above the parapet, a raucous roar of enthusiasm and morale echoed from what remains of the 54th Massachusetts Infantry Regimen. Under cover of fire, all they can do is hunker down and wait for reinforcements to arrive. They are surrounded by the enemy still and full victory is clearly untenable.

He fought to stay awake and alert. Gunfire can be heard all around them. His breathing is shallow, and he is getting weaker. His leg is swollen, and his arm is limp. From the distance, he can see the reinforcement marching towards them. The decimated army of the 54th Massachusetts Infantry Regimen slowly planned their retreat back to the lines of the Union army. Still holding the flag high, he limped down to join the ranks. He is weak, he has lost all strength, and he exhausted. Death seems imminent. No, keep fighting. You can do this. The Lord gives strength to his people; the Lord blesses his people with peace. As the Confederate enemy inch forward to regain the territory they momentarily lost, he was being helped by his Union army comrades. He passes the star spangled flag of blue, white, and red to another soldier who volunteered to be the color guard. With his last ounce of strength, he tells them: Boys, I only did my duty; the old flag never touched the ground. And then darkness fell upon him.

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The Battle of Fort Wagner ended in September 7, 1863 when the Confederates abandoned the fort after two months of shelling. This is a massive Confederate victory over the Union forces with less than 200 soldiers dead or captured for the Confederate army, and over 1500 soldiers dead or captured for the Union forces.

Due to his injuries, he was honorably discharged from the Union army in 1964. He lived to be a regular civilian after that, returning to a life of peace in New Bedford with his family. Upon his death in 1908, the flag at the Massachusetts state house was flown half mast, an honor usually reserved for distinct leaders of the state: deceased senators, governors, members of Congress, and US presidents --- something a former slave could have never dreamed will ever happen to them . His greatest fear was never realized. In the end, his life story is that of courage, faith, and triumph.

His name is William H. Carney. And he is the first ever African-American to receive the highest military honor there is for his exceptional bravery: The Congressional Medal of Honor. It was awarded eight years before his death. This is his incredible story.

HAPPY INDEPENDENCE DAY!!!

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THE END

Sheep : A Black Lives Matter Story in Trump Country

2020-06-27T01:18:00.000-04:00

It has almost been a month since the world witnessed the gruesome death of George Floyd at the hands of police officers in Minnesota on social media platforms. At this time of writing, the protests, the riots, and the demonstrations have eased. At its peak, large swathes of cities across the United States were filled to the brim with protesters screaming "No justice, No peace!". The Black Lives Matter movement was reinvigorated. However, just as quickly as the protests have caught steam, what started out as peaceful demonstrations eventually turned into horrifying chaos as rioters and looters took over the streets burning and looting shops. People watched in horror and shock as they watch looters break into stores and grab whatever they can, razing and breaking everything in their paths. Business owners hurried to board their stores up to avoid the fate of the surrounding businesses.

The news media flooded the airwaves with stories of protests across the United States. As the mainstream media focused on the protests, their right wing counterparts put the riots on blast. While the nation is rocking with protests against racial discrimination, suppression, and police brutality, the irony is lost on a largely demoralized police force trying to restore order to the cities whose citizenry have seemingly lost its trust.

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A 100 miles away from DC, Shenandoah County boasts of its bountiful farmlands and apple orchards, and its riveting views of the Appalachian and Blue Ridge mountains ranges to either side of the valley. The equally breathtaking Shenandoah River, immortalized in John Denver's classic song Take Me Home Country Roads, snakes through the land and keeps the valley verdant green. Population: 44,000. Deep red, very white, very conservative Christian populace. There is one church for every 500 people in Shenandoah County, compared to the liberal DC suburb of Fairfax County, which has one church for every 2,700 people.

Shenandoah County is Trump Country, proudly and unabashedly. The county also represents the cookie cutter Trump base: it is very white (90%), blue collared, rural, with only 20% of the population holding Bachelor's degrees or higher. Shenandoah County fought and won to become a gun sanctuary.

In this part of the world, protests in Washington and Richmond are viewed with disdain and even open contempt. "It is not just black lives that matter", they say, "All lives matter." On online community forums, the majority lashed out on their standard boogeymen: Antifa, George Soros, the Clintons, Anthony Fauci, the WHO, the CDC. "Why are all those people protesting in the midst of a pandemic?," they asked. "It is darn stupid, and hypocritical. But then what can you expect from sheep?"

A sheep is person who cannot think for himself, that he merely obeys the government without question. A sheep is a person ruled by fear. He gets his information from mainstream media, which constantly lies about President Trump just to make him look bad. A sheep is a person who wears a mask because of the coronavirus, what an idiot.

Out here in the Shenandoah, all lives matter. It's not just the blacks. The lives of whites, browns, and Asians matter too. That belief is as wide as it is strong in this area. We respect law enforcement here. We are proud of our Southern Heritage. The Confederate flag is but an acknowledgment to our history, not a symbol of slavery and oppression. Racial inequality doesn't exist here.White privilege is bullshit. We don't have that here, sheep.

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Officer X has always dreamed of being a policeman as a child. He is native to Shenandoah county and has been on the police force for several years. As he has always been, he woke up today to face another work day, serving his community and coming home at the end of his shift to his loving family. He got along well with his neighbors, has many friends, and is a respected member of the community. He loves to fish, is a fixture at the local Moose lounge, and gets along with pretty much everyone. He considers himself a good cop--one who is honest and fair. As he finishes his breakfast, he kisses the wife goodbye and hugs the kids. He checks himself at the mirror one more time before heading out. Oops, the badge is a little tilted to the side, he fixes it, and steps out of the door.

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Leon is a pastor at one of the local churches in the town of Edinburg, one of the six towns of Shenandoah county, pop 1,100. He is an outstanding man, self-made. He is a real estate investor, and a decorated Master Sergeant of the USAF, 24 years in. He owns rental properties in town. He has never been arrested, has zero criminal records. He is an outstanding citizen.

Leon did not think that on the first day of June, exactly 7 days after George Floyd's death, he will have his wrists cuffed, and he will be hauled off in front of the mob who was mocking him and calling him racial epithets. Leon experienced his first arrest, at the hands of Officer X, who has known him for years in the community.

Leon is being arrested for brandishing a concealed carry gun which he claims he needed to show as he felt in danger of his life. A group of 5 people cornered him when he reprimanded them about taking an old refrigerator at the dump of his apartment complex. He was verbally abused and physically threatened. He felt that he needed to get his gun out while he called 911 for help.

Leon was arrested. The group of 5 mocked his arrest. The group of 5 are all white. Leon is black.

***********************************

Tensions across the political spectrum boiled over in DC and other major cities. The president was rushed into the bunker, news media reported. The historic St John's Church was set on fire. And eventually, protesters were allegedly tear gassed and pushed aside so the president can walk to St John's to call for law and order. With so many things happening around the country, it took more than a week before the regional news outlets got a hold of the story about Leon's arrest. Several more days before national news outlets brought it out into the open.

The local sheriff promptly and publicly apologized. He apologized for Leon's arrest. That should not have happened, he says, and he would have done exactly the same as Leon did had he been in his shoes. The apology was sincere, and he vowed that the department cares about the people of color in our community. Two sheriff office personnel were placed on leave pending investigation.

The story eventually reached the community pages of Shenandoah county on Facebook. There was righteous anger towards the group of 5. They were called different names, judged to be practicing incest, drug addicts, "crackers", scum of the earth, they cried. Fists up in the air, they raged against the apparently racist incident.

It seemed like at that moment, the racial tensions that pervade the big cities have started coming home to roost in the backyard. It is real, it is happening, it has happened here, and it has been happening here.

But as expected with any news regarding frail race relations in this part of the state, within a couple days, interest in the subject has faded. The community social media page has moved on to other topics of interest. Throughout the entire social media post interaction, white privilege was never talked about. It is a touchy subject here. It is hard to talk about white privilege when the county which is 90% white has lower than median household income compared to the rest of the US, and a staggering $20,000 lower household income that median household income in Virginia.

For many people here, it is quite hard to empathize with the Black Lives Matter movement because there really isn't a whole lot of opportunities for social interaction and integration to make them form an opinion, their own perspective. Sure, there might be a token minority person at work who they have a pleasant relationship with, or a neighbor down the road who do neighborly things with them, or that cheerful gospel choir member at church. But that hardly qualifies as social education on race. There is a serious gap in racial familiarity that a holistic paradigm shift from a narrow point of view on race cannot be fully realized and therefore is capriciously filled in by Fox News, Breitbart, and other right wing organizations to fit their agenda.

They are told that there is absolutely no reason for them to feel white guilt. After all, they have nothing to do with the slavery that happened centuries ago. They are told that if "black lives really did matter", then why aren't we talking about the murders in Chicago and black-on-black crime? Why aren't we talking about the widespread poverty in the inner cities run by the libs? Why aren't we talking about that blacks hold the highest incarceration rates despite only making up less than 20% of the population? They are told that the Civil War was about fighting for the principles of the people of the South--it was never about slavery. Robert E. Lee is an American hero, not a traitor. Why aren't you sheep talking about this?

Remarkably but not really surprisingly, racial inequality is a taboo subject in the area. Talking about it is considered race-baiting. So, the path of least resistance that people take is to simply not talk about it. It is an uncomfortable truth that racial disparity and white privilege exists where we are even though we refuse to talk about it. The general populace of Shenandoah county are not aware that black students are 338% more likely to be suspended at school than their white peers. Nor are they aware that black people are 7x more likely to be wrongfully convicted for murder than their white peers. Or that black people are 20% more likely to be pulled over for routine traffic stops, and along with Hispanics, are more likely to get tickets during these stops. Or that the percentages of students who attend high-poverty schools are blacks and Latino at 45% compared to their white counterparts at 8%. How about the fact that black business owners even those with excellent credit scores are denied business loans at twice the rate of their white counterparts?

Racism is so deeply embedded in the fabric of social consciousness that we cannot even see it even if it is staring directly back at our faces. Due to a serious lack of racial familiarity and connections, we helplessly submit to racial prejudice to mask our own ignorance and biases. In the way society views racial stereotypes, blacks are often portrayed as inferior, less intelligent, less pretty, more animalistic, more prone to violence. The stereotype for blacks has always been negative. Black men have historically been portrayed as brutish, violent, and hypersexual.

Systemic racism has made it so that society elevated Asians as the model minority to further degrade the confidence of the black community. Systemic racism is the reason why in the subject of Colin Kaepernick's kneeling during the national anthem, Fox News mouthpiece Laura Ingraham called Drew Brees' initial racially insensitive comments as his right to express an opinion. The same Laura Ingraham who told Lebron James to "shut up and dribble" when he did the same. Systemic racism has made it so that blacks have to go through a whole lot of hurdles inorder to access the same conveniences and opportunities in society that is readily available for white people. Systemic racism is present in the voting booths that are purposely suppressed to weaken the black vote. Systemic racism is present in the underfunded inner city schools. It is present in the disproportionate number of minorities working in low wage jobs while facing the threat of death in the midst of the coronavirus pandemic.

Systemic, deeply ingrained in the collective subconscious of society itself, racism is the reason why Officer X arrested Leon in the first place. Officer X did not wake up today bent on arresting a black man and call it a day. The inconvenient truth is that Officer X was conditioned to believe the white man first over one with a darker pigmentation regardless of circumstance. That, my friends, is systemic racism. Had Leon been white, and was surrounded by a group of 5 black people, the story would have been different. The story would be about a servant of God, standing his ground, gun in hand in full defense of the Second Amendment. In that alternate universe, the group of 5 black people will have been arrested with Officer X calling for back up squads to "diffuse the situation".

In a world where the fairness of your skin alone inspires trustworthiness, innocence, and righteousness, the darker pigmented populace are tasked with the burden of proof every time. Emmett Till paid with his life under this circumstance and inspired the Civil Rights Movement more than half a century ago. The Civil Rights Movement whose envisioned goals remain elusive in its entirety. The struggle persists even after a black man was elevated to the highest position of power of the only superpower in the world. The struggle will continue to persist until society itself truly look inward, listening to understand rather than just hear, and experience a holistic paradigm shift.

*********************************

In one of Shenandoah County's 80-some churches, a pastor looked over towards the attendees. Spaces in between them and masks on, the faithful listened to the Parable of the Lost Sheep, Luke chapter 15. When you have a hundred sheep and one goes missing, Jesus said that you will leave the ninety-nine and look for the lost sheep. In the story, Jesus lets the people know that the other ninety-nine sheep are not in danger, their lives matter, but they are not in danger. The one lost sheep needs saving, and the shepherd will be filled with joy once he finds it, takes him home, and keeps him safe.

The symbolism of this parable to the current struggle of the Black Lives Matter movement cannot be emphasized more. Be it spiritual salvation or the daily struggle of survival in pursuit of happiness, the parallelism is strikingly powerful.

A half-mile away from this church, a squabble breaks out at the entrance of a local grocery shop. A shopper was refused entry because he refused to wear a mask as mandated by the governor of the state.

"I am an American, and I am exercising my freedom! I am no sheep like the rest of you! You stupid liberals are too dumb to think for yourselves. Sheep!". The irate shopper storms back into his parked truck. As he leaves the vicinity in rage, a light breeze picks up and his signature blue flag wavers in the air: Keep America Great! Trump 2020.

********************************

END

The Man from Davao

2017-09-24T20:33:00.000-04:00

Nelia hails from Bulacan. Her family fondly calls her Neng. She left for the big city after graduation in highschool to help her family in the province. She is lucky, she says. She shares rent with her two friends in a run-down but reasonably livable apartment building in Manila. She wakes up every morning at 5 am sharp, readies herself and grinds it out with other commuters to get to the mall where she works as a sales person at one of the kiosks that sell knock off fragrances. She brought two pandesals and a boiled egg on her way out to eat for breakfast. Traffic is terrible so she leaves really early than be late. Trains are unreliable she says so she commutes via jeepney. Neng makes minimum wage and still needs to send money back to the province every pay check. She is fine, she insists, even lucky, as she has kept this job for seven years now without any problems. She smiles as a female customer, her first one of the day, approaches the kiosk.

                                   **********************************************

It all started as a grassroots movement of sorts. This brash, unassuming mayor from one of the biggest cities in the country, waded into the national political spectrum at the last hour and shook the comfortable political standings as we knew it. People were in awe of the Man from Davao, a living legend who transformed a lawless city in the politically turbulent South into one of the safest cities in the world. He had the quiet respect of Christians and Muslims alike, and even the communist insurgents were soft on him. He was after all, very much anti-establishment. He was very straightforward and undiplomatic but he also was very relatable and did not sit on his high horse like a regular politician. He radiated the aura of Filipino action movie heroes of the 80's and 90's, a "maginoo pero medyo bastos" personality, the one thing that stands between the oppressed poor and the abusive oligarchy. He looked into the cameras and in his signature Tagalog with a Visayan accent and diction, promised to replicate his success in Davao with the rest of the country.

The Man from Davao waltzed to win the presidency against the administration's bet in a big way. Islamic and communist rebels have sent feelers to once again sit at the negotiating table and let bygones be bygones. There was talk that his Cabinet will be comprised of the best and the brightest in the country. His victory was hailed as a victory of the common man. Until it no longer was.

                                      ********************************************

The Man from Davao inspired a populist movement. He is fondly called "Tatay" meaning father, by his admirers. He raised his fists into the air and screamed death to all those who deal and use illegal drugs. His admirers smelled blood and went into a frenzy. And so did the policemen. There were 4 million drug addicts in the country, the man from Davao said. Four percent of the entire population of the country takes part in the drug scourge. Four million drug addicts. That is more than all the doctors, nurses, policemen, armed forces, and teachers in the country combined. The nation shuddered at the figure. But they believed him. He was after all, Tatay Digong.

He curses on live TV, and that is forgivable, they say. He speaks from his heart. He cursed the Pope, a beloved figure in the largest Catholic nation in Asia. His words were taken out of context, they say. He spoke from his heart when he threatened to kill each and everyone of those involved in drugs. He will kill them all. Out of fear, hundreds of thousands surrendered to the police. They knew that the man from Davao was not playing around. Better come off clean now and promise to rehabilitate instead of being shot to death by the notorious DDS (Davao Death Squad), a hush-hush group of vigilantes who mete justice to repeat offenders and hardened criminals under the cover of darkness, and has now gone national. The already bursting jails became SRO spaces for all the drug repentant.

Then the bloodletting began. And the crowd cheered. The bodies piled up. And the crowd roared louder. A lady senator spoke against it and was thrown in jail, with the gang lords implicitly pointing to her as the mastermind of the drug trade in exchange for clemency. The crowd glared their evil eye on the lady senator, tagged with the color of the sun, the color now associated as the antithesis of all the glorious change that the man from Davao promised them. The man from Davao has by now transformed into a demi-god.

                                    **********************************************

Then a pattern started to emerge. Everyone who disagrees with the Man from Davao, is an imbecile, an idiot, a drug addict, and an unpatriotic goose all at once. Every protest, every disagreement is a form of disloyalty. And the Man from Davao tolerates none of this foolishness. The first to go is the duly elected VP of the country. She was disinvited to all executive functions in the cabinet while the Man from Davao cozied up to an old pal, Marcos Jr. She became the de facto leader of the yellows, now bitterly ostracized by the masses for not standing in line with the Man from Davao's policies. F the USA, F the UN, F the CHR, F the yellows, F anybody that does not shower the ground he walks on with petals. Disloyalty will not be tolerated in his presence. He is the best political strategist there is, his followers say. He knows what he is doing; he has a secret plan. Like how Scar the antagonist lion in the Lion King rallied the hyenas to his side, he embodied the "stick with me and you'll never go hungry again!" verbiage.

Next came the fake news. He did not openly endorse them but he obviously welcomed anything that would appeal to his base. All of a sudden, finding the best and the brightest is not so appealing anymore. He demands complete and utter loyalty. His base has gone rabid by this time, willing to attack any platform that shuns their savior. Suddenly, the mainstream media became a target. Fake news, fake news, complete with a Donald Trump pout. He handpicked a C-lister showbiz personality known for her outrageous blog to be part of his cabinet. Loyalty is rewarded in his domain. Disagree and you become a political pariah.

                                   ************************************************

There are rumors that the Man from Davao is deathly ill. The rumors strengthened when he went absent from the public eye for several days. His spokespeople have all the answers, skewed or otherwise. The Man from Davao reappeared before the world and did not look any bit less of himself. On the sides though, political upheaval was in the works. Movements in the political spectrum appear to be preparing for the worst: Marcos Jr was pressuring the Supreme Court to expedite his election protest case, an impeachment case was being readied vs the VP, a scandal emerges involving the head commissioner of the Commission on Elections, an impeachment case was in the works for the chief of the Supreme Court, and the operational budget for the CHR was slashed by the always administration friendly lower House to a measly $25. If you are not aligned with the vision of the Man from Davao, then you are an enemy. If you stayed with the lionesses in the movie, indeed you would have grown hungry and desperate.

                                 ***************************************************

His loyal followers are unshakeable. Their president is omnipotent and omniscient. He is the antihero this country needs, just like Lee Kuan Yew did for Singapore. We need to cleanse the country of its filthy underbelly and we will prosper like never before. Kill all the drug addicts, the users, the dealers. Don't hesistate, Tatay Digong, we are behind you. F the yellows, we have your back. Kill them all. They have made their choice, kill them all. I want you to kill them all while I pray to God for your safety and good health. The irony is putrid, like the bodies policemen fetch from canals with bullet holes agape and hands tied behind their backs. Must be a drug user. Dear God, please keep our Tatay Digong healthy and strong, always dear God. But that drug user, kill them all.

                                 ***************************************************

Neng ends her workday with a bang. She has exceeded her quota for the day. Her boss will be pleased. She already knew it will be dusky or even dark when she gets home, depending on traffic. Today is Thursday, it is payday. Neng walks into a pawnshop to send money back home. Later, she will pass by the neighborhood store to buy some canned goods, eggs and pandesal for daily consumption. She walks to the curb where she will take her commute back home. Traffic is going to suck this afternoon, she can already tell.

She gets home and turns the TV on. Her friend, Sandra, was just getting home too, while her other room mate Mai-Mai is getting ready for work. She works the night shift at a nearby hotel as an attendant. A news report about the Man from Davao chastising a former soldier turned senator on live TV came into view. Neng, blurts out "buti nga sa kanya" he deserves it, to which Sandra nods in agreement to.

Tonight, Neng will sleep in the same bunk bed she has slept on since coming to the big city, she will wake up at the same time, eat the same breakfast, take the same miserable commute and get paid the same amount she always had for the past seven years. Nothing has changed, really. None of that change is coming business happened. It is just more of the same. The same inept government. The same bickering Congress. Same pointless Senate hearings. It is the same for many people like Neng More of the same, day in and day out.

In the distance, three gunshots were heard. Followed by a screech of motorcycle tires and the panic of alarmed citizens. Neng, goes straight to the door and locks it. They turn the TV off. They already know what happened there. It has happened a couple of times before. For sure, they will see a 30 second clipping of it on tomorrow's evening news. Must be a drug user. Kill them all.

Philippine Physical Therapy---In Crisis?

2015-03-18T23:33:00.000-04:00

(Disclaimer: This blog entry is created solely for entertainment purposes. The content of this entry is the sole expression and opinion of its author and does not necessarily reflect those of any other entity, organization, company and such. The characters mentioned herein are, uhm, to cover my behind, entirely fictional. Any likeness to actual persons, living or dead, are, yeah, strictly coincidental. True story, bruh.)

The future of physical therapy in the Philippines is in crisis and you may not even be aware of it.

No, I am not just talking about the steady stream of therapists leaving the country in search of greener pastures in first-world countries with a rapidly aging population, most notably the United States. Or that because of the hiatus of hiring of PTs in the early turn of the millennium resulted to a drought of PT graduates to replace those who have already migrated. Or that the recent batches of PT graduates opt to prepare for the NPTE as soon as they pass the local licensure exam instead of opting to get experience first in their community hospitals and health centers. True, all of these contribute to the sustained decline in the quality of delivering physical therapy services in the Philippines. But what could be the biggest factor in this continued deterioration is us--the physical therapists ourselves and the culture we have grown so accustomed to. We are slowly asphyxiating our own profession, our calling, our service and our unique practice.

Most of us are probably unaware of it. But throughout the years, we have developed a PT culture that is closed-minded and clannish. Arguably, the best years of Philippine PT practice was in the late 80's to the mid-90's, when we were producing therapists who were top-notch and brimming with clinical competence. After that, the slow and steady decline began, and we haven't even noticed it.

Are Physiatrists Over-reaching Into Our Practice?

One of the main reasons that our profession is as it is right now is that we have made the practice of Physical Therapy so physiatrist-centered and thus, medical management has completely taken over the rehabilitation process, pushing nursing care and physical and occupational therapy to the sidelines. The result is poor patient outcome once they are discharged from acute care. Let me get this clear, though; I am not blaming the physiatrists for what our practice has become. In fact, the person I most look up to as a physical therapist was my dean, friend and mentor who is a physiatrist. What I am saying though is that this captain of the ship principle has gone too far. Philippine PTs have vague recognition as to what a physiatrist really is; most of us know that they are the head of the rehab department. In truth though, they are medical doctors trained in the medical aspect of physical rehabilitation. Ergo, they are largely knowledgeable in medications and pharmacology affecting physical function and movement; they are experts in performing and interpreting medical and special tests to determine the source of pain and physical dysfunction; they are adept in providing treatment alternatives to surgery; and because of their diverse awareness in multi-system affection that impact physical function, they serve as the primary contact person or lead practitioner in a medical team that may include therapists, neurologists, orthopedic specialists, cardiologists, pain specialists and such.

So, being doctors of physical medicine and rehabilitation and head of the rehabilitation department, it is their responsibility to make the plan of care and for the therapist to follow that plan of care, right? Both yes and no. By law, yes; a therapist cannot evaluate and execute a plan of care without the signed approval of a physician. Take note, people, a "physician", which means that other doctors can sign off on the order and the therapist plan of care. It is not exclusively the physiatrist that can give physical therapy orders. Therefore, as a PT, by law if, for example, an orthopedic surgeon has given PT orders and your resident physiatrist is out for a few days, you can evaluate the patient and establish a plan of care. That plan of care can be executed immediately providing the surgeon agrees to it and signs off of it. You do not have to wait for the physiatrist before you can implement a plan of care.
And although the physiatrist is an expert in physical medicine, they are NOT trained in specific therapeutic exercises, modalities, manual therapy and such. They are NOT experts in training a patient in the proper, safest and most efficient way to transition from supine to sitting at the edge of the bed. They are NOT trained in teaching a patient how to use a walker and how to walk with it safely with the correct hand and foot placement and even advocate for compensatory strategies when a physical limitation cannot be overcome. They are NOT experts in fitting and measuring wheelchairs and assistive devices for patients with different disabilities and positioning needs. Those things I just mentioned (and many more) is the job of (you guessed it right) the physical therapist. It is our responsibility, our task, and our job description to the T!

Now let me be the one to call out that although I recognize the physiatrist as the head of the rehab department in the Philippines, I find it utterly ridiculous and reprehensible that he/she will limit my ability to exercise my clinical decision-making by boxing me in with orders for PT to execute a combo-meal style exercise prescription every single time! And the sad thing is, this combo-meal style exercise prescription is commonplace everywhere you go. Example: Stroke with L sided weakness. Mx: AROM on R UE/LE, PROM on L UE/LE x 10 reps, 2 sets, AP. E-stim L UE flexors, L LE extensors. Walking inside // bars. This is just so common everywhere. And some of these managements go on and on for years. Hotpacks with TENS x 20 mins on the low back for low back pain. Motor point stimulation on facial muscles for Bell's palsy. Lumbar traction x 20 mins for low back pain patients. Sigh.

This. Is. Ridiculous. And it has to stop.

Moving forward, what physiatrists should start doing is to give orders that are broad and non-specific but are generally encompassing, rather than orders that are restrictive and confining. With "non-specific", I believe it would be better if physiatrists wrote orders for "therapeutic exercises" rather than specific orders for AROME R UE/LE and PROME L UE/LE x 10 reps x 2 sets, AP. Or, for example, the physiatrist has interpreted the brain MRI or CT scan and determined that the patient has cerebellar degeneration, he should write an order for "balance training" or "fall prevention strategies" or "compensatory strategy training for balance dysfunction", statements that are generally encompassing. This way, the therapist can make his own determination as to which exercises precisely fit the patient. Therapy prescription should be individualized and although there are many gray areas in prescribing treatments, there should be no room for this combo-meal type treatments. Not only do we subject ourselves to irrelevance by following orders for exercise that we have not ourselves evaluated for their appropriateness, we also are party to the crime if the patient fails to progress at a reasonable amount of time because we leave all the power to the physiatrist to evaluate and re-evaluate patient function and progress which, most of the time, does not include our thorough professional output.

The therapist should be given utmost discretion to do their own evaluations and discuss them with the physiatrist and they should make the plan together. This way, the physiatrist can focus more on really tackling the medical issues surrounding patient care. Once as an intern and again once as a practicing PT in the Philippines, I have encountered cases of Stevens-Johnson Syndrome, which is actually extremely rare. Both cases were pretty textbook manifestation of the disease and both would have been preventable. Turns out, both cases are most likely caused by an allergic reaction to certain antibiotics (if memory serves me right, both cases involved pneumonia among their diagnoses) and would have been prevented if it was caught on earlier. I am not putting the blame on the physiatrist for not catching this on as I believe the nurses and other medical staff involved in the care would have had more access to the patient, what I am saying is if we free the physiatrist from micromanaging even the exercises of the rehab patients, then they would have more time to deal with really important medical stuff. Like minimizing chances of preventable medical complications such as this.

A Serious Lack of Medical Coordination

Another factor that gravely affects effective delivery of healthcare to the general population is the serious lack of medical coordination. This arguably stems from our especially vibrant but also greatly diverse cultures. As a people, we are very clannish. The Ilocanos have more affinity to Ilocano-speaking people they meet in a new place, the Visayans do the same, and so on and so forth. Therefore, if an Ilonggo, for example, is placed for the first time in Australia and he seeks out a FIlipino community, the first acquaintances he would get to know more would probably be another Ilonggo. This does not mean he would not be friends with the other Pinoys, it just that our cultures make us lean towards those which are closest to ours.

This mindset, unfortunately, has also been deeply ingrained in our hospitals and other healthcare venues, and this greatly affects patient care. Ergo, the nurses take their own vital signs, the therapists take their own vital signs and the doctors also do a quick check of the vital signs for their own purposes. Never did those three disciplines come together to discuss the significance of those data. Why? The nurses and the therapists all rely entirely on the judgment of the doctor himself, never once considering that their input could actually be crucial to how the doctor makes his medical decision. The nurses and the therapists hold an invisible grudge against one another stemming from their imagined rivalries in college and thus offer some sort of cold interaction with each other. So in the corners of their spaces, the therapists refer to them as ass-wipers, while the nurses consider therapists as glorified masseuses. We should break this set-up and engage in better communication as a medical team, not a sectarian labor force without any form of synchonicity.

How important is it that we coordinate what we find out, as physical therapists, to the nurses, the doctors and our own physiatrists then? Take for example a patient with an acute stroke. He has been given pharmacological and medical management by the doctors and the nurses have been taking his vital signs (in the bed, supine, head slightly elevated), and he has been cleared for therapy. Now, the therapist comes in there, takes the vitals, then sits the patient up and then, the BP drops and the patient starts complaining of lightheadedness. Therapist then moves to the feet and start the (ugh!) passive ankle pumping then rechecks the BP again, still low. Repeats the process. Still low, still lightheaded. Therapist then puts him back to bed, reports this to the physiatrist, who promptly orders patient to be trialed with a tilt table. And so it goes. Pt shows signs of orthostatic hypotension results to default management by MD as part of the combo-meal prescription: tilt table pronto! Boom! We could have saved our energy and regained our self-worth if we have been in good coordination with the nurses and doctors in the first place. The remedy would probably have just been a lower dosage or a different anti-hypertensive drug, rather than directly assume that the patient is appropriate for use of the tilt table. (For the record, since I moved to the States a few years ago, I have not heard a patient or a therapist mention that they have ever used a tilt table. The only reference to tilt tables were those therapists who have been in the practice for 20 some years and mention that they have used them very long ago).

Oh, and another thing, stop hyping up this PT vs Nursing rivalry in our schools and in the hospitals and clinics. It is not helpful to both our practices and it is pointless to try to upstage one another because we are clearly separate entities of the medical practice who seriously need to get our acts together if we want to elevate the medical practice in the country. Oki?

The Culture of Elitism in Healthcare

As a people, Filipinos are arguably very elitist. We give so much emphasis on titles, pedigree, skin color, affiliations, etc. In essence, we put blind faith in certain politicians despite their lack of track record because they have a familiar sounding name. We silently admire the balikbayan who hails from the US without even knowing that this balikbayan works minimum wage as a grocer at Walmart and outright dismiss the OFW from Hongkong as a lowly household help. We have a deep fascination about the the lives of the hacienderos, the glamor of the elites, the next door neighbor with a famous last name and is allegedly related to the town mayor. We take the local bishop's interpretation of the Gospel as truth because as a bishop he must have a direct line to Jesus Himself and therefore, speaks the truth. Yes, we are an elitist society, and our healthcare system has been subjected to this too.

By many measures, the high regard that society places on doctors is well-deserved. They spend years in medical school, learning, studying, preparing for the day ahead when they will be tasked to make a decisions that will dictate if another human being lives or dies. They have to take many exams, trainings, internships and such to deem them competent to practice their professions and a new set of education, training and such to specialize. They spend their productive years in medical school while their peers are raising a young family and are slowly creeping up the corporate ladder. In many ways, the respect that the common folk gives them has been earned. The typical patient would believe what his doctor tells him because he is a "doctor", he knows what he is doing.

This sense of respect that doctors get, however, is also a double edged sword. This could lead to sense of entitlement, prejudice and condescension. Trust me, there are a whole lot of good doctors out there breaking back and sweating blood in service of others; but just like any other medical profession, you also see the bad ones in abundance, wherever you are, in the US, the Philippines, Saudi, wherever, just like you see excellent doctors everywhere. And the problem is that like all people, I myself, after awhile forget those incredible moments when a brilliant doctor blew my mind away; but I can clearly remember those few times, when a bad doctor has a blunder and digs a deeper hole each time he does something in an attempt to cover it up. These incompetent doctors in charge of other people's lives walk among us, and they are too arrogant or/and ignorant to ask for assistance and advice from colleagues and fellow medical professionals. They look at themselves too highly to ask help from the therapist or from the staff nurse who has been there for two decades and serves as a treasure trove of knowledge because, hey, I'm the "doctor" here. They fail to see that the best doctors in the world started out as novices with broad minds, learning from mentors and patients alike, a little bit over here, a little there until they have found their niche and became icons in their respective fields. The key is to keep learning, from peers, patients, family members, caregivers and not sit on your medical high horse because you are a "doctor".

These are the very same doctors who prefer to write their diagnosis as a "mild stroke". A "mild stroke" even if the patient is completely flaccid on one side, is choking on his own spit and is completely belligerent. A "mild stroke", they diagnose, to calm families down and to avoid worried questions from spouses and adult children as to what will become of their sick loved one. Their reason might even be the subconscious attempt to not offend because our culture also does not condone frankness and being straight forward. The wordplay, though, of calling a stroke "mild", carries a lot of power when it comes from a person of authority, such as the MD. Because the MD officially called the stroke "mild", people believe that they can be lackadaisical in their approach to it and God knows how much impact it has to compliance to taking medications and adopting a lifestyle change. So next time, call a stroke a stroke, don't add colorful adjectives to make other people feel better. They need to be educated and consoled up to a certain point, but they definitely do not need the sugar coating.

In the rehab setting, I have encountered physiatrists who are so high up on the pedestals they refuse to listen to reason. I have encountered physiatrists who have questionable ethical practices but then again, as I mentioned earlier, we have an elitist society, and therefore, as an intern, I should know my place in the social order: physiatrist > head PT > staff PT > PT volunteers > PT interns > earthworms/vermin/pests. I have once been ordered to put Estim on B UE/LE flexors and extensors simultaneously, to save time. Omg. Another physiatrist, who was a geniunely good and likeable person but with very bad osteoarthritic knees, had a patient on the second floor ward without elevator access referred to her. She, of course, could not manage stairs and without evaluating the patient told me: "Siguro pareho na rin yan sa ibang patient natin na stroke. So same management na lang ha", and proceeded to write the orders. A female physiatrist from Bacolod allegedly prescribes glutathione pills, grapeseed and other supplements to the tune of thousands by misleading patients and their families that they help them. Glutathione pills help cure stroke patients? Yeah right. Like its antioxidant properties will heal necrosed nervous tissue. There is a physiatrist who comes in like a thief in the night into the patient's rooms for a few minutes to talk to them and then we would find out later from the patients that they got billed by the thousands for those unmerited visits. Another physiatrist refuses to order home health therapy to patients even if they live hours away and insists that family bring them in each time because "they can be closely monitored in the clinic", which I believe is really stupid. It takes a lot of money and effort to transport a patient who lives an hour and a half away each way thru jeepney rentals and caregivers to the clinic for something that can be safely performed at home anyway in the presence of a licensed and perfectly abled therapist. But then again, if he orders home health PT, the money goes to the PT and not to the clinic so, yep, no home health for you, sorry. I didn't say anything, I was an intern, I had to know my place. That place is a fixed, immovable position just above earthworms and vermin. Thank you very much.

In my entire practice as a physical therapist in the Philippines, there were only several times when the physiatrist actually asked me to evaluate the patient myself; the physiatrist would then leave me alone with the patient and come again later to ask me questions about my evaluations. Those "several times" were afforded to me ONLY by one physiatrist, my mentor and former dean, Dr Manuel Gayoles Jr. He would actually take the time, if he can spare some, to do impromptu lectures and demos in front of interns and staff. Most physiatrists don't think that way though; they reserve a certain aloofness towards volunteer staff and throw cold invisibility cloak over the ever-rotating faceless interns. This detachment translates to the staff where the head therapist arguably looms over as lord of rehab when the physiatrist is away ordering staff therapists here and there according to his whim; the staff therapists in turn, project their hatred to their lead PT towards the volunteer PTs and, most especially, the lowly, scum of the earth, interns. When the head of the department projects an aura of exclusivity, everyone else finds their own corners of solace and bubbles of discontent and ill-feelings brew, acidic and unhealthy. Interns, (I guess rightfully so) speak in hushed whispers about their growing discontent and anger but in the breath in fearful overtones of just bearing it out so they can graduate. And this is not an uncommon incident. Clinical instructors everywhere either have an inkling to power trip on interns or intend to develop romantic relationships with them. Ugh.

The most striking experience for me, though, that reveals this failure of leadership through condescension and elitism, is when I was relegated to treating a patient who was extremely difficult and bitched a lot, excuse my French there. She was being very difficult because she was in so much pain. I vaguely remember her face and I forgot her name. I just remember she has thick, shoulder length hair, she was in her early to mid-40s, and an assistant manager at a bank. Her treatment involved hotpacks across her entire back, soft-tissue massage and cervical traction. She came every day at about 1 pm and everyday she harped about how bad her back pain was. I asked my CI then why she was in so much pain and what her diagnosis was and the CI dismissed me offhandedly with "Oh, she just has neck and back pain". Three weeks into treatment I finally stumbled into the patient's chart, and there as I thumbed thru her diagnosis page, clear as day, an XRAY report revealing a suspected lung mass. The patient had a metastatic tumor from the lungs that has spread to her bones and the physiatrist madapacking missed it! The C.I. just followed orders from the physiatrist without doing thorough evaluation and chart review and missed it too. And this lowly intern had to carry the burden of hastening her eventual demise. I did not get to find out what happened to her next after that. I remember she flew to Manila to get treatments but how truthful that was, I don't know. I only heard it from the same CI who was still as clueless to her serious medical blunder as the physiatrist who ordered them. That case happened almost ten years ago, but that experience truly opened my eyes to how F-ed up our system is.

Is the Education System Failing Us?

Our education system is probably one of the biggest contributors to our decline as a profession. We are basically stuck in the 90s, 20 years behind where the rest of the physical therapy world is gearing towards. Whereas the APTA is fighting for DPT as an entry-level professional requirement I assume to further the cause for direct access care, the Philippines curriculum for PT has relatively remained the same in the past 20 years, except for a few subjects added here and there (like research and emergency procedures) to comply with education requirements in the States. [Sidebar: Direct Access care just means that patients can go directly for PT evaluation without MD orders; I know the State of Michigan has already approved their own Direct Access Law but I believe Medicare rules have not changed and if the patient has Medicare as their insurance, they need MD orders to eval. Private insurance companies follow Medicare rules, so if they have private insurance, they still need MD orders.] I find it sad that CHED requirements are changing inorder to comply with education requirements in the US and not because the therapists themselves find that our education is inadequate for our increasing responsibilities in the practice. But, then again, how do we know right? After all, we just follow orders, we don't know how to think for ourselves, it seems [insert sarcastic eye rolling here].

I, for one, am guilty of perpetuating a failing education system. As a student, I was made to believe that PT is one of the hardest courses there are, figurative mortality is high and the board exams are one of the hardest with one of the lowest passing rates in the country. I was in awe at the third and fourth year students carrying gigantic tomes of PT knowledge, stacks of photocopies on one hand, Braddom on the other, silently mumbling memorized codes of muscle origins and insertions. And then I became them, reading chapter after chapter of Physio and Ana, praying to the high heavens that I will remember all of them tomorrow during the short quiz that Dr so and so is going to give, after the major practicals in assistive device training, and right before the long quiz for the anatomy of the UE. I felt like I was gonna die.

And then I became an intern, where I was expected to be a well of knowledge by my CIs randomly telling me in the midst of treatment: Okay explain the Virchow's triad. Or, a random question such as: What is the hallmark of Rheumatoid Arthritis? Or something like: Please enumerate the different types of polysaccharidosis. All the while the CIs would look at me expecting an answer. And, inside my brain, I am mumbling "Watdapak are you talking about?" while outwardly slumping my shoulder and letting out a nervous defeat giggle like "ah..eh...uhm... I forgot, sir, ahihi, sorry, sir". I can almost feel their disgust from my utter cluelessness about all the questions they asked. Haha. My worst exchange went like this. CI: Can you tell me the origins of the long head and the short head of the biceps? Me: What long head and short head? CI: Long head and short head of the biceps brachii!! Me: Oh, it has two heads? CI: (walkout). Burn. Big burn right there.

And then I took the boards, passed it no sweat and eventually became an instructor at my university. I took that job seriously. I prepared for my classes very well. I taught multiple subjects and took pride that I read multiple books to compare data and share it with the students. I taught them everything I can think of, anything that could be covered when the board exams came, anything that my former teachers missed to teach me, I taught them everything in the playbook. And I was damn good at what I did (with confidence talaga).

And then I went to the States. And it is there I realized, I messed them up. Or my education messed me up. Either way, I think we need to change it.

Our PT education in the Philippines is like a hyped up hamburger. The toppings are all there, but the bread is way too thick and the meat is thin and tasteless. And I don't know if CHED is at fault for its inadequacy, or is it the board examiners fault for making the tests as it is (anatomy, med surg conditions, PT apps). It is like a which comes first, the chicken or the egg problem. Is the board exam patterned that way because CHED requirements lean towards those subjects or are the CHED requirements changed to determine that the passers of the boards fit the standards that the examiners set? Whatever the reasons, it is not getting us anywhere. It just leaves us with too much information that are generally irrelevant to the practice of physical therapy. For example, I understand our great need to master the musculoskeletal and neuromuscular systems because those are really our area of expertise. But tell me this: How does knowledge of the different mucopolysaccharidosis impact my practice as a PT? Is it in the off chance that sometime in the future I might encounter someone with the exact diagnosis? Tell me why was I asked in my board exams a question wherein the choices involved the types of the human teeth? Will that make me a better clinician if I can differentiate the purpose of the molars from the incisors? Why was I asked in my board exams in how much aqueous humor each eye holds? Will mastery of the anatomy of the human eyeball make my manual therapy skills better? Tell me why in my board exams in a question where the choices involved the correct words for the acronym of LASER? Or how many METS are there in downhill skiing? Or at what age is the chicken pox vaccine given? Ahhh the ridiculousness of it all! The examiners are making a living off of "good-to-know" information that have little to absolutely no bearing to the practice, in my opinion. What is the Borg scale score if the patient describes the activity as "hard"? What is the wavelength of infrared light? Who developed the PNF techniques? Tell me how in the world will knowledge of this trivia is going to impact my clinical decision-making.

When I was reviewing for the local boards almost a decade ago, I was in awe at the lecturer who listed down almost ten other names for Reflex Sympathetic Dystrophy (which is now more commonly referred to as CRPS). I was in awe because I really believed deep in my heart and I know that he truly believed deep in his heart that knowledge of this "other" names, almost all of which are seriously outdated, might come useful in the off chance that the examiner "might"ask the question. In hindsight, he, too, was messed up by the system. There is too much focus on this "pageantry", to prove that we have to keep the mortality rate of PT board examiners high, because we are "one of the hardest" exams ever in the Philippines. I'm willing to bet my neighbors' house and dog that if we hypothetically read through all the questions they give for the medical-surgical conditions portion of the board exams, at least half of those questions are NOT physical therapy related; they are too medical, more for our physiatrists than for us. In my brash opinion, knowing the presentation, common functional deficits and bigger clinical picture of the patient is more important than knowing (in the off chance that the examiner will ask the question ugh!) and learning the specifics of an impaired anatomy. For example, as a therapist, it is more important to me to discern, with very high probability, that a patient presenting with severe balance problems both in bright and dark environments, ambulates with a wide-base with poor foot clearance and tends to "miss" the edge of the bed when putting her hands back to sit down may have a cerebellar pathology. And I would address those deficits if I can and develop compensatory or/and adaptive strategies if I truly cannot. It is NOT significant for me to know that the damage is at the vermis, or paleocerebellum, or the flocculonodular lobe, or the middle cerebellar peduncle or wherever. It is good to know, yes, but that should NEVER be the focus of our education. We should take it as whole, it is of cerebellar pathology and we treat the subsequent deficits. The specifics of the cerebellar pathology is for the physiatrist and the neurologist or the neurosurgeon to know because they will deal medically with the issue. Our job is deal with the physical manifestation of dysfunction, not fix the pathology if it is not musculoskeletal in nature because that is not our job. Period.

And so when I passed the boards and became a member of the faculty, I employed the same misguided delivery of lectures as the board review instructor did, full of good-to-know information and pageantry, lots of toppings, little meat. So do I believe that my students learned from me. The answer is a definite, yes. It is just if I learned that the system is broken early on, I would've been able to streamline what I was teaching. I was meant to teach them how to think like physical therapists but instead I leaned to having them think like doctors. Yes, our education system is broken and something needs to be done, and done soon.

Are We Failing Our Patients?

We all live for the hype and pseudo-prestige of being a Physical Therapist. For all the overly medical and less practical education that we suffered through, we have remained an extraneous medical profession, forgettable, no pizzazz. We didn't study for five years to become massage therapists, we say, yet we seldom do anything distinct and significant to change people's mindset about us. We follow physiatrist orders blindly. We don't question. We don't produce research. We don't research. We don't participate in research. We wallow in mediocrity. But the worst offense we ever do to ourselves and our profession: we never, ever, ever provide consistent, thorough, and practical education to our patients and their families.

Maybe it is just because we were never trained to be educators. Maybe that is never part of the specially worded order by the MD. Maybe we don't know what we need to educate people on, where do we start, how much do we tell them? After you read and spent hours and hours of reading through all those books, PowerPoint presentations and photocopies, you were never able to apply that knowledge into practice. Is the reason being that you don't really know what you are supposed to be doing? I will tell you right now even as a licensed PT in the Philippines I was clueless about my job description. I know better now as a practicing Physical Therapist (the real thing not the pretend PT who is not allowed to do evaluations, progress patients, set goals and work with patients and their families to reach those goals, prescribe physical therapy treatments, apply my clinical judgment, exercise my clinical eye, and really make a difference in patient lives). If we want to be free from the stigma that demeans us, then we should learn to have better marketing for ourselves and for our profession. If you think that people who think we are masseuses are ignoramuses, then we should cure them through education.

No, you don't have to explain to the patient's family about the Circle of Willis when the patient has a stroke. Chances are, they won't understand and thus, won't care, and you'd probably get it mixed up anyway. Don't be way too technical and speak medical jargon (unless necessary), nobody cares and you would end up repeating yourself anyway because nobody would understand it but you (pat yourself on the back, congratulations, you know a lot of good-to-know info from your board review, nobody cares). Instead, we should start talking to family about plans and discharge. Yes, at the beginning of treatment, at the start of evaluation, expected discharge should already be discussed. Why? Because you tailor therapy goals towards eventual discharge of the patient. We are NOT meant to see patients forever! Sadly, in the Philippines, patients are on caseload forever, if they have money, forever, if they have no money, sorry (walang forever). There is no line between skilled therapy and maintenance programs. You don't write goals, you don't save enough time to train family members, who will most likely become the primary caregivers, and you don't train your patients to become functionally independent. If you are reading this right now, be honest, how many times have you trained a patient and his caregivers on how to transfer safely from his wheelchair to his car, a tricycle, a jeep or a pedicab (whichever is his mode of transport is to go to rehab)? You may have done hundreds of AROM on the R UE/LE and PROM on the L UE/LE but really, be honest, how many times have you trained your patient to get up from the bed, walk to the bathroom, open the door, walk to the toilet, turn around, pull his pants down and do his thing? Did you ever look at those free wheelchairs from city hall or somewhere (yes, the one with plastic Orocan chairs on them) and tell you patients and their families to return them if they could because they are not ergonomic and safe? Have you ever trained families and caregivers, and I mean trained not just demonstrate, on how to turn patients in bed, get them out of the bed, transferring them and have them walk? Have you given suggestions on how to improve patient safety inside the home, it doesn't matter if it is a mansion, a condo or a hut? Have you ever trained patients to walk on the sidewalks and get up curbs? My point in all of this is we should have been training our patients and their family to be able to return to their highest function and not to impress with their repetitive performance at the therapy gym. Our constant education and training of patients and their caregivers will carve out a better understanding by the general population of how our practice really works. We are doing a remarkable disservice to the patients when we leave out education because we are so focused on completing the AROME and PROME program that we were set up to do. Sad thing is, the patients have very little choice but to only go with what we offer them. We compound the problem by doing the "I'm the therapist, let me do my job" thing instead of working together with the family to accomplish goals, their goals, not solely the clinic's financial target. If you are able to significantly improve a patient's quality of life by simply putting up the extra time to train someone's husband how to transfer the sick wife into her wheelchair from their bed so he can take her to watch Miss Gay at the barangay fiesta, then you are A physical therapist. If you are able to educate and train a patient's son, how to guard him and walk him safely with his cane down the steps of the house so the poor man won't be cooped up inside the house all the time, then you are A physical therapist. If you are able to educate the family that the fake Havaianas flip flops they have Lola wear is too big and is a safety hazard and you recommend a better alternative to decrease her risk for falls, then you are A physical therapist.

Education and training goes a long way, folks. Never, ever, ever underestimate its power. And never, ever, ever be remiss in it again.

And so, my friends, yes, Philippine physical therapy is in crisis. We can always argue that you really cannot compare our PT practice from that in the US. We are a third world country, anyway. But let me tell you this: It is true that we are a third world country and that our understanding and delivery of physical therapy services is still in its infancy, but that doesn't mean we cannot aspire to provide world-class and competitive physical rehabilitation. We have a big-ass room to grow, but we are running out of time. We have to make changes and do them now. If we are still beholden to merely defending our practice to the premise that we are not "masahistas", then half the battle is already lost. If we spend our energy merely maintaining the affluence of having the hardest board exam that does not translate to the workplace anyway, then our energy is seriously misplaced. Our practice is dying a slow, painful and inevitable death, just like the small grocery stores at the wet market when an SM mall sprouts out of nowhere. Where will you be when the sh*t hits the fan?

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Post-script:

I re-read this entry before posting and it might seem very abrasive towards our physiatrists and the MDs, in general. Do know that I am speaking out of frustration and genuine desire to make our concerns known. This is not to trash our medical professionals, but I would speak out strongly against the culture of medicine that I believe leads to mediocrity and poor service. I would like to (though unsolicited) act as the mouth piece of physical therapists (licensed practitioners, students and interns alike) to mention things that they themselves would never say to their physiatrists, CIs, professors etc. I never intend to hurt feelings or put down the medical profession by mentioning my negative experiences. And I hope no one should use this blog entry as an excuse to start waving the I-know-crap-that-you-don't flag at the clinics because that is just downright distasteful.

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For those reading the blog and feel that I am all mayabang because I moved stateside, it is actually quite the opposite. I was humbled when I moved here. At least back home, I was a respected educator. When I moved here, I actually didn't know how to discharge a patient. Like, really, I didn't know when and how to discharge a patient because in the Philippines, we see patients until they run out of funds to pay us or when they die. The more I learn about how they practice therapy here in the States, the more I realize that my professional growth has been stunted even before I became one. It is as if I feel like I was robbed, my potential stayed that way--a potential--and nothing more. I feel like I have to relearn how to be a therapist, or maybe I felt like I was never a PT back in the Philippines. Because really, what we do there in the Philippines, is what PT assistants do here in the States. Ask anyone you know who is here, and they will tell you the same thing.

Yes, my potential was not realized when I was still practicing in the Philippines, but the future generation of PTs has a chance at something more, something we have not had before. But we have to grab the bull by the horns and act now.

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This blog entry is not just to point out issues without offering solutions. My next entry will focus on possible solutions to the problems I presented, and then some. They won't be perfect, they won't be based on facts merely opinion, and they might not even be something worth looking at twice. But I will do it anyway. I can't stand the status quo. I will not stand for the status quo. And I will strive for change. So should you.

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I would like anyone reading this blog entry to say something. Stop being so damn passive. Speak up. Spread the word. Share this blog entry. Write a short comment. Write a long comment. Say why you think I'm right. Speak out louder if you think I'm wrong. Let us debate point for point. Let us have a discussion. I don't care if you agree or disagree with me. But this is an issue for all Filipino PTs. We have an issue. We have many issues. It is time to speak up. It is time for us to talk about this. So spread the word everyone. Here is some fool who thinks he can change the world. Here is a truly passionate clinician fighting for his practice. Here is why he is wrong. Here is why he is right. We need to have a serious conversation about our practice. I started the talk. It is up for the rest of you to keep the conversation alive.

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10 Things Your PT Books Didn't Tell You (Part 1 of 2)

2013-07-02T01:10:00.001-04:00

It's been quite awhile since I've written a PT blog entry. I have received several messages through Facebook "encouraging" me to start another entry for PTs to read. So to those who message me on FB, thank you so much for appreciating my write-ups and I will try to fill up the void. I guess reading a PT blog entry is sometimes a welcome relief from the mundane exercise of going to your PT class, PT review and PT job.

Let me start off by saying that everything I am listing down here is completely unscientific. There is no research to prove anything that I am about to say--- and I don't read researches anyway like duh! Thus, you cannot quote anything here without justification. And you cannot debate with the contents here in a well-Kisner-said-this-and-that manner. All of what I have written here are purely based on observation and experience. Now, all of us will have them differently but I'm sure at least one way or the other you can relate to the errrr "truths" (misinformed or otherwise) that I am going to share.

It is also very important to discern that if you are preparing for the US licensure exams and some of the contents confuse you, ALWAYS pick the other source, not this blog entry. Remember, this is NOT scientific. However, I would also like to point out that the things that I will discuss are completely relatable especially if you are or will be assigned in a skilled nursing facility or a nursing home.

Now as I went on writing this piece, I realized it was getting way too long so I decided to make it in two parts for easy reading and less information overload.

As always, reactions, corrections and intellectual discussion are highly encouraged. Feel free, in any civil manner, to express your opinion on the subjects presented. Now with everything in place, let us start the countdown.

1.) Be wary of giving water to patients during exercise.

Yes, I know that the Bible tells us to give water to the thirsty. And yes, all health magazines highly recommend drinking fluids before, during and after workouts to maintain steady electrolytes and prevent dehydration. So why, you ask, should we be wary of giving water to patients during exercise? Here's why:

Remember that the patients that we see in skilled nursing facilities and nursing homes are mostly elderly. Many of these patients have many medical complexities including history of stroke, Parkinsonism, dementia or a combination of everything. Many of these medical complexities have direct or indirect effects on swallowing muscle control. Hence, the importance of you not giving water freely especially when you have no idea if the patient is at risk for aspiration pneumonia. The best thing that you should do is, of course, consult your speech therapist.

Now, in the Philippines, I believe most PTs have not been exposed to speech therapists (ST), aka speech-language pathologists (SLP). As their title implies, of course they are involved in evaluation and management of speech impediments arising from neuromuscular conditions. Aside from that, they are also specialists in cognitive therapy such as memory enhancement, pill management and implementing safety strategies for patients. The most important aspect of their job, for me, though, is their evaluation and management of the pt's ability to swallow bolus. It is, therefore, the ST's job to determine if Lolo can still safely eat the steak he loves so much. It is their job to assess if Lolo is at risk of having his half-chewed steak down into his lungs instead of his gut. Well, you all know that if it goes to Lolo's gut then it turns into poop, normal, old boring poop. However, if it goes to Lolo's lung, with his age, Lolo could easily succumb to aspiration pneumonia sending poor old Lolo into the great big steakhouse in the skies.

Question 1: If we have no ST at the moment, how would you determine that Lolo is choking on his food or his water? First of all, you look into the obvious signs: Upon drinking, Lolo starts coughing, or clearing his throat, or grunting, or a wet voice, or coughs again. That is a very overt sign that Lolo is aspirating. However, there is also such a thing as silent aspiration wherein Lolo doesn't show obvious signs of choking but food or water may still be going towards the lungs. Some of the signs would be: watery eyes, runny nose, and change in voice quality after ingesting fluids.

Question 2: What happens then if you determine that Lolo possibly might be aspirating on food/fluids? You automatically refer the patient to your ST for evaluation if they are still not under caseload. If the ST determines that the patient is indeed aspirating, he/she might be able to downgrade the patient's diet. For food, if the patient is not aspirating then he is given "regular food", meaning he can eat anything he wants at any consistency. The downgrade would be "mechanical soft" which has softer sides and chopped meats (also given to patients who lack dentures and can't chew meat very well). The next downgrade is puree in which everything is put into a blender. If the patient is still aspirating on pureed food then a gastric tube might be recommended.

The texture of the food though doesn't really affect us PTs because we are mostly uninvolved with feeding unlike STs and OTs. However, we are very involved with the fluid intake of patients. When we exercise patients, of course they would feel tired and thirsty and would sometimes ask for water. When a patient is not aspirating, he is given "thin liquids" or basically just regular drinks. A downgrade would be "nectar-thick consistency fluids" and further down is "honey-thick consistency fluids". The further the downgrade the thicker the consistency is. Remember: Never ever give patients any water unless you know the consistency that the patient should be on less you risk the patient developing pneumonia.

Also, remember to check the chart or ask the nurse if the patient is on fluid restrictions. This is usually the case with patients with CHF or/and using diuretics. Ask the nurse how much water you can give the patient during exercise. The patient is only sometimes allowed a certain amount of water throughout the day and thus, we cannot just freely give water to the patient even when the patient asks for it.

2.) Watch out for skin tears in patients on blood thinners.

We learned from Goodman/Snyder that bruising if typically observed on patients on blood thinners. What the book didn't inform you is that bruising is not the primary concern of PTs as the patient can bruise even without trauma. Our primary concern is to decrease the patient's risk of having his skin torn.

Remember that as PTs we are involved in training patients in ambulation and transfers and unless the patient is high-level, we usually are in close contact with the patient during transfers and ambulation. Our close contact relationship with the patient, plus equipments that we use (e.g. walkers, rolling walkers, gait belts, parallel bars) increase the chances that a patient may accidentally rub his skin on the area and tear it in the process.

A patient in chronic use of blood thinners literally give new meaning to the expression "balat-sibuyas". Their skin is sometimes so thin that they tear even while asleep. I can only assume that they probably rub it in the creases of the pillow or blanket.

Question 1: Your patient has a skin tear during exercise, what should you do first? My first action is to make sure I am not in contact with the blood (don gloves whenever possible). I will ask the patient if he is alright and then I will call the nurse. I won't do first aid or put pressure on the artery above the tear (wow, manual arterial pressure ka pa ha? panalo) or attempt to stop the bleeding. Remember, this is just a skin tear, this is not a medical emergency, so calm the f--- down. The nurses will come in, assess, measure the size and clean the wound and they would usually tape the skin back into place so it doesn't flap around. You would also probably be asked to write an incident report on the matter.

Do not be terrified of writing an incident report. It will not ruin you or your career. Just write everything in detail and that same incident report which you dread so much will protect you in the future. If a patient has a skin tear, it is most likely not due to your negligence, it is just a side effect of prolonged blood thinner use.

3.) A patient with chronic hepatitis may no longer manifest with jaundice

Jaundice as a review is caused by the inability of the body to complete the breakdown of old dead red blood cells in the body. The heme in hemoglobin will be turned into bilirubin which the liver will process to turn into bile which will assist in digestion of fats (note: it's been too long since I have read anything about hepatitis so this may not be accurate; correct me if I'm wrong). With hepatitis, the liver becomes inflamed and swollen, it no longer is able to process bilirubin and bilirubin floods your bloodstream in a condition called hyperbilirubinemia (tama ba?). The yellowish hyperpigmentation will manifest first in the sclerae and then the skin including other mucus membranes.

Now the history of my patient who had chronic hepatitis was vague but basing it from what his mom said, it is alcohol related. What was curious was that despite not turning SpongeBob-color, he did have manifestations of chronic liver disease. Since his liver can no longer detoxify very well, the toxins in the body try to escape via his skin, so his skin appears to have many eruptions and vesicles. It didn't appear flaky like dandruff but it was rough and his hands were always itchy.

He also manifested with hepatic encepalopathy. I reported this observation with his nurse who informed his doctor. He was a high level patient but he needed O2 supplement prn. The hepatic encepalopathy developed within three days wherein I noticed at first that his attention span became shorter. That was followed by lethargy, then complete confusion and total decline in function. He was one who was walking around the facility pushing his wheelchair and now he can barely stand up. They did lab work and found out that his bilirubin was off the roof. He got back to his old self after a few days of medical management.

I never got to find out what happened to him after that since I moved to a different facility. Also, I never got to find out if he had clay-colored stool as what Goodman/Snyder said. Haha

4.) You can survive without kidneys

One of the most interesting cases I've ever encountered is that of an extraordinary woman without kidneys. She lost both kidneys, 10 years apart, from kidney cancer. She is in dialysis three times a week where she stays for about 4-5 hours each time.

I already know that a person can survive sans one kidney. What happens is that the remaining kidney usually enlarges to almost twice its original size to compensate for the missing kidney. Remember that the kidney is also an endocrine organ which produces the hormone erythropoeitin, which triggers the production of erythrocytes. Without the kidneys, red blood cell production is severely limited and causes erythropoeitin-deficiency anemia. So aside from the fact that the patient undergoes dialysis which makes him very tired already, he also suffers from anemia, the patient would most likely be able to participate in only very light activities.

Beware/ Warning: During dialysis days, treatment time for a patient is usually reduced and the day after the dialysis, treatment time is increased mainly because of patient's activity tolerance. A reasonable rehab director should be able to identify this. However, there are facilities and companies which always put all patients in the ultra-high RUG level. Ibig sabihin, the patient should and must be seen at the highest possible minutes that you can, irregardless kung me dialysis siya or what. If you belong to a facility/company that forces you to treat a dialysis patient who appears very weak for 70-90 minutes for that day, or even forcing you to treat a patient for the entire assigned minutes who appears dying (dying na! malapit nang matigok!) make sure you develop an exit strategy from that company! When your gut feel tells you that the patient is not able to tolerate anything but you still force him to do stuff just because you are being told to do so and you know that what you are doing is unethical or simply alam mo na it's not right, you should be firm and stand your ground to justify why you are not getting his entire minutes. Then, get out of that company as soon as you are able. You are risking your hard earned license and your future! That is borderline fraud, and believe me many companies do that. I am just lucky that both my rehab directors are reasonable people. Not all therapists are that lucky.

On a lighter note, the patient I had (who also became a very dear friend) who lost both kidneys, is no longer able to PEE! Paano ka pa iihi eh wla ka nang kidney? Haha. She told me that the fluids get flushed through her bowels. And we would always joke around that "she would laugh so hard she would pee herself". And then we'd laugh again. I just learned yesterday that that wonderful patient passed away just a month and a half ago. I surely would miss her and her vibrant spirit.

5.) Depression largely goes undiagnosed with the elderly

A lot of elderly residents in my facility are diagnosed with depression. However, I don't think that the extent of their depression are accurately determined by the psychologists and psychiatrists. Based on my experience, depression is high among the elderly but even I cannot be certain and am certainly not the best professional to make a judgment if the resident is merely sad and homesick or has fallen into real clinical depression.

Clinical depression is a persistent unhappiness and feeling of emptiness that affects activities of daily living for weeks or months. Sometimes, I feel like it is so subtle you can barely notice it. It is very important that we, as therapists, although we are not clinical specialists for depression, should be sensitive to this anyway as in the long run, we might just happen to save a life.

I personally think that undiagnosed or underdiagnosed depression may cause adult failure to thrive. I don't perfectly comprehend what what they call "failure to thrive" is, I know that it is a reason for residents to be picked up by hospice. But my understanding is that failure to thrive is that a person is showing signs of decline (e.g. losing weight, poor appetite, weakness etc) without apparent cause. Lab results would be normal or very close to normal, no signs of infection whatsoever, but for no apparent reason the patient is just going downhill. I still think that depression is closely linked with this phenomenon.

I work in a wonderful nursing home with completely diverse staff from all over the world. The facility is Medicaid-supported, shared by three counties and has two assisted-living buildings on its wings. It has constantly ranked highly and has had a five-star rating for a long time. It has consistently been included in the top 50 best nursing homes in the entire US. There are more than 16000 nursing homes in the US and to be counted in the top 50 means that you are giving the best care there is that a nursing home can offer. Now, if you ask if the nursing home is grand with exceptional amenities, the answer is no. It is Medicaid-funded so you won't expect that it will have swimming pools or spas or bowling alleys. But it does have a great kitchen staff, exceptional nursing care and all.

Add to that, the activities department of this facility is wonderful. They have a lot of programs and activities for the residents all the time to keep the residents entertained. They have games, movies, pet therapy, parties, parades, trivia and many more that keeps the residents entertained and busy all day long. Compared to my old facility whose only activity is bingo, everyday bingo, this new facility is actually way above its class.

You would think that all of these parties, karaoke, therapy dogs that are too cute and sweet, musicians, art classes etc will keep the residents happy. Sometimes, they do. But there are times that these poor elderly just feel...sad. These elderly people sometimes talk about suicide. Suicide for God's sake!

Question: What do you do if a patient tells you he wants to kill himself? First, try to empathize with the resident. Ask him what is bothering him and how you can help. Try to talk to the patient and comfort him. Whether you think the patient is serious about his suicidal ideations or not, you have to let the nurse know. Any desire of a patient to harm or kill himself is urgent, you have to let the nurse know. Alarm the nurse. They will assess the patient, and would do necessary measures to ensure that the patient does not harm himself. I had one patient who told me he wanted to kill himself. I knew he had a history of deep depression and I immediately reported it to the unit manager. They took off everything that he might use to hang himself like belts, nurses bells and blankets and they set a 24 hour watch on him with a standby CNA.

On one of the assisted living units though, during the early part of this year, a resident committed suicide. She called a cab to pick her up (they are allowed in ALFs to use public transport), then she had herself dropped near a train station, walked towards the rails and leapt to her death towards an oncoming train. If I were to guess how she felt before she decided to end her life, I would say she felt depressed. Why else would you end your life?

Which leads me to a very important point. You may not think of yourself as important. But know that as a therapist, you have a close relationship with a patient. And sometimes we take for granted that we might be the only person, the whole day, that the patient can really talk to. Yes, nurses talk to patients and so do CNAs. But casual talk is not real talk. We therapists talk to our patients while we exercise them and it sometimes our silly conversations with our patients help them make it through another day in a nursing home, where they are resigned to live a mundane life until their Maker takes them.

My friends, let me end the first part of this blog entry for now. I hope you learned something that might be of use to you in the future. Once again, commentaries are very appreciated. God bless us all, God bless Filipinas!

side-by-side

2013-06-15T15:05:00.000-04:00

side by side, we sat
    the tension there once was
        has faded like
            the sounds of our laughter

the look in our eyes is of
     nothingness

we are the strangers we
didn't know we could become

strangers, we have become
    and still we cannot tell
        the difference
          between holding hands
and
    hand-holding.

side by side, we sit

strangers
there is nothing here
      nothing
and the hand I am holding,
   the hand that remains,

is my own.

6/15/2013 3:03 pm

Visiting Lexington

2013-05-20T01:08:00.005-04:00

It's been quite awhile from since I wrote my last entry for this blog. Let's just say I've gotten preoccupied with pretty much a lot of useless stuff completely unrelated to fruitful living. I've been hooked on the same computer game with a few new serious player friends I met online. Also, I've been trying to work out. Yes, me, the botod, is trying to get fit. Nope, I am not giving up pork or beer or smoking completely. But I have started running on the treadmill and lifting weights. So far so good. I haven't bulked up yet and I see no guns on my arms but I noted that they are not as flabby or as lard-soft as they were before. I have also noticed that my endurance for running on the treadmill has improved. Whereas when I started I can only manage probably a maximum of five minutes before my thighs start burning prompting me to slow down and catch my breath, I ran for forty straight minutes without slowing down just yesterday. That is a feat for super sedentary me. I have lost several pounds and gained a couple back during the past weekend when I went over to Teffy's place for another whine and wine experience.

Now, Teffy is my former colleague and boss at the College of PT at St Paul University where we also both went to PT school at before becoming instructors there. She lives about a three hour drive away from me at Lexington, VA. Lexington is a quaint picturesque historical small town famous for its significance in the American Civil War. This is also the burial site of the famous Civil War general Stonewall Jackson and the location of his house now turned into a museum. I just love how this small town thrives and bustles with life, a strange blending of the old and the new, literally and figuratively speaking.

Lexington houses two well-known universities: the VMI, Virginia Military Institute and W&L, Washington and Lee, which is a very reputable law school. Lexington, however, is also considered a retirement community where mostly middle-aged to senior couples find solace in the peace, beauty and laid-back atmosphere of this town. I find it refreshing how the burning red energy of youth can blend in well together with the calming blue aura of wisdom in this lovely town. True, occasionally, they would clash with mostly the elderly complaining about the college people's noise but generally, the town is peaceful as it's meant to be.

One thing that draws me towards this town is that the school system here is doing really well and is highly ranked within the state. If you would want to raise a family, you would want to have your kids go to a decent school and Lexington offers them such. Teffy was trying to sell me the idea of moving over the area once my wife comes over. I still have my reservations but yes, that place looks promising for me.

However, unlike where I am now, that small town is less diverse than what I am used to. I have seen only a handful of Asians there, a few Blacks and almost no Hispanics which is weird as Hispanics can be found almost everywhere. I don't know if discrimination exists there but it would be hard to expound and build other friendships when the town is overwhelmingly white. I don't know though, because to be honest so far I have not experienced discrimination in the strict sense of the word, maybe because I am quite lucky to be more educated than most.

Anyway, I am just letting you into what I have been up to for the past couple months: starting a book I never got to finish, starting my exercise regime (holding up for almost a month now), and driving up and down Lexington twice. I already have an idea of what my next entry would be for this blog. The only problem is when will I ever get to writing it. Till then, stay tuned.

TOEFL-ibt and You... A Love Story

2013-03-12T20:10:00.001-04:00

The bane of many therapists since its conception, this dreaded exam has broken many hearts comparable only to its equally, if not more, challenging big brother we shall nickname NPTE. This exam is a lingering wraith on your back, a heavy shadow on your future, a dragon you need to kill to get through the first phase of your American dream. Yes, I am talking about the TOEFL-ibt, frequently mentioned with colorful adjectives preceding it such as: P. I.ng TOEFL yan! or lintek na TOEFL yan! The popularity, or lack thereof, of this particular exam continues to grow. More often than not, it invokes a strong sense of dread and hatred but at the same time of intimidation and respect. For some, it has grown into a sort of urban legend, fed by the many stories of failures, to which quite a few have balked to take it.

A lot therapists do complain that the requirements for TOEFL is quite steep, most of them up in arms with the speaking cut off score of 26/30. It doesn't matter if your other scores are good, a failing score in speaking is a failing score overall and a headache for the examinee. Now he has to take the exam again or to risk having it rescored which can go either way. The more painful part is that most therapists who fail TOEFL fail the speaking part by a mere point or two. So, if you ask me, would it be better if the speaking requirement of TOEFL be decreased to 24/30? That way everyone is happy. My answer might surprise you. I will say no.

Now before you bitterly spew out the words: Wow pare ang yabang naman! Feeling! Let me explain why I don't think they should lower the requirement. First of all, you want to come here to the US to work. You do understand, though, that for every PT job given to a foreigner, like you and me, it is one less potential job for a US citizen, irregardless if they can fill that position or not. Therefore, that foreigner has to prove that he deserves the job. One way to prove it is having a good command of their native tongue. Being able to communicate well in English is a must in our profession. We will be interacting with many patients, nurses, doctors, social workers, nursing aides, etc. Sometimes, it just isn't enough that you understand English. It is necessary that you KNOW how to communicate in English and communicate well at that.

As a therapist, you will have to go to care plan meetings every now and then. A care plan meeting is a convention of the patient/family of the patient and everyone else involved in the patient's care: therapy, nursing (floor nurse, nursing aides, Medicare nurse, wound care nurse etc), dietary, activities and social workers. At care plan meetings, the team will be discussing the patient's current status, the family's concerns if there are any, the goals, the outcomes, the discharge plans and a lot more. It may take a long time especially if the patient has a lot of medical complexities. However, as a therapist, you would only be able to attend for a short period of time. During that short period of time, you have to discuss the patient's functional progress with the family and with the rest of the medical team. The family might ask you questions and you have to be prepared to answer them. Will my mom be able to walk again? My dad is speaking, why does he still have speech therapy? Would my mom always need a walker? Will Dad be able to climb up steps to get into the house? A lot of different questions can arise during care plans and your main goal there is to get in and out as fast possible while giving clear and satisfactory answers to the family's queries. Why the hurry? Well you have other patients to see and care plans (if the patient is not present) is considered non-billable time which means that therapy is losing money the longer you stay there and not treat patients. Therefore, your responses have to be straight to the point and yet should not lead to confusion. Ergo, you need to speak fluent English and not waste time with your "uhms" at every word. "Uhm... Mrs Smith, uhm... would probably use the, uhm, walker to, uhm, get around the house to uhm, go to the bathroom, but, uhm... she would need somebody to...uhm...assist her". This just doesn't cut it. It will make you sound like you don't know what you're doing. And yes, those who are generous with their "uhms" usually fail the speaking part of TOEFL. Or am I wrong in that assumption?

Also, the subjective parts of TOEFL include the dreaded speaking part and the writing part. The writing part of TOEFL can be trained for, mostly in review centers. The speaking part errr... not so much. They can give you all the advice in the world but at the test center, you're on your own. Now, in review centers they would probably advice you to write in a basic format: a heading (the intro), a body and a tail, which would be a brief summary of the intro and the body. It would really help if you train yourself to think in English rather than think in Filipino first and translate it to English.

The need for you to think in English and transform your thoughts into sensible sentences would eventually benefit you when you are working in the rehab setting in the US. Tandaan: Each workplace have their own productivity expectations for their therapists. What is productivity? Productivity is the amount of time you spend treating a patient over the total time you spend at the facility. My company has 82% productivity expectation per therapist. This means that at least 82% of the time you are treating patients and making money for the facility. You have 18% of your 8 hours (if your patient load allows you) to do everything: write notes, print papers, send emails, write orders in the chart, fetch patients, take patients back etc. That is about an hour and a half each day to do stuff not directly related to billable patient care. Lahat yan, technically, is counted against that hour and a half: washing hands, going to the toilet, asking aides to get patients up or cleaned up, chatting with co-workers etc. It is hard to keep up with productivity expectations especially if you have a ton of notes to write. It certainly wouldn't help you if you would spend (read:waste) time translating your thoughts into English when writing your notes. It is important that you know how to express your observations in a clear and concise manner when writing your notes. You won't be able to do that when you don't have good command of English. Hence, the need NOT to lower TOEFL requirements but rather, us, Pinoy PTs, should step up to the challenge of this test which has delayed many a therapist's American dream. Some even gave up totally dahil hindi mapasapasa ang lintek na TOEFL na yan. So pano nga ba ipasa ang TOEFL?

How to pass TOEFL ibt:

I'm sure you all have received a lot of advice from fellow PTs and from review centers on how to pass the exam. Probably, the few tips that I might share may not even influence your opinion on how to approach the test. But I'll try anyway, who knows I might be able to help someone out here.

I took my TOEFL-ibt test five years ago and passed it on my first try. I hope I don't sound like a douchebag but I got a really high score. I don't mean to brag but I got a score of 117/120. I got 30 for reading, 29 for listening, 28 for speaking and 30 for writing. Now, before you make the assumption na ako'y nagmamayabang, let me explain this first. All of us were given extraordinary gifts by the Lord, some are talented musicians, others mathematicians, others are gifted athletes, others are gifted with charisma, others with beauty etc. I was gifted with the gift of linguistics, I have a knack for language, meaning I always have excelled in English class, literature class, Pilipino class, anything that has anything to do with words, writing, vocabulary, pronunciation and language itself. Although I believe in humility as a virtue, I also strongly believe that failure to acknowledge the Lord's gift by shying away from compliments like saying "Hindi, chamba lang yan" or "Sinuwerte lang" is in a way a form of rejection of His love. But that's just me, I don't want to impose my beliefs on anyone at all.

Anyway, let me give you some unsolicited advice on how to improve your TOEFL scores. First, start reading real reading materials in English. This does not include beauty magazines, Harry Potter books or Shades of Grey. Instead read opinion sections of newspapers, essays by Patricia Evangelista, Fr Joaquin Bernas or Conrado de Quiros, books by Jessica Zafra or National Artist Nick Joaquin. Read something that will enrich you while improving your vocabulary. Your vocabulary will grow without you having to try very hard when you constantly bombard yourself with these kinds of reading materials. Difficult words, when encountered in sentences often, will eventually reveal their meaning to you. You don't have to look up the dictionary all the time, sometimes just by how they are used in sentences you get their meanings. By following this advice, you have hit two birds with one stone: you'll have better reading comprehension while improving your vocabulary to use in your writing.

Second, with listening, there is nothing much really I can do to help you with this part. No one can train you in how to understand what you hear. So probably the best thing to do is to take down important notes while listening to the conversation. Remember: I said take down important notes not everything they said. Some people rush to scribble everything said that they eventually don't understand what the conversation was all about. By doing that, they won't be able to answer the questions for the speaking part of TOEFL.

Finally, the speaking part. Here is the advice no one has told you before: SPEAK YOUR LOUDEST during the speaking part. Speak loud short of screaming. I did that when I took my test. I didn't care that there were other people beside me taking the test. I didn't care that they can hear my answer. I didn't care if I intimidated them or I sounded stupid to them. I didn't care if I am distracting them. All I know is that I just wanted that even if the Internet connection is not perfect or the recording machine is f*ked up, the person on the other end will still HEAR me. So I spoke as loud as I could without shouting. That way my answers were clear. Of course, I had my uhms and of course, I was nervous, but the hell with all of that. I need to pass this exam and I don't care what the other test takers would think of me afterwards. So there you go: this is one good secret for the speaking part.

As I conclude this rather lengthy blog entry, let me remind you that the TOEFL exam, does not and will never define you as a therapist. Just because I passed my test on the first try and you passed yours on your seventh, doesn't mean I am a better therapist than you. Physical therapy is a profession, a culture, a passion, a devotion and a calling. It rises waaay above an objectified and potentially flawed language test called TOEFL. So treat TOEFL like it should always have been, a worthy opponent but a roadblock not worthy enough to stop you from success and your American dream.

Dyud and the Zombie Apocalypse

2013-02-19T23:34:00.003-05:00

Just when the world has gotten pretty much over with the 80's and 90's alien invasion as the would be cause of humanity's demise, the new millennium ushered in speculations that zombies would eventually overtake the world. The new zombies are still flesh-eaters and are seen overrunning cities and metropolises in their slow never ending limp to eat human flesh, blood trickling down their half-opened mouths, uttering guttural sounds. Blockbuster movies like Zombieland and I Am Legend, and widely popular series The Walking Dead and even social activities like Zombie Runs have highlighted the world's fascination for the dead who don't want to stay dead.

In deep thought, yours truly had an epiphany. If, God forbid, we indeed would have a zombie apocalypse in the future, distant or near, yours truly would not be the crusading hero, (in ascending volume) blowing zombie heads off, scouring and eventually finding the remaining survivors of the human race ready to make one last stand for the sake of the future of the human race and of the world. Whew! Like, yeah right, like that is soooo gonna happen.

The epiphany I had was the complete opposite. I realized I will not be able to survive the zombie apocalypse. In fact, knowing me, I would be the first to be converted to a zombie. Now how did I reach that conclusion? Here, let me show you a picture:

That is me, about three weeks ago, in Pennsylvania. That is me, posing, like the poser that I am, pretending that I know how to ski. I sucked at it. I even took group classes for beginners so that I could at least get to learn how to do basic skiing. And yes, I sucked so bad at it, the instructor eventually gave up on me. (For the record, though, the instructor wasn't even remotely good. He just showed us once and expected us to do it right the first time and moved on to the next task). Anyhow, my balance was bad and I spent all the precious little energy that my poor deconditioned body can muster getting up from the snow cause I fell...again...and again. What broke my heart though, was not merely that I was falling every time, unable to maintain even just a little bit of stability, and ski peacefully in the soft almost flat out horizontal beginner's slope. It was the fact that each time I struggle to get up, there are a couple three or four year old kids running circles around me in the skis or snowboards, making it look so easy for them but not for me. You have to fight the urge to whisper: Your parents don't love you, you are adopted just so they feel as bad as you do. It shakes your belief that all men were truly created equal. And yes, there goes your dignity. So there I was, defeated and cold, waiting for my friends to finish up so we can go home.

During the summer, we went to my roommate's friends lake house in North Carolina. The owners of the lake house are the the most humble secret millionaires I have known (errr well I don't really know a whole lot to begin with). Anyhow, they own a speed boat, a couple jet-skies, a couple kayaks for water sports. Of course, the amazing muah decided to try wakeboarding for a change. My roommate went first and did it seemingly without any difficulty. I tried it next and viola! Before I knew it I was struggling with life and death, gurgling lake water and using up whatever questionable amount of energy I had splashing around to get back into the boat. That, despite having a life vest on me. In fact, I was so weak, the boat had to circle down several times so they can get me from the water. Ah, the shame.

My weak body and my weak spirit, ultimately, will be my undoing. I can never be a soldier or a warrior. I can barely do ten decent push ups, can barely run a mile without stopping to breathe and walk. And I am not even fat fat. I can't tie ropes very well, can't fix a car, know nothing about electronics, know nothing about computers except the addresses of free porn sites. I can never survive on my own, in the wild. I can never be a warrior, a fighter, a soldier. Hell, I don't think I can defend myself if my life defended on it.

What I do think though is I would have made a good propagandist in wartime. I would be one of those instigators, rallying the crowd to the cause and slipping back into the shadows as chaos ensues. I have always known how to inspire and to provoke. I would never, ever want to be in the frontline. I revel in shrewd, calculated cowardice. For me that is an art form. I learned in psychiatry class that I am passive-aggressive and I will probably play that part come the zombie apocalypse.

I won't be able to run far, so chances are 1.) I would be eaten first or 2.) I will hide. I would probably be the last to pack up provisions and when people would start the exodus to go away and hide, my dissenting opinion would be to hide where I am, praying desperately that the zombies don't get me. Hide in the shadows and wait for the opportune time to escape or the perfect time to be eaten and converted.

If I turn zombie, I would probably be a picky eater. Like I won't eat the hairy ones, the fat ones and definitely not the ugly ones, especially the fugly ones. And I would probably prefer to eat a vital organ, heart, liver or brain. Intestines would be out of the menu, same for hair and sex organs, ewww. Oh and if I turn zombie, I probably won't do the zombie walk: slow, lumbering eternal steps. Lazy as I would ever be, I would be one to drag my leg on the floor, or hide in fresh loam and stick my hand up like this:

That is probably how I would get my prey assuming anyone even dares to come near it. At the end of the day, it doesn't matter if I survive the zombie apocalypse or not. I found a wonderful meme to summarize everything I have bitterly typed here today:

Have a great zombielific day ahead!

Cultural Competency: A Therapist Trying to Understand America

2013-01-20T23:02:00.001-05:00

This is a crash course in cultural competency from a wanna-be know-it-all trying-hard physical therapist trying to make his mark in the world. Now, whatever I am gonna say would purely be based on my observation and may not entirely reflect the truth. While it is impossible to paint a complete picture of what is America and what makes America America, especially one who is not really into the science of sociology and more into the informal art of people-watching, it does not hurt to at least try as seen through the eyes of a full-blooded Filipino.

Let me give you a little background about myself then so you can pass judgment on my judgment. I haven't been here very long in the US, and there are still a lot of things I am trying to get around to. I am based in the State of Virginia, first from Chester, somewhere south of Richmond and then I moved up to the northern part of VA near Washington, D.C. when my former facility decided to go in-house. My experience is limited to skilled nursing and long-term care rehabilitation, at least for now. I am now working in a wonderful nursing home with a racially diverse staff and residents. In the rehab department (speech, OT and PT), we have four Indians, two Filipinos, three Caucasians and one Hispanic. Interesting to note, too, that the four Indians have different religions: Islam, Hinduism, Sikhism and Roman Catholicism. In the entire nursing home, we have a healthy mix of races from Asians to Africans to Latinos to Middle Easterns to Europeans for the staff. The cultural diversity in this facility opens up your mind more to different cultures and beliefs that encourage acceptance and tolerance. I hope that what I will be sharing will give you a little bit of insight about the most culturally-diverse country in the world.

Hablo español. Americans, of course, speak English but Spanish is gaining a strong ground all over the US as Hispanics are the fastest growing minority here. At first, when I think of Hispanic, I only think of Mexicans. I was wrong. I found out that everything south of the US, from Mexico all the way down to the tip of South America, they all speak Spanish. Except for Brazil, which speaks Portuguese. So although, speaking Spanish is not a pre-requisite, it can give you an advantage in dealing with Spanish-speaking patients. The good thing is, as some Filipino words are the same or close to Spanish, we can understand a little bit here and there about that particular language. Also, if you affectionately address your patient as dad/father in Spanish, don't use papa as it can be mistaken for potato (also patata in Spanish). Use papi instead.

Weather. I found it odd at first that people talk about the weather quite frequently around here. Initially, I thought it was just some ploy for small talk. But, no, people take the weather seriously around here. In the Philippines, people don't talk about the weather very much, not unless a very dangerous storm is coming. Back home, when you wake up in the morning and see that it's bright outside, chances are it will be sunny the whole day. If it's gloomy, it will probably rain the whole day. It's simple as that. Maybe now with global warming, Mother Nature can't decide very well what to do with herself, the weather gets a little unpredictable back home but I would still bet on either a sunny day or a rainy day, period. Here, it is quite different. It may be gloomy when you wake up, sunny at around 10 am, cloudy by 3pm and thunderstormy by 5pm and back to humid by 9pm. It matters to know what the weather is because it affects safety on the road during commutes and rush hours. However, you can lay off blaming Pag-asa all the time about inaccuracies in its reporting. Even here in the US, they can't predict weather patterns perfectly all the time, so give the Pag-asa guys some slack.

Umbrellas. Since I started talking about the weather first, let me go to the next topic at hand. People here do NOT use umbrellas unless it rains. We, Asians, are used to carrying our folding umbrellas to combat the scorching heat of the sun and avoid getting soaked in a down pour. Here, umbrellas are only used during rainy days. They do not use an umbrella for shade even during the summer when temperatures can reach a hundred degrees Fahrenheit (that's about 38 degrees C). The umbrella is solely for rain and sleet.

Rice. Americans are actually in bewilderment in how Filipinos can consume so much rice everyday. It is not that they do not eat rice, they do, but only once in a while. Even my Indian co-workers, themselves having rice as a staple, are amazed by how much we actually consume. Indians don't usually eat their rice plain, like us Pinoys. They usually have something mixed in it like some curry dish. So they are surprised that Filipinos actually eat rice for breakfast, lunch and dinner, plain rice at that, too. I explain to them that Filipino dishes are designed to be very flavorful, hence bland plain rice is needed to temper the strong, delicious flavors.

Traffic. For us living in large Asian cities, we grew up in traffic and noise with senseless beeping and honking all around us. Eventually, we have gotten immuned to it as it becomes part of our daily lives. Here, traffic is the pet peeve of Americans even though I noticed that they almost never have bumper-to-bumper traffic like what we have back home. If a regular ten-minute commute turns to a twenty-minute commute due to "traffic", they go ballistic. Also, honking is considered rude around here. You don't honk unless it is absolutely necessary. You could trigger road rage by using your horns inappropriately. Having said this, as the general population here drives, a big majority of them are pretty responsible drivers. They really do follow the traffic signs and have a good grasp of road courtesy towards other drivers. Not unlike back home when every driver feels like he is king of the road and you have to get through traffic with jeepneys, and pedicabs, and tricycles weaving in and out of traffic the whole time.

Handsoap. Americans pour soap into their hands first before wetting them unlike us who wet our hands first before applying soap. I found it odd at first not to wet your hands before applying soap but this is how they do it here. Americans are also very particular with toilet hygiene. That may be arguably limited to toilet hygiene, not hygiene in its entirety. They want their toilets flushed after use and people to wash their hands after using the toilet to do number one or number two. They would be repulsed if they found out we wash our bottoms with our hand and soap and water. You could always argue that soap and water beats tissue paper for proper cleansing purposes but it just grosses them out. They would also be grossed out if they found out our men pee anywhere, not wash their hands, sit back on the table to continue drinking with other men sharing a single shot glass for everyone. Yes, I know you like to "strike anywhere" just like I do but hey, in here, you don't want to pee on that tree if you don't want to be called out for indecent exposure.

Handshake. The American handshake is firm and not too brief nor too long. It is firm to signify truth and sincerity. Not too brief because that would indicate disinterest and not too long because that is errr... creepy. Now, we are accustomed to the Filipino handshake, which is relaxed and soft. The Filipino handshake is soft for goodness sake! I don't think it is because we are not sincere when we shake hands with other people but rather we associate soft hands with being elite. Those who give firm handshakes are ruffians with rough dirty hands that are associated with having menial jobs. Giving a soft handshake with soft hands indicate that you are educated and didn't really do a lot of housework for yourself. Alas, not here though. So when someone introduces their name to you and reaches out for a handshake, give him/her a firm and not too brief not too long grip.

Weekend activities. Americans work the whole week. Yes, you might say, well I work the whole week too. Not really. Filipinos work AND play the whole week. It is not uncommon to grab a beer or two with friends after work, or maybe catch a movie with your girlfriend after work, or maybe go shopping with your friends after work, or maybe just hangout. Bottomline is, a Filipino's workday doesn't end with you just going home, unless you are a really really busy mom or dad (which even then every once in a while you get a break). In the US, they work M-F and seldom do stuff after that. They work for the whole week and almost always have plans for the weekend. They would ask one another about what are their plans for the weekend or what happened during the weekend. I don't know about you guys but personally, I don't really like to plan weekends. I'm good with having a very busy weekend or a very lazy one. But as everyone here, again, wants to take the pressure off from working hard during the week, I understand why they want something less drab to do during the weekend. Just a tip, you usually have to drive to get to bars and you gotta be careful if you drink or drive around here, you get yourself into some serious legal mess. Also, you can't get too drunk and decide to go home by foot so as not to be caught drunk driving. That would still land you in legal trouble for public intoxication. So if you plan on getting buzzed and wasted during the weekend, your option is to have a non-drinking friend be the designated driver or to stay at home altogether and get wasted there instead.

Eating shrimp. Americans cannot eat anything that has a head and a face staring back at them. They cannot eat shrimp or squid with their heads on. Heck, some can't even eat anything with bones on them like chicken (boneless chicken like nuggets are okay for them). Squid, if it's too small, is not food for them, it is bait. Shrimp, they can only eat if it's headless. Few of them will try dinuguan unless they are ignorant of what it's really made of and fewer still will brave eating the notorious balut. On the brighter side though, almost all Americans I know who have tasted the world-famous Philippine Adobo have all praises for the dish. And they mention it just out of the blue. Like I have a patient who when she found out I was from the Philippines said: "Well, my grandson just married a woman from Philippine and oooooh that woman from Philippine is so sweet and she makes this wonderful dish..what, it's called..what, it's called...oh! adobow!" Sometimes, I think that adobo will bring the Philippines recognition faster than our now growing economy and our wonderful beaches.

Freedom. Americans value freedom more than anything else and that is why the American president is considered the leader of the free world. Having said that, respecting personal space is something they all exercise here to the limit. That means my business ain't yours and your business ain't mine. Unless I do something illegal, you have no right to interfere with my life, my home, my backyard or whatsoever. It is inappropriate for you to give me advice unless I ask for it, tell me how to do my job unless you are my superior, tell me how to raise my children etc. Back home, if it's someone's birthday, you do your videoke, disturbing the peace of the neighborhood, until midnight or something like that, and the neighbors seldom complain or send the police over as long as it is not too much, knowing that you will give them the same consideration if they will celebrate their birthdays with a bang like you are doing now. Here, you have to take that ruckus down or else the police will be knocking on your door. Though it is true that you have the right to do what you want as long as it is not criminal, your neighbors also have a right to peace and not be disturbed by the uber-energetic party animal that you want to be.

My friends, this is all that I have for now, I'm sure as I discover their culture more I can share more with you. I am very open to corrections and if other people would like to share their experiences and observation, I would welcome it, too. Again, my insight is far from perfect and I tried to generalize everything. In the end, we are all unique and not one quality can define us all. For those of you who are not here yet, I hope this helps you understand the country you want to work in even just for a little bit. For now I bid you all, adieu!

Coping With Medicare Changes

2013-01-08T22:41:00.002-05:00

Some of you may have read my previous blog post and worried yourself sick over the future of PTs in the US. Some of you are students, some are professionals on the path to achieving their US license and some are already PTs in diaspora scattered throughout the US. Now, after reading my last blog entry, a little hope might have died on you or you may have lost a little faith in yourself and in your future as a therapist in this country. This blog entry I am now writing, is intended to restore whatever was lost in you and make you dream big again.

Once more, I am no expert in Medicare as well as in the many different practices of healthcare in general and physical therapy in particular. Therefore, I would very much welcome all statements and comments from other US PTs in our community to help clarify the real goings-on in our practice.

The thing I want all of you to engrave in all of your being is that there is a need for PTs in the US. There is a need because the baby boomer population is getting older and they would need therapy eventually. There is a need because PT programs here reach a staggering seven-year curriculum to get a DPT. Education is very expensive in the US. Unlike in the Philippines where it is considered the parents' responsibility to send their kids through university, here people work to get themselves an education. A whole seven years to spend schooling is seven years of maintaining high grade point averages while working at least one job on the side. Most people would have a hard time coping with such a schedule. Thus, fewer Americans are taking up physical therapy as a career and as older American PTs go to eventual retirement, they would need replacements and even more PTs to keep up with the demand from baby boomers. Most likely, they would hire Indian and Filipino PTs because of our good command of English and very close resemblance of our PT school programs to theirs.

Now I did mention of Medicare going bankrupt and the Manual Medicare Review being a pain in the ass in my last entry. It is largely out of frustration that I blurted that one out. Though the fact remains that Medicare may run out of money if drastic reform is not undertaken to curtail unnecessary expense and fraud, I am hopeful that the reforms they will apply are reasonable and can be worked with. The Manual Medicare Review (MMR) will eventually become more organized and efficient and will be streamlined with private insurance company procedures. Now, private insurance companies may be stingy with the amount of treatment they would be paying for the patient (like allowing only 10 treatment days instead of the fifteen days you would request to work with a patient) and are also very demanding with paperwork, private insurance companies are efficient in their delivery of benefits. It is like you contact them regarding a patient under their insurance policy, send them the necessary paperworks including your prognosis and expected outcomes for the patient, you would usually receive a reply from them within the next two days. MMR, on the other hand, would take a month to process everything and send out a reply to you. However, once the MMR system becomes more organized, delivery of services and reimbursements will be faster and more efficient.

I would also like to clarify that the mess that MMR has gotten us into, so far has no effect on Medicare A patients. Medicare A covers hospital care and that means PTs working in acute care rehab (hospital in-patient) and skilled nursing facilities (sub-acute care) are not affected. MMR affects outpatient services under Medicare B which includes homehealth therapy, outpatient rehab and long-term care such as nursing facilities. (Take note that a skilled nursing facility is different from a nursing facility. A nursing facility is basically a nursing home, a retirement home for the elderly where the patients are usually long-term whereas a skilled nursing facility is more of sub-acute care. Patients in SNFs are usually short-term; they are those that don't really require very close medical monitoring but are not yet healthy enough to go back home. It is not unusual that a nursing facility may have several skilled bed units or a skilled nursing facility have some long term care residents). The new Medicare changes will have the MMR process continued for this year, so hopefully those running the system start getting the hang of it and get things done faster. To cap it all, life goes on easy for PTs working in SNFs and hospitals but PTs working in nursing homes, home health and outpatient facilities will have to make necessary adjustments.

Another point I would like to stress out is that the demand for PTs continue to be really high in many parts of the US. We probably never hear of them because almost all of our peers are concentrated on the Eastern and Western seaboards. Almost everyone is in NY, NJ, California, Florida, Illinois, Maryland, Washington and Texas. These become supersaturated with PTs that it seems you won't be able to find another place to work at if you move. However, if you think about many other mid-Western states and other states without the very large metropolises, this is where PTs are needed most. Think New Mexico, Arizona, Alabama, North Dakota, Oklahoma, South Dakota, Ohio, Oregon, Missouri, Iowa, North Carolina, Tennessee, South Carolina, Louisiana and Mississippi. In these places where it is less flashy and more quiet, you can get the most out of your money. I live in Northern Virginia, about thirty minutes from Washington DC, and I pay fourteen hundred for a two-bedroom apartment. My friend in New Mexico pays five hundred for a three bedroom house with a fenced yard. I get paid slightly higher than her but with the cost of living here, she gets a whoooole lot more for her money. Try living in New York and your wallet would hurt more. True, you probably would have to drive at least two hours (or maybe five) to get to something exciting over there in New Mexico. And true, Washington DC is but a half-hour drive for me. But the fact remains: How many times do you really need to see the White House and get your picture taken before you're satisfied? Even in a big city like New York, you won't even be able to enjoy exploring it if you are working hard five times a week. At the end of the day, it is best to pick a place where you have a good work-life balance. And another tip, if it is possible, don't pick a state where there are a lot of Filipinos. You'd be free from all the drama and pataasan-ng-ihi events. It is best to pick a state where Filipinos are afew and therefore are a much tightly-knit and closer community. You'd thank me later.

Finally, my friends, our best defense against evolving Medicare regulations is to hone our ability to perform a very necessary but seldom emphasized skill in the clinic: documentation. In the Philippines, we take for granted writing notes because 1.) we directly communicate with a patient's family and his doctor regarding his progress and 2.) we copy/paste our notes for almost all our patients involved (e.g. PT Note dated today: Pt was seen with the same management as so-and-so date. Pt tolerated tx without untoward incidents.) We write this PT note for all our patients sa Pinas. This is way different how we do things here. Our notes are more detailed and functional progress (or regress) should be stated clearly and in a meaningful, complete but concise detail. In order for you to be able to do that, first of all you should be keen in your observation and evaluation of your patients. I mean, how can you write a good, accurate and scientific PT document, if you don't even know what to observe in a patient in the first place, or what questions to ask the patient in an interview or if what a patient is explaining to you may even be relevant in your note-writing?

Your clinical decision-making skill will be called upon if you want to keep a steady caseload. It is very important to know how to screen patients who are appropriate to be picked up by physical therapy. Take note that I used the term "appropriate" instead of "need". Not all patients who need therapy are appropriate to be picked up by physical therapy. It is you who make a clinical determination of that. Remember that the appropriateness of giving skilled physical therapy services is among the factors that will ultimately determine denial or approval of MMR. Modesty aside, since October to early December 2012, from among the fifteen or twenty patients that I have sent out for MMR, I only had one denial. That denial was based on technicality (wrong Medicare number or something) so that isn't my fault. The reason for my success with the MMR process is simple: proper and complete documentation. I am not saying my notes are perfect, but they are definitely suffice to the standards set by Medicare.

As I conclude this blog entry, let me leave you with some advice. 1.) Don't worry about the future of PTs in the US; we have a good future here. We are skilled professionals. People will get old, people will have fractures, people will get sick. There will always be a need for us. Worry ka ng worry sa future mo hindi mo nga mapasa-pasa yang lintek na TOEFL na yan. Focus on the present first and later on decide to cross the bridge when you get there. 2.) Despite the rumors (or urban legend :-D ) that documentation is really hard, the truth is, it is only hard in the beginning. Once you get the hang of it, it will just flow more easily from you. 3.) Learn to drive. Unless you want to live in NYC where you can get anywhere with trains, anywhere else you would need to be able to drive around. So before you leave the Philippines, take some driving lessons (with an automatic transmission car); it will make your life way easier and acculturation way faster. 4.) If your main goal of going to the US is just to earn money, you will never be happy here. Better stay in the Philippines with your loved ones than come here and hate your job and situation. To be satisfied with your lot in life as an expat PT, come here to LEARN first, and to EARN second. Money is not the end-all and be-all of your life as a PT. Happy New Year to all and I hope nabuhayan ng kahit konti ang mga pangarap ninyo.

P.S. I would very much appreciate comments and additional information that you guys would like to add to paint a more complete picture of our experiences here. Let us work hand in hand to ensure that more PTs will discover their true calling as extensions of God's healing hands.

P.P.S For the grammar Nazis, my apologies. Tao lang po.

How Medicare Reform Can Affect Your Future as a Physical Therapist

2013-01-03T23:46:00.002-05:00

I originally wrote this piece on the 31st of December 2012 but unfortunately was unable to finish it until now. It is the fourth of January, and the both Houses of the US Congress has finally set a deal a couple days ago preventing the much feared US fiscal cliff from happening.

The US fiscal cliff is an economic apocalyptic event of drastic spending cuts and dramatic tax hikes to reduce the US budget deficit. With spending cuts, jobs will be lost resulting in decreased consumer spending. Decreased consumer spending means companies, for example Walmart or McDonalds, will not be hiring more people when they don't have a lot of costumers to cater to. Otherwise, they might also start laying people off. Imposing tax hikes means less money for every family to spend and presents the same effects regarding decreased consumer spending. This will send the fragile US economy back into recession and will pull the world down with it. Which leads me to my next point, what does it have to do with healthcare workers, in particular physical therapists? Let me explain.

Medicare alone accounts for almost $600 billion in 2010 and is expected to rise to more than a trillion bucks in 2022, when most of the baby boomer generation would require more health services. All physical therapists based in the US, in one way or the other, are dependent on Medicare reimbursements for their services may it be in out-patient clinics, home health services, skilled nursing facilities, nursing facilities or acute care rehab. If this fiscal cliff happened, and the s--t hit the fan, cuts to Medicare will seriously affect delivery of care to patients and may result in loss of employment or underemployment for therapists. For foreign trained PTs, like us from the Philippines, it may be harder to get working visas when there are no jobs available to start with. There is always talk of increased demand for therapists as the baby boomer generation enters their twilight years and would need more help to increase mobility, improve function and quality of life but the lingering question is who is gonna pay for their therapy when Medicare cuts are implemented here and there? Most won't be able to pay out of pocket. Our skilled services are expensive so to speak as new PTs here spend an average of seven years to be a DPT. However, I personally think it is justified how much we are compensated for our services.

I work in a nursing home with a few skilled beds so I cannot really speak in behalf of other PT specialties but let me explain this one too. As a PT, my job is not only to evaluate and make a program for every patient I have, short-term care or long-term care patient it doesn't matter. It is also part of my job to constantly assess the patient and be in constant communication with other therapists (OT and speech) as well as nursing (which basically encompasses a broad base of unit nurses, restorative nurses, Medicare nurses, unit managers and nursing assistants/aides) with regards to the overall health of the patient. Everyday that I work with the patient, therefore, I am evaluating him if he is making progress, if this program is working for him, if he is at baseline and most especially, if something is off with him. I don't have to diagnose what is wrong with him as that is not part of my job but it is my job to let everyone involved in his care know that something isn't right and has to be put into observation or noted. There are times when a patient is making good progress and then gradually declines for no obvious reasons. Having reported it to nursing, nursing may reveal that his medications may have been changed and when they found out that the patient is not doing so well with the new meds may contact the physician. To make the long story short, a therapist is involved in a large part of patient care and as we play a central figure in restoring patient function and overall quality of life, it is only right that we are paid decently for our clinical judgment and responsibilities.

With a deal reached in Congress, the 27% pay cut to doctors (and by extension to us, therapists) will not happen, or perhaps more accurately, at least not now. However, Medicare reform will soon be an area of great interests to the politicians as they try to rein in the cost of healthcare. According to Wikipedia, only less than 5% of all Medicare claims are evaluated, which means that 95% or more of claims get refunded without adequate verification of appropriateness of reimbursement. Having said this, many firms, both bogus and legal, have turned Medicare into their cashcow, essentially draining the system of much needed funds faster than these seniors can go into full retirement.

In New York alone, Medicare must be losing hundreds of millions on fly-by-night physical therapy clinics that are essentially hot-packs-TENS-factories that change names every two years to avoid detection from government agencies for fraud. These clinics, employ unlicensed PTs to treat dozens of patients a day and are in cahoots with a licensed therapist who comes in only once a week to sign documents to make the operation appear legal. I know this for certain as I have a couple friends verify this.

Insurance fraud such as this adds up to the bankruptcy that is facing the Medicare system in the face. Many reforms have been introduced and as recently as October of last year, they introduced Manual Medicare Review (MMR), towards which they hired (I assume) non-healthcare professionals to assess, evaluate and approve or disapprove request for more therapy for patients who have reached their caps for the year. A cap is the maximum amount of money that Medicare can pay for each patient receiving skilled therapy for the year. If the patient goes beyond cap, theoretically he has to pay out of pocket. Before the MMR, even if the patient reaches the cap, a therapist can write justification explaining why the patient would need more therapy despite having used up his money for the year. With MMR, you are only allowed an evaluation once the patient reaches cap. Then all the necessary documents pertaining to the patient will be sent out to the agency performing the MMR, on which the agency will have ten business days to decide and approve or deny the evaluation and need for therapy. Their response will be sent out via snail mail back to you.

I will say it up front. The whole MMR process is a mess! A big, and utter mess! For starters, ten business days is two weeks from evaluation. Add the days for completion of documents and the days for snail mail and you are looking at at least three weeks (or in my experience even two months!) before you get to know if you can start treating a long term care patient. How in the fucking world can you expect the patient to stay at the same level, set the same goals for the patient after evaluating him a month ago? How in the world do you expect the patient not to have declined in that span? For example, I have a patient evaluated for a fall and I sent the patient's paperwork out for MMR. The evaluators took their damn sweet time processing the papers and I received a reply more than a month later approving twenty treatments for the patient. By that time, the patient has had fallen two more times and has now progressively weakened from the pain and the fear of falling again. How in the world do they expect me to fix him now? I'm pretty sure I need to re-evaluate him as his needs, level of function have changed. But I can't! Because if I do, I would have to wait for God knows how long again before I get their reply. By then I'm not even sure if the patient would still be alive.

The inefficiency of those doing the MMR was so blatantly upsetting, that by the end of the year, three months after the MMR was introduced, I was left with only two patients to see. Two patients mean I can only stay for work for a very short time thus leaving me broke by the new year. Many other therapists who work in nursing homes also reflect the same sentiments. And all the papers I sent out are just there awaiting nothing, no response from MMR whatsoever. I have sent out at least ten patient evaluations and no response from them. It was very frustrating and my fear is that this Manual Medicare Review might go on as the future of Medicare reform. This does not bode well for the future of the healthcare practice and professionals. But most of all, it does not bode well for the quality of life of patients.

It becomes a big irony when they tell you the need for PTs will continue to rise in the future as more and more baby boomers get older and need therapy but at the same time the politicians are looking at choking the lifeline of these same health care professionals and eventually driving them off the workforce. We can only pray that they would know better and make better recommendations at health care reform. Before we all drive ourselves and jump over a real cliff.

Bond 2012: SKYFALL

2012-11-13T00:36:00.000-05:00

I remember when I learned that Daniel Craig was to play the coveted role of James Bond several years ago, my first reaction was: Daniel who? I never heard of the guy and when the poster was shown I shook my head and dismissed the actor and the franchise to ultimate failure. Daniel Craig did not look like the former James Bonds. They all used to share Sean Connery's tall, dark and handsome features. All of them dashing, smooth, debonaire. Daniel, on the other hand, is not even good-looking. He is also shorter than the other Bonds, is bulkier and more muscular and has blond hair. So as one of the earliest naysayers, my foot is stuck in my mouth as Daniel Craig rose up to the plate and became the most bankable James Bond in history, probably even outdoing the feats of Sean Connery, Roger Moore and Pierce Brosnan.

This movie, Skyfall, is set to become the highest grossing in the 50 year history of the franchise, and not surprisingly so. The movie is great, the script intact and the cinematography superb. I would like to commend its director Sam Mendes for doing a wonderful job at the helm. The cinematography was also breathtaking particularly with the train crashing towards Bond in the tunnel and the fight scene on a Shanghai skyscraper. The actors themselves were very good at showing their vulnerability. The script was almost flawless with a good injection of humor throughout the film. This, in my humble opinion, is the best Bond film to date.

Since the first installment of Craig as Bond, the production behind the Bond series have intelligently transitioned to a more believable and more human depiction of the famous fictional English assassin. They have done away with invisible cars, exploding fountain pens and weird disguises that fool no one. Instead, the director has used Daniel Craig's eyes and sharp-lined mouth to make the viewers realize that Bond is not immortal. Bond is a human being who hurts, who feels, who gets tired, who gets old. It is with Craig that we have seen Bond tortured, wounded badly and almost die. It is because Craig, despite not being good-looking, can pull off the hero-who-becomes-the-underdog-to-rise-and-become-hero-again stint. What's more, Craig is definitely believable to play the part.

The other cast members also performed very well.

I am in awe of Berenice Marlohe, a French actress, who looked and played an Asian concubine/employee of antagonist Javier Bardem. Not only is she stunningly beautiful, she was able to beautifully project deceit, fear, loathing and hope in rapid succession during her conversation with Bond at the casino. Her hand trembled at the thought that Bond wanted to meet her boss. She shook with fear, her mouth quivered as she told him: Be careful what you wish for. And her eyes shone with hope when she asked him: Are you gonna kill him?

Naomie Harris in the film, I think was confident and played the her role well as Eve a field agent who was mistakenly shot Bond as he struggled with another assassin on the train. At the end of the movie, she is revealed to be the returning character Ms Moneypenny, secretary to M. In the Bond series though, her name is Jane not Eve. I didn't think that she was as good as Marlohe in this film but yes she does have the better ass. Yep, ass as in behind. Go Ms Moneypenny!

Another great addition to the film is Ben Wishaw who played Q, a computer wiz who is at the helm of anything computer related within the MI6. He played his character very well too, looking all dorky and unkempt but with the sarcastic verbose nature that all high-IQ nerds possess. He was also able to project very well the short but plot-decisive virtual chess game with Javier Bardem.

Judi Dench played her last role as M and will be replaced by Ralph Fiennes (aka Voldemort) in the upcoming films. Both actors played their roles well although at times I felt veteran actress Dench looked stiff. She did have to play a tough role though, to play an impassive and cold director of the MI6 who calls the shots and carries the burden of dead agents or failed missions at her behest all in the best interest of England. I did expect more from her especially during her confrontation with Javier Bardem and during the opening scene when Bond was inadvertently shot by Eve upon M's command where she looked more lost than impassive.

The most striking of all the actors though, including Daniel Craig, is Javier Bardem who was marvelous in his portrayal of Bond's nemesis as Silva, a former personal favorite of M, who was disgraced and eventually let go by the MI6. He was portrayed as a power-hungry evil genius attracted to power and strength which birthed to his homo-erotic scene with Bond. Silva returned as a devious and ruthless cybercriminal, fanatical in his desire for both revenge and acceptance from M. His brilliance and cunning always put him a step ahead of Bond and the MI6 as he unleashed a wave of cyber and actual terrorism. His portrayal of Silva in this film proves that his talent as an actor and his Oscar recognition is no fluke. Plus, having a Penelope Cruz for a wife is a prize in itself.

This Bond movie has solidified the idea that in the world of espionage and covert operations, the concept of you-snooze-you-lose cannot be emphasized more. This was also relayed by Liam Neeson in Taken when he confronted his former French friend at the dinner table with: That's what happens when you sit behind a desk for too long. You forget things! Like having a gun that's loaded and one that's not. The skill and the instinct may be there, but the precision, dexterity and reflexes definitely slow down. In this particular film, for instance, Bond retreated to seclusion and alcohol after his widely perceived death. He returned a lesser assassin, who looked and moved like the shell of his former self. And since I love David Morrell's (creator of Rambo) Brotherhood of the Black Rose book so much, I would like to imply again that between two equally skilled and deadly assassins in combat, the younger one always has a higher percentage of winning. The reason is the younger you are, the faster your reflexes are. Bond, in this film, was shown as getting old with not-so-subtle hints of having him retired. But, of course, like all protagonists, he persists and eventually triumphs over Silva and his goons but at the sad expense of M.

As for the assassins themselves, it is clear that emotions and feelings are considered a great liability and bad for business. The has been well-documented in the Bourne series and in Mr and Mrs Smith. Assassins are trained to kill without remorse, without doubt, with indifference. But, no, like in all the Bourne series, Mr and Mrs Smith, Taken as well as the books of David Morrell, Daniel Silva, Frederick Forsythe and Tom Clancy, assassins are not without heart and at times risk their lives for that split-second moment of doubt or surge of regret or love. This is the very first time in the history of chauvinistic, womanizing James Bond to have seen him at his most vulnerable. For the first time since his parents' death, James Bond shed tears for his boss, M, Mom, the closest thing to a mother he had. He openly wept for his love of country, his love of M and for his freedom from the dark memories of Skyfall.

P.S. It seems that this movie can do no wrong. Adele, the British vocal behemoth, who has inspired multiple eargasms with her soulful and bluesy vocals, has sung the hauntingly beautiful theme song of Skyfall, named as such. Sometimes you just wonder if they made the movie just so she can sing its theme song. It really captured the essence of the film. I recommend that you watch it in theaters. It will not do justice to this movie's perfection if you just download it and watch it on the small screen.

Pictures II

2012-10-14T21:19:00.004-04:00

Green Means Go

Shadow Over Apples

Orange Globe

Fruit of the Earth

Bounty

Shaded Beauty

Hiding from the Sun

And my favorite pic of the day:

Autumn Willow

Destination Anywhere

2012-09-23T00:52:00.001-04:00

I have stumbled upon this documentary from one of the write ups of the opinion section of the Philippine Daily Inquirer. It's opening line is like an uppercut to the diaphragm: Imagine a nation where the #1 career choice is leaving the country. Yes, it is talking about us, the collectively heralded heroes of the present, the overseas Filipino worker.

The Pen Artist

2012-09-19T23:48:00.002-04:00

Funny, I only realized that after my puberty was over, there were only two things that persisted: (1) my acne and (2) the fact that my best days of impassioned writing was over. Yes, I still do write poems and essays such as this every now and then. But I know not how I managed to conjure up an obra maestra of letters and verses in one sitting. Where once I could sit and write a love poem in less than half an hour inspired by the works of Edgar Allan Poe and Maningning Miclat, I am now resigned to squeezing my brain to write even a single verse for my wife or to type a blog entry that probably only a couple people will read anyway.

I did not know when I lost the passion for writing. Its slow but inevitable death probably has started when my mom told me I will not take up Creative Writing at UP Diliman. She told me poetry and short stories will not feed a family. You will live and die by the poverty that the pen can only bring. She told me to pursue my passion for the arts yet remain grounded in the fact that too many artists died starving before a Picasso becomes priceless. Keep writing she said, but make it a hobby not a career. Now that I think of it, she made sense but it did bring the near-death of my writing passion. I don't think I would have been recognized as a great writer anyway, a good one yes, but not good enough to be great. I don't think I can play with words as well as Patricia Evangelista or Conrado de Quiros. My essays are pretty much decent, but even I don't think they are special.

Yeah, yeah and you give me the litany of believe-in-yourself-believe-in-your-dreams-keep-dreaming-and-someday-you'll-achieve-it bullcrap. There are hundreds of thousands of people told to follow their dreams no matter what other people say or no matter the odds. Almost all of them died with eyes wide open and skin pressed deeply against their ribs. Those who didn't die chose a day job way different from their first passions. To think of it, how many people try and try again and fail to produce a Michael Jordan or a Michael Phelps or a Michael Jackson? There are literally thousands upon thousands of cabaret and bar singers who at one point in their lives really thought they stand out and that they would make it. The world is hard on artists, that is a fact, and when the truth comes crashing down it dawns on you that you have been strumming that guitar for twenty years now, writing that novel for fifteen years now, or playing in some random rundown theater for ten years now and still the break that you were looking for is far from your grasp. How long will it be before you realize that nobody listens to your songs anymore, or your graffiti which drew oohs and ahhs from way before remain that? How long before reality breaks you down and poverty transforms your creativity to despair? At one point in their lives, artists of pen or brush or song will struggle.
Struggle and the triumph over it is what defines each artist and will engrave his legacy.

Ah, but how wonderful it was when I was an impassioned writer. How I miss the magic that my heartbreak brought or my desire to save the world can do. Pain is what drove me. Pain of an unrequited love. Pain of adolescent rebellion. The passion that rages in your chest and flows in your blood to the ink of your pen. Life seemed more... vivid then. And now I just chill. As I stare into this entry that wasn't supposed to be an entry, I wonder what drives me now. Now that the pain is gone and the heartbreak has healed a long time time. Where do I get that fire? Where do I get the itch to pick up a pen and write down a story or a poem so spirited my blood will roll again into my canvass of letters. The moment is now. The time is now. But like all has-beens do, I'd say nay and put off the obra maestra till tomorrow or until probably forgotten.

GRANDMA

2012-09-11T23:06:00.001-04:00

My former boss sent me a text last Friday. She rarely texts me other than news about Grandma. I smile when I remembered her. She was my former patient at my old facility. Her name is Marion Rapalee. She was born January 20 or 21st (not sure) 1919. She is ninety-three years old but claims to be two hundred. It doesn't matter how many times other patients tell her that she can't be two hundred it's impossible. She strongly believes that she is and that is that.

I never knew anybody who didn't like Grandma. She was sweet and kind and always looks at other people with empathy. I remember one day we were in the gym exercising, and another patient rolled in in a wheelchair. Grandma asked her what happened to her. She told Grandma that she missed the chair when she sat, slammed her butt on the floor and broke a hip. Grandma came close and gave her a hug and consoled her: Oh you poor thing. Later, we found out why she was so compassionate about other patients. Grandma Rapalee was a nurse her whole life. She told us (over and over) again that she had been a nurse for sixty-three years (this too cannot be confirmed but we all know she had been one for a long time.)

Grandma was also a wonderful singer. She told us she sang in the choir and in church. Everybody would amusingly hear her singing her heart out along corridors or in her room. When you don't hear her sing, it means she's sick. She belts out Somewhere Over the Rainbow again and again. Or Someday my Prince Will Come. She also likes Elvis' Blue Suede Shoes, Love Me Tender and Can't Help Falling in Love. But because of her dementia, she makes up her own lyrics to the songs, admit that she's making them up and we'd all laugh about it. Something like: Someday, my prince will come; Someday, I'll find my love; And the moment that he comes to me; I will hang him up the old apple tree...

I remember the first few times we met. We were in the parallel bars and I asked her if she remembered who I was. She told me no. I told her: Well, Ms Rapalee. I'm the mayor of this town. Her eyes widened and looking all surprised she asked me: You're not. I said: I am, really. She replied: Wow! Then suddenly looking disinterested said: If you say so! Then, we both cracked up.
What I didn't realize is that she truly identified me as the mayor. And she would talk to the nurses and other residents about meeting the mayor. In the dining room, she would loudly introduce me to her table-mates as the mayor of the town much to my chagrin. The name stuck though and some of them started calling me Mayor in jest. I started calling her Grandma when she told me she will adopt me. Apparently, she told a lot of people she will adopt them according to her family. I've seen her daughter and granddaughter visit her several times a week. Both of them were attractive older women who are about as sweet as Grandma. One day while she was doing her therapy at the gym, they came to visit her. Grandma insisted that they take her home immediately without delay. They told her: But, Grandma, you're too old to go home. Nobody will stay at home with you all day. We work. You're two hundred years old remember? To which Grandma replied: Two hundred's not old. It's not like I'm two-fifty! I burst out laughing again right then and there.

Three weeks ago, the same former boss texted me to tell me that Grandma is back on caseload. She had bowel obstruction and they picked her back up after hospital discharge. Grandma remembered the Mayor and the therapist (my boss) who's seeing her as my step sister. I told her to tell Grandma that I miss her a lot and she better get well soon.

Last Friday, she sent me a text again. She told me Grandma was on a decline since last week and they finally sent her out to the hospital in the morning. She told me, Grandma passed at the hospital. It broke my heart. Funny, how that same morning, I heard Somewhere Over the Rainbow being played on the piano by one of the residents. I thought of Grandma then, just as I am thinking of her now. It is amazing how God plans our lives. There are some people who stay in your life for a long time and not leave a mark at all. And yet there are some who pass for the briefest of moments and leave an indelible print in your being.

I will miss Grandma so very much. And I thank God for giving me her for even just a short time. I know who I want to be as a healer. I know who I want to be when I grow old and gray. She must be making all the angels laugh up there and making heaven an even happier place than it's ever been. So I bid her adieu, until we meet again, somewhere over the rainbow.

Click and View please

2012-09-06T17:19:00.003-04:00

http://www.youtube.com/watch?v=oL4lzKCYDEw&feature=youtu.be

Certified Nursing Assistants

2012-08-28T23:43:00.002-04:00

Today, Fiona, my boss who's an OT, and I went to do an in service for a pt who was referred by nursing for transfer training using a sit-to-stand lift. This patient uses a Hoyer lift for transfers, meaning he is completely dependent in the transfer. In attendance were maybe five or six CNAs (certified nursing assistants) (in the Philippines, we refer to them as caregivers) to check out the transfer technique. After showing them how to do it, we were greeted by a straightforward response from them: Transferring the pt through the sit-to-stand lift is cumbersome, inefficient and very time consuming. It is not plausible, they claim, to use it on him cause it will just take too much time and there also would be a safety concern when they try to use it.

I understand what they are getting to. They have to see many patients at a time and using the technique that we just taught is gonna take a lot more time that using a Hoyer. In a way, I feel for them. CNAs do the dirty job that the nurses don't do. They are at the bottom of the pt care hierarchy: an RN is usually the unit manager and then you have the LPNs (licensed practical nurses) and then you have the CNAs. The CNAs literally do the dirty job: clean up the pt, bathe the pt, dress the pt, change soiled clothes, feed the pt, get pt up and back in bed when needed. They also get a measly pay, maybe several dollars more per hour than minimum wage. What they do is physically taxing and I would not wonder why they would entertain thoughts of using the Hoyer on my patient right now because it is faster and convenient. However, I also would want my pt to get better and that means I need him to have more active participation during the transfer which the Hoyer could not offer.

It is disappointing and sad when sometimes patients tell me that they have clicked on the nurse's call bell cause they need to go to the bathroom and nobody shows up until thirty or forty-five minutes later. By then, they have already soiled themselves or have slid down on their wheelchairs from exhaustion. Because of repeated instances, some of them no longer use the call bell and instead attempt to transfer themselves to the bathroom which eventually leads to falls and fractures. They put the blame on the hapless and helpless CNAs. Yes, like in every profession, there are good ones and bad ones. But then again, maybe one or two CNAs are assigned for maybe up to ten beds at one time. It is possible that while a patient turned the call bell on, the assigned CNA was helping another patient in the bathroom too. But still they get the blame if they don't get out there and assist as soon as possible.

It is a sad reality. But we cannot always give the best care we want for our patients. And, though, I would still insist on recommending the use of the sit-to-stand machine for toilet transfers with that particular patient, for now I would take time and appreciate the CNAs who were present there today. At least they told us face front: We're not sure if we are gonna use it often with him, but let us at least try. So for now, here is a hats off to my seldom recognized teammates in health care: the certified nursing assistants.

The Bourne Legacy

2012-08-26T00:34:00.002-04:00

Last year, when I learned that a new Bourne movie was coming out but Matt Damon was no longer the lead role, I didn't really care much for it. But eventually, I wanted to watch the movie because it was shot in Manila, capital of the Philippines. On the day it was released, I checked out rottentomatoes.com to see if it fared well with them. It got a rating of 55%, not a really rotten tomato but not a red juicy one either. It means that this movie seemed mediocre at best.

I just got to watch the movie today, more than a couple weeks since it was released. For me, at least, it didn't disappoint up until the end when the conclusion of the film just came crashing like a sack of potatoes without warning. I understand that they have to leave the movie hanging to keep the audiences expecting a sequel, but I really did wanted to have them pen a better ending. The rest of the film, though, was fast-paced, well shot and has gotten its act together so I highly recommend it.

The new lead roles played by Jeremy Renner and Rachel Weisz were played very well. It wasn't flawless but they did very well. They also had the chemistry to match it with. I did not understand why some critics say that their relationship was not established well in the movie. I think they were able to develop the relationship at a good pace and did not seem contrived at all.

My main concern about the movie is that the plot is neither cohesive nor is it novel. It almost resembled the first three Bourne movies without a new twist into it. In the former movies, the CIA went after the tagged-rogue agent Jason Bourne and eliminate him to shut Operation Treadstone down. Jason Bourne escaped and caused collateral damage in his path to save himself, his lover/wife and fight back against the agency he formerly worked for while discovering his identity and trying to stay very low profile to keep the agency off his back. In this new movie, all Bourne-like operatives have to be eliminated inorder for a new set of Bourne-like-without-the-emotional-connection-aka-drama operatives could be set in place. Renner, of course, survives the assassination attempt, was able to discover that he had his genes mutated by a virus to have permanent physical enhancement (increased strength, reflexes etc) and with the help of Weisz, travel to Manila to have his genes mutated again-- this time to have permanent neurological enhancement ( increase nerve regeneration, sensation etc). Now, the CIA is tracking them down, wanting to kill them but because they are the stars of the film and there is a need for a sequel (with sarcastic rolling of the eyeballs), they manage to get out of it all, kill the lone Bourne-like-without-the-drama operative and in the end were sailing smooth along the beautiful lagoons of the Hundred Islands (this I am not sure of). ---okay, just now I've been told it is El Nido, Palawan :-)

In order to keep the movie sequel interesting, Renner should have a real meeting or even a collaboration with the real Bourne, Matt Damon in the movie. They called it the Bourne Legacy, but Damon didn't even make a cameo appearance in the film. I don't think the franchise will survive without Matt Damon, the face of the Bourne franchise, in the film at all.

The shots taken in Manila was surprisingly very good. It really caught me off guard. I was expecting a less than savory portrayal of the Philippines as a third world country. The film, however, managed to showcase a picture of what Manila and the entire Philippines is all about. It is about a nation who is rising from the clasp of poverty and is getting ready to take center stage as a booming economy that could no longer be taken for granted. The film showed the high rise buildings along with the simple, old, tin-roofed apartments and they even have a shot of Renner losing his footing on one of those roofs. (I was wondering at first how Renner could have run on top of those tin roofs without having one of those roofs crash down. Well, one of them eventually did.) The movie also showcased the people traffic along the overpasses of EDSA, which was also accurate especially if you pass there at rush hours. The portrayal of a woman screaming magnanakaw (thief) when she discovered a stranger (Weisz) in her home is also accurate. The same could not be said of the ensuing events that followed. In reality, the policemen will be last to answer the call for magnanakaw and God-forbid by the time they get there, Weisz would've been beaten black and blue by the townspeople. Hahaha! It was good though, how the movie portrayed how industrious our factory workers are and even that pharmacy lady who opted to give out medicine for free to the foreigner. That would surely have escaped the eyes of all movie-goers except the real Filipino patriots like muah.

All in all, I would rate the movie a 7.5/10. The storyline was legit and I don't think the movie would have gotten fairly harsh criticism if only it wasn't compared to the original Bourne trilogy which is a classic. It's like nothing was ever as good or nearly as good as The Godfather trilogy until GoodFellas came along (and perhaps none since). Furthermore, it was able to project my country in a new light, something full of hope this time not of despair. It featured the Philippines and its people with vibrancy and dynamism, an economy that is growing and healthy and it did showcase the beauty of its islands for which it should be known for as it should be. Kudos to the cast and crew of the film and I am looking forward to its next installment.

(P.S. for the Pinoys who were in the film [I googled them, of course] we have Antonette Garcia as the landlady, John Arcilla as the security guard and comedian Lou Veloso as the fisherman/owner of the fishing boat).

Language

2012-08-23T23:18:00.003-04:00

So here I am deliberately deciding to allot time for writing an entry into my blog. I am laying tummy down on my bed and staring at the laptop screen with nothing to write about in particular. I decided to type away anyway. Random things, random thoughts, random people.

I read this from the net this afternoon. http://ph.news.yahoo.com/yes--some-pinoy-%E2%80%98languages%E2%80%99-are-on-the-brink-of-extinction.html

Many people I met here in the US wonder if Gemma, my friend and housemate, are related. We tell them we are not and they would then ask from which country we came from. When we tell them we are from the Philippines, many of them would ask as what part. That is sorta hard to answer. I am surprised many of the Americans actually know where the Philippines is. When they do, it is usually because of WWII or the former US military bases here in the country. Few of them know of our beautiful beaches and culture, fewer still know that we were once an American colony.

I have to tell them that Gemma comes from the northern island, where Manila, the capital, is located. She is from Isabela, an 8-hour bus trip from the megacity but I don't give them the details anymore. I also tell them I come from the middle islands. I was even pleasantly surprised when two of my patients were able to know where Iloilo is: one used to be a navigator during the WWII and the other married an Ilongga who died from breast cancer some 30 years ago. I am amazed that my seemingly insignificant hometown is known to some people halfway across the world.

Some are taken aback if they learned that Gemma and I have been here in the US less than a year. I personally think I speak good English. God did not give me good skin, towering height, broad shoulders, athleticism, musical ability, a long penis, a penchant for numbers or business. But He gave me a gift for languages. So I would like to say that given time and adequate training I can learn a language and speak it well, at least to a level deemed acceptable with true speakers of the language. When I tell my patients, " Pacencia, no comprende, me no habla Espanyol", some of the bilingual nurses would tell me I sounded like I did. I wish I truly did. I wanted to be fluent at least in these four languages: Spanish (spoken by everybody from Mexico to the entire South America except Brazil), Niponggo, Korean and Chinese. That will be for another lifetime, though.

When I tell people that Gemma and I don't speak the same language, they are curious how we communicate with each other. I tell them we speak the common language which is Tagalog so we can understand each other. With more than seven thousand islands in the country, we have amazingly have developed many languages and many more dialects. Hiligaynon, for example, is a language and Karay-a and Akeanon are dialects or sub-languages. Karay-a is spoken by people from the western to the northwestern part of Iloilo and Antique. Since Karay-a is mostly spoken by people from the fields and mountains, it is considered by the city-dwellers somewhat inferior compared to regular Ilonggo. Therefore, although fiercely defending their heritage, the Karay-a speakers eventually transition to speaking the more conventional, more acceptable Ilonggo. They would still speak Karay-a when speaking to family and friends from their hometown, but their intonation and diction transform to the more fluid and somewhat musical way of speaking Ilonggo. That, I believe eventually leads to the death of a language/dialect. People become socially intermingled and start losing some of their individualism.

I speak Ilonggo myself, but I can't stand listening to a Mass in vernacular. I couldn't understand the words that the priests use. Not being able to use many words in daily conversation eventually erode you ability to comprehend even your own language. The loss of vocabulary will eventually be replaced by typical common words that does not reflect the distinction of your language. I hope these endangered languages could be saved, if only for purely academic purposes. They surely would bring light to our past as a people, united by a country of many islands and a horde of wonderful, wonderful languages.

Yes, I am Pro RH because I am Pro-poor

2012-08-04T17:00:00.001-04:00

We just moved to our new apartment after almost a couple months being holed up at Best Western Hotel and I just got my internet back. I would have written more entries in the last couple months if only I got time and space to write everything down. Today, I got both so here I go.

I am writing about the RH bill and the reasons why I am supporting it. If you are able to read this blog entry at all, I assume you already have made a choice--you either support it or you don't. Let me be the first to tell you that you don't have to read this to be informed. The fact that you are reading this right now online I reckon means that you have access to the information you need on reproductive health, family planning and sex education. If you say you don't, then your ignorance is your own fault altogether.

Let me start by saying that the RH Bill is not for you and I. You are reading this entry, you are reading this online. I assume you are educated. Therefore this is not for you. The RH Bill is for the millions of Filipinos who are poor, those without access to the right information on reproductive health and family planning, those who cannot read this entry just because they don't have access or they don't know how to turn on the computer and much less use it to be informed. The RH Bill is for the poor and the poorly educated, not you and I.

Families and couples have the right to choose how large they would want their families to be. It is mostly subject to the availability of funds. Yes, a big family is fun. You have a lot of hands to help around the house, farm or business. You have a lot of support in times of crisis. You will not run out of playmates and nannies to watch over the kids. You have more people to help you with work, with projects, with assignments. But common sense also dictates that having more people to support entails that you have to have enough resources to support them: basic necessities, education, healthcare, etc. All of those things will put a strain on your resources unless you are enviably wealthy. A couple with a college degree for example with a combined income of thirty thousand a month would probably be able to support one child quite comfortably. But even they would fall below poverty line if they have five or six children. How much more a lavandera and a tricycle driver with the same number of kids? Or a saleslady and a security guard? Which is why I am saying that the RH Bill is not for you and I, the somehow okay people. People who can get by. This is for the poor. When a lavandera comes to the government for help because she can no longer support the number of children she has, it is only rightful for the state to help her. How? One way is to educate her on alternative methods of contraception. Education is still the best way to set our people free from the chains of poverty.

The Philippines is the 12th most populous nation in the world. Now there would be studies claiming either population is or isn't what makes a country rich or poor. I just find it so contradictory to common sense whichever says that a huge population doesn't equate to poverty. We have a hundred million people cramped like sardines in a tiny piece of land in the Pacific ocean. We have one-third the entire US population and one-tenth the entire Chinese population in a land of dwindling resources. Note though, that China and the US are the third and fourth largest countries in the world respectively. The Philippines has a hundred million mouths to feed three times a day. A hundred million mouths requiring sustenance and support pushing our land and resources to the brink of total devastation. Add to that the fact that we are at the center of climate change with massive storms claiming lives, livestock and grain every so often. How much more can our fragile land of diminishing resources take before we have a land left barren and unable to provide food, water and basic necessities?

Overpopulation, they say, is not the problem. It is the corruption in the government, inequality in the distribution of wealth and greed of the rich. They say that if they get these resolved first, then poverty will be eradicated. Yes, I admit they are problems. They are very serious problems indeed. I hope I don't sound so cocky and condescending but not even Jesus Himself, when He still walked the earth, was able to eradicate them. Yes, they have to be addressed but as they are so deeply rooted on our beings, on our culture, on our society, they won't be resolved in a year or even ten. That is a fact. We can stem them little by little but we can never eradicate them completely. That, too, is a fact.

The barrage of anti-RH bill supporters finding all that is wrong and evil about contraception is now overwhelming. They have researched thoroughly all the studies pointing to the relationship of contraception and cancer and diabetes and whatever there is they can find. I would like to thank them for that. Because if the RH Bill is passed into law, their information would be vital for couples to choose which one they would use, if they indeed decide to, based on their pros and cons. I just hope that they stop implying that with the government supplying people with their chosen contraceptive, they are in effect giving them cancer. That is just so f****d up, pardon my French.

I am thinking of probably writing a second part for this entry as this is getting too long and long blog entries bore people. Let me just explain one more thing before I finish this. The issue of the being pro-RH or anti-RH is not just as simple as being left or right, black or white, up or down. It is not even just about the degradation or preservation of our nation's morality. Nor is it just about correct or incorrect management of the country. It is more about choice. It is all about choice. If you think that using contraceptives is immoral and sinful, then don't use it. If you think that it's a blessing to have many children in your family, then go ahead. It's your choice, it's your right and it shall be rightfully respected.

However, if a couple decides they cannot support any more and they choose to use contraceptives. Respect their choice, too. If they cannot afford to do so and asks the government for help, it should be the government's responsibility to look after them. If you say, "but they are using my taxes to pay for their contraceptives", shall I assume that not only are you anti-freedom but also anti-poor? Just a question to ponder.

Failing Heroes

2012-05-20T16:19:00.002-04:00

We all grow up with our own heroes. Hero: a person we always wanted to become. As kids, we have always looked up to our parents. Boys wanted to be big and strong like their dads and girls wanted to be beautiful and loving like their moms. Boys wanted to be like Superman or Wolverine. Girls dreamed of being Barbie or the Pink Ranger. We all wanted to become like our heroes. What happens then if the heroes that we look up to fail?

The first hero (or should I say heroine) I looked up to was Maningning Miclat. You probably never heard of her. But I did. She was an artist, a painter and a trilingual poet. I have always written poetry even as a kid. But it was my discovery of Maningning's work (as well as Robert Frost and Edgar Allan Poe) that influenced me to take poetry writing seriously. I was in highschool then, with all my raging hormones to compel me with burning passion to write about life and love begotten or unrequited, it didn't matter. I wrote with a passion the way Maningning did on hers. I so adored her I would sneak into National Bookstore during the weekend to read parts of her Voice from the Underworld book. It broke my heart, then, when I learned she leapt to her death from a campus building. My heroine was gone. My heart was broken.

I was, too, a strong environmentalist as a child, hence my vast knowledge of nature stuff and my profound love for nature documentaries. I would rather watch a nature documentary than watch a film on TV for that matter. But my nature-freak nature doesn't end there. Until now I am never comfortable throwing anything not into a garbage can. I rather bring a candy wrapper home and throw it properly into the trashcan than just flip it conveniently into the streets. And so when I learned that actress Chin Chin Gutierrez was a strong environmental activist, I fell head over heels for her. She is also unbelievably beautiful and ageless. She became my other heroine, even more so when she grazed the cover of Time magazine in 2003 as an Asian hero for the environment. My heroine though, is fighting a losing battle. In my beautiful country, the Philippines, poverty and overpopulation is pushing Mother Nature on her back. By the end of the 21st century, if people and our leaders will not act soon, the country will be but and empty shell of of bare rocks, our people starved to death and ravaged by war and hunger.

For the last nine years, the hero that I looked up to is Lebron James, the basketball superstar. I watched the NBA again because of him. I looked up to LBJ because he is everything I wanted to become in my next life: Big, strong, athletic, unbelievably wealthy. He is of the same age as I am, a month younger than me. And I've always cheered him on despite all the controversies surrounding him. I wanted him to win a ring so bad to shut all the haters up and have his place in history as one of the best players to ever grace the basketball floor. It is his ninth season already, and he is almost 28 years old. Not as young anymore. Still no rings. It seems like he remains a promise, a promise that is about to be blown out again this year in the playoffs. I am writing this entry while watching their game. I hope they win. I don't want another hero in my life to fail. Not now. Not again.

Nocab

2012-05-14T22:35:00.002-04:00

I would like to dedicate an entire blog post to one of the best things in life:

No, I am not talking about love between these two characters. I am talking about what they are cooking. Crispy delicious bacon! Look at that orgasmic expression on that woman's face. Bacon! Bacon bacon bacon! You are so delicious to the taste. You make my heart go pit-a-pat, literally and figuratively. But oh how tasty you are. And you know it:

The wafting smell of bacon cooking in the frying pan gets me high. Bacon is my weed. My coke. My meth. It gets me high. So does my blood pressure. But I don't care. Bacon. Bacon. Bacon. You are my one true love. You are a king among hypertensive foods. I love you with all my heart. I love you more than I love my heart. Heart attack or cardiac delight? Bacon bacon bacon! You are mine!

I. Love. Bacon.