My HMDP training on “Physiotherapy Management of Circulatory Complications in Diabetes” took place from 5 Sep to 28 Oct 2005.  The focus is on the management of circulatory disorder secondary to diabetes and its related complications, such as amputee rehabilitation, peripheral vascular disease, diabetic neuropathy, wound healing (arterial, venous and neuropathic), venous stasis, and lymphoedema.  The training was carried out in two large health-care organizations in the mid west USA, Barnes Jewish Corporation, St.Louis Missouri, and ProMedica Health System, Toledo Ohio.  Including a day visit to University of Michigan Health system, Ann Arbor, I have visited 7 hospitals and 2 clinics in total.  The learning is primarily observational and also through discussion with the area specialist, including physical therapist, prosthetist, nurse clinician, and vascular surgeons.  Four areas of vascular rehabilitation were stressed during the attachment: 1) Management of minor foot amputee, 2) Claudication exercise class, 3) Prosthetic fitting and Post-prosthetic amputee rehabilitation and 4) Wound management. 
     

Barnes Jewish Hospital                   The Toledo Hospital - Jobst Vascular Center

This attachment allows the identification of projects/ protocols that are well developed and at the same time, revealing areas that need further improvement.  My observations led me to conclude that SGH in-patient therapy service for major amputation and vascular bypasses are comparable to the United States.  Valuable information was learnt in the areas of minor amputation, prosthetic rehabilitation using various state-of the art prosthesis such as the C leg  â with microprocessor knee, and Harmony  â system, as well as and wound healing.  

                    

Harmony system             C leg â with microprocessor knee  

Aspects of the knowledge / skills acquired that can be introduced in SGH includes 1) using offloading mechanism (utilization of walking aide and heel strike shoes) for patients with minor foot amputation, 2) utilization of electrophysical agent (High voltage pulsed current and Ultrasound) as an alternative for chronic wound healing, and 3) A new interim prosthetic system PREP  for early gait training. 

Heel strike shoe for forefoot offloading          Using electrical stimulation for a pressure ulcer

Clinical exposure aside, the opportunity to network and exchange experiences with various experts in the field of vascular rehabilitation is the biggest benefit I had acquired for my personal development. The interactions with fellow PT, administrators, vascular nurse clinicians, and vascular surgeons have broadened my understating of healthcare dynamics. I believe that exposure to new people and places are a good stimulus in generating ideas for service improvement and implementation of new programs. I am certainly grateful for such training opportunity.