NP Worldview

Reflections from stateside

2012-01-30T16:56:00.002-05:00

I've asked my colleague, Mary E. "Betty" Ulrich, MSN, RN, ANP-BC, FNP, to write a guest post. A nurse practitioner with the U.S. Foreign Service, Betty, a retired U.S. Army major and a member of the Honor Society of Nursing, Sigma Theta Tau International, is presently stationed in Kabul, Afghanistan. — Judie Pruett

Upon my return to the United States from Kabul, Afghanistan for a little R & R (rest and relaxation), I spent some time in a U.S. hospital system when my sister required a biopsy. As a nurse practitioner who has practiced in many places in this world, including Africa, Asia, Europe and the Caribbean island of Haiti, I sat in wonder of the U.S. medical system I had taken for granted.

To my colleagues who also work in remote places, I say, imagine a hospital with clean floors, medications available when the health care provider orders them, an efficient administrative staff, air conditioning in the summer and heat in the winter, a safety-conscious environment, meals delivered to your patients’ rooms, clean linen, disposable gloves, patient call buttons and access to mammography before a lump is palpable. These are all items normally available at U.S. hospitals. Life under these circumstances would be heavenly for those of us in the “field.” Understand that these benefits are not the norm in many hospitals around the world.

In Africa, most hospitals require families to provide meals and perform daily bathing and changing of linens. There are too few nurses to take care of too many patients.

Morocco has recently started encouraging women to get mammograms. Unfortunately, the service is not affordable for most women. In Casablanca, the Institut Pasteur reports that the pathology department is seeing more early-stage tumors. In previous years, most tumors were stage 4 specimens. It’s a sign of progress.

In Hungary, local nurses told me that, historically, disposable gloves were washed on the night shift and reused, as there was no money to purchase additional gloves. Poor funding of public hospitals in pre-European Union days demanded adjustments in techniques. The public hospitals do good work under severe budget restraints, but only privately funded hospitals can afford to comply with all the regulations and recommendations.

In Liberia, a nurse told me she thought piped-in oxygen was a wonderful idea but did not expect to see this modern equipment during her lifetime.

In many hospitals around the world, when a medication is prescribed to an inpatient for PO or IV use, the family must go to the pharmacy, purchase the drug and bring it back to the hospital for the ward nurse to give to the patient.

I remember my African housekeeper asking for extra money to treat her malaria. When I questioned her about the results of her tests, her remarks stayed with me a long time. “We can’t afford both the tests and the medicines, so we buy the medicine when we get the fever.” Education comes in many forms.

I do not want to convey an unwritten message of “Don’t get sick outside the USA.” I have seen many doctors around the world, with excellent skills and little technology, who perform some pretty impressive diagnoses. When X-rays aren’t available, listening to a chest with a stethoscope takes on different intensity. When the nearest CT is 100 miles away or in the next country, a well-performed abdominal exam by an expert physician is held in extremely high esteem.

In many countries, very little high technology is available to doctors who take care of the common man or woman. Consequently, physicians have honed advanced ultrasound skills seldom seen elsewhere.

While I am only days away from ending this R & R and returning to Afghanistan, I am gently reminded that, even though our system isn’t perfect, I am grateful that it does struggle for continuous improvement.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Do you know TED?

2012-01-05T10:00:00.004-05:00

I’ve been in Karachi over the holidays, and I admit to enjoying the quiet. Many of my colleagues went to the United States during this time, and others used the decreased workload as an opportunity to take a regional vacation. I used the quiet time in the office to do those work things I view as a chore and won’t do, unless I have nothing else on which to focus my attention. So, today, I feel rather proud of myself for starting the new year with a clean slate—no nagging odd jobs to complete.

Not having many people around the compound meant extra quiet time on my “off” hours, too. I admit I have hermit tendencies, so being alone in my apartment with my books, TV and computer is really quite all right for me. Over the years, I’ve perfected the ability to entertain myself when there is nothing else to do.

One of the things I enjoy most is going to the TED website and catching up on all the amazing things that are happening in the world. Do you know TED? “Technology, Entertainment, Design: Ideas Worth Spreading,” is an amazing site of information. Check it out for yourself. I guarantee you will find something that catches your interest. These short 5- to 20-minute videos are perfect for my equally short attention span, and the information is often cutting-edge stuff.

My parents always told me that what you do on New Year’s Day, you do all year long. If there is truth to this, my 2012 will be excellent. I am rested and healthy. I’ve enjoyed Skype visits with my family, watched a good movie, visited with TED and spent the evening with friends. I hope your January 1st was equally as satisfying.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The babies of Karachi beach

2011-12-20T14:21:00.001-05:00

I never expected my tour in Karachi to present me with a once-in-a-lifetime opportunity, but it has. It turns out that the beaches of Karachi are among the top seven hatching grounds in the world for green sea turtles, so when we learned that the Sindh Wildlife Department had offered to provide a turtle experience for the consulate staff, I was eager to sign up. I’ve never seen a sea turtle outside of an aquarium or a movie and, although I grew up on the beaches of south Texas, turtles don’t visit there. I’ve seen lots of land turtles, of course, but this is different.

Late one night, a group of us were driven to a secluded beach outside the city to view turtle egg laying. We were told there were no guarantees. It isn’t like the turtles make an appointment to crawl up on the beach to lay their eggs. While this is the busier season for egg, there are nights when no turtles arrive, or they come later than we are allowed to stay.

After reaching our destination, the rather long, bumpy ride getting there quickly faded in memory when the scientist running the facility informed us that this was a special night. Not only was there a mama turtle digging her laying hole right then, but a group of turtle eggs had just hatched and we would be able to see them before they were released to the sea. It was like winning the turtle jackpot, since the hatchlings have to be in the water in less than two hours after hatching.

This facility, part of the Pakistan wildlife conservation effort, has been in operation for 30 years. It was easy to discern that it is run on a shoestring budget, but the commitment of the scientists and facility employees was impressive. We were led into a shell of a building about 50 feet from the water’s edge. It was pitch black, except for the flashlights our hosts carried. Inside, we were shown a PowerPoint presentation about the two types of turtles that come to this beach to lay eggs, and given information about various endangered turtle species around the world, the predators they face—humans are the most dangerous— and the destruction of their habitats by pollution and the spread of dwellings onto their spawning grounds.

To prevent the extinction of these majestic creatures, their newly laid eggs are dug up and transplanted to nurseries where they are protected until they hatch, approximately two months later, from the elements and from poachers—both two- and four-legged. Once the eggs are hatched, their caretakers deliver them to the water’s edge and hope for the best. It is estimated that less than .01 percent of the hatchlings will actually grow to adulthood and complete their natural lifespan of around 100 years.

My group was first introduced to the new hatchlings. Why are all babies cute? That must be some type of universal law, and the hatchlings were no exception. Their tiny flippers were in full motion swimming vigorously in the air and, after we each had the incredible opportunity to hold one and get a very close look, into the sea they went.

Next, we were escorted down to the beach and to the laboring turtle. The only light allowed was one dim flashlight aimed at her growing pile of eggs deposited in the 3-foot deep hole she had dug. While she largely ignored us, we were told that lights would confuse her and she would stop laying and return to the sea, and that would not be good. We stood watching this incredible act of nature until the turtle indicated it was over and began to use her hind flippers to cover the hole.

Four men then gently picked her up and moved her away from the hole so the eggs could be retrieved, but she didn’t seem to notice the ride. Her back flippers just kept scooping sand. She would do that for the next couple of hours until some instinct told her it was enough, and she would then return to the sea. The eggs were carefully removed, measured, weighed and taken to the nursery for reburying, and this amazing experience was over.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

No, a fish pedicure was NOT on my bucket list!

2011-12-05T17:49:00.006-05:00

One goal I will never attain is to work in East Asia. The opportunity has just never arisen for me and, since this is my last post, I’ve accepted that it’s not going to happen. So when a friend of mine invited me to visit her in Kuala Lumpur, Malaysia and I discovered there are direct flights from Karachi to Kuala Lumpur, it was too good an offer to let pass.

This past month, in the same week we celebrated the U.S. holiday of Veteran’s Day, several local holidays were also strung together. As a result, only one day of actual office time was required of me that week and thus seemed the perfect time to hop a flight.

When I arrived, I was surprised to find my friend was hospitalized, with discharge still a couple of days away. It gave me the opportunity to learn a bit about the local medical system and how care is delivered.

My friend had an attending physician and several consultants who visited her daily for examination and updates on her condition. The hospital itself might have been in any downtown U.S. city, complete with a Starbucks on the first floor. The only thing that set the Malaysian nursing staff apart from their American counterparts was that they have retained the custom of the nurse’s cap, a tradition I was very happy to see dropped in the United States. The only thing I noticed that was very different, at least from the hospitals I’m familiar with, is that each time a patient leaves the room, the door is locked until his or her return. Otherwise, everything was very familiar and that was a comfort to my friend. It isn’t easy to be in a hospital in a foreign country with no family present. Familiar looking surroundings are a real bonus.

After a couple of days, I brought my friend back to her apartment, and we basically became couch potatoes for the rest of my visit. I did take one day to use the hop-on, hop-off bus that ran through the city so I could get a taste of this peninsular nation. Wherever I travel, I try to use these buses when available, as they usually provide a great overview and an efficient way to cover the highlights of the city I’m visiting.

At the central market, I hopped off the bus to participate in something that has peaked my curiosity since the first read of it several years ago. I had a fish pedicure! I dangled my feet in a large vat of water while small, sardine-size fish hungrily attacked dead skin everywhere they found it.

The first two minutes were almost unbearable, not because it was uncomfortable, but because of the freakish sort of tickle. But after the initial shock, the sensation diminished and it was quite pleasant. A half-hour later I was done, evidenced by the few fish still paying attention to me.

Each time another person came to the tub, however, it was like a feeding frenzy. (Maybe we have different flavors.) The fish would swarm to the new feet and do their thing, then eventually lose interest and disperse.

I can declare two things. This was by far not the best pedicure I’ve ever enjoyed, but it sure was the most unusual, and I have a photo to document it.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Babu, a different breed of diplomat

2011-11-14T16:10:00.001-05:00

I am typically amused when I see diplomats represented in the movies. The character, who is good looking, tanned, expensively dressed and dealing with international intrigue, is frequently shown attending a cocktail party or driving a convertible down a curved mountain road, hair blowing in the breeze. These people don’t seem to have actual jobs, families or concerns outside of their glamorous lives. In short, they are depicted as living a life of travel and comfort and, if there is an element of danger, it is portrayed as adventure.

That is diplomacy in the movies, of course. In reality, the scene is very different. In real life, diplomats are fairly ordinary people who slog through fairly ordinary jobs, many times under different, if not difficult, circumstances. We do choose this life, of course, and it suits a particular type of person, I think. Not many people would be fond of picking up their lives and relocating every two to three years. But the constant for most U.S. Foreign Service officers is their family. The family is the force that keeps us centered, normal and able to do our chosen jobs well.

Family is defined in many different ways in the Foreign Service. Many officers have the traditional spouse and, perhaps, children. For other officers, family is a parent or partner who travels with them and, for many of my colleagues, family is a pet. For me, an absolute necessity is a reliable Internet connection. I require video chats with my children and grandchildren to keep me on solid ground, and I would not accept a post where that is unavailable. The point is, we U.S. diplomats need a sense of home and a grounding of reality, no matter where in the world we might live and work.

We have a few posts—Karachi is one—where the ability to have that sense of home is compromised. Karachi is an “unaccompanied” post, meaning spouses or other members of one’s household are not allowed. To make matters even harsher, pets are not permitted here, either. People assigned to these posts are literally removed from most of what is normal in their lives, and it is a particularly difficult stress to manage. As the medical officer, I frequently see the physical reactions this stress causes.

Respite from that stress is provided, however, in one small but very significant way. One of our officers, through unexpected circumstances, arrived in Karachi with her Chihuahua, Babu. There was nothing to do but let him stay, and he has become the mascot of the compound. Babu is a very friendly fellow, adored by all who meet him. He considers every person his friend, and he is quite willing to accept petting and scratching from all who wish to give it. When Babu is out for a walk, people come from all directions to speak to him and give him some love, which he happily returns with nuzzles and wagging tail. It is impossible not to smile and get a warm fuzzy feeling when Babu is present.

Babu

As a diplomat in residence, Babu really is living the good life. He has plenty to entertain him, lots of admirers and, when his mistress goes for a swim at the compound pool, Babu hangs out on a boogie board catching some sun. If he could learn to drive a convertible, I’m sure Hollywood would have him star in a movie.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Er, Doctor, would you wash your hands, please?

2011-10-28T16:38:00.010-04:00

Global Handwashing Day was October 15, so, in keeping with the Southeast Asian time scheme, we celebrated it on October 21. Things are always a bit slower in this part of the world. Anyway, my health unit was asked to “participate” in a program sponsored by the consulate and our public affairs office. We were told there would be presentations to an audience of nursing students selected from various hospitals around the city.

The time was set for Friday morning and, since that is the time I routinely supervise vegetable sanitizing—not to mention that I don’t speak the local language—Mehroon, my Urdu-speaking colleague, volunteered to represent our office. We only heard about this event a week before it was scheduled and, three days before it was to happen, we were told the presentation—now singular—was us!

Mehroon and our computer-whiz administrative assistant put together an amazing PowerPoint presentation, complete with videos from Centers for Disease Control, to drive home the point that hands spread germs and germs make people ill. The presentation especially focused on hand washing prior to touching patients in the hospital and how microbes can be spread from one patient to the next by staff members who are not particular about hygiene.

Mehroon teaches proper handwashing technique.

Mehroon strongly encouraged the nursing students to remind family members, hospital staff and—gasp!— physicians to remember to wash hands or use hand sanitizer between patients. Evidently, there was a bit of worried discussion about the latter suggestion. Sure, it is reasonable to instruct families and other staff members might be amenable, but the physician? The students were absolutely sure that offering this suggestion to the physician would not be tolerated.

I’ve been in medicine for a long time, and I remember those days—not that they are completely gone—when physicians were at the top of the heap, and no one dared to suggest or question. Most of the docs I know now think that type of isolated existence is lonely and not very safe, and they welcome rapport with the health care team. It is a worthy concept, and I hope some of these nursing students take the dare and mention what they learned for Global Handwashing Day, maybe even to a physician.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Go fly, kite!

2011-10-14T14:08:00.003-04:00

I grew up amongst seagulls; a noisy, messy bunch, but not at all threatening, even when they came in large groups searching for treats. Once I left Texas, I was largely removed from groups of flying critters, except for occasional swooping pigeons, but living overseas has changed all that.

In Africa, swarms of fruit bats filled the sky at dusk, darting in and out of the trees and, sometimes, flying so close to me as I walked I could hear the “swoosh” of their giant wings.

In Islamabad, we had crows. To discourage them from roosting, we hung fake owls in the trees—owls are evidently a natural enemy of crows—along with shiny strips of twirling metal. It didn’t work. The crows would foul the ground below the trees and make a terrible racket at both dawn and dusk. The worst was when they became infected with H1N5 (avian influenza). Dead birds, scattered by the dozens around the grounds of the embassy, caused a minor panic.

Karachi has kites, black kites to be exact. These large, rather intimidating birds soar and swoop in groups all day long, not unlike vultures waiting for carrion to appear.

Black kite

My apartment has a very nice balcony with some lovely teak furniture. It might be a nice place to sit and read a book. I say might because I will never know. The kites like to land on the balcony rail and sit on the arm of the teak chair, and they are aggressive. I got a good look at a kite perched outside my window, and that thick, curved beak and the menacing talons were enough for me. My balcony belongs to the kites. I will never venture there.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

It's just my southern hospitality!

2011-10-03T11:32:00.011-04:00

If you have had even a passing interest in world news, you know that the United States and Pakistan are in an ongoing spat, and a number of issues this past year have caused dissatisfaction on both sides. This past week, the most recent political upheaval inspired a peaceful protest march to the U.S. consulate in Karachi. The consulate was informed there would be a protest of possibly a few hundred people, but that the protesters would not be allowed to actually reach the compound.

I should explain that the consulate in Karachi is in a self-contained compound surrounded by a high wall and is under tight security. Our office building, where all the work takes place, is about 150 yards from the residential building, where we all live. Between the two is a totally open area of sidewalks and palm trees but, since the wall is so high, it is impossible to look into the compound from the street. Or so I thought.

As I was leaving the consulate, one of the security officers cautioned me to go straight to the residence as the protesters had been allowed, in spite of what we had been told, to move up the street outside the compound and they were gathering right then. I moved on through the entrance and began my walk to the residence. I was about a third of the way when I heard the music and shouting. It wasn’t threatening shouting, and it wasn’t cheering. It was just lots of noise coming from the area outside the wall and, when I looked in that direction, I was absolutely shocked to see people—lots and lots of people—standing above the level of the wall.

So there I am in the middle of the otherwise deserted area between the two buildings, looking at these folks who are looking right back at me. Many of them were waving their arms, and it seemed to me they were waving at me. I didn’t feel threatened at all, but it certainly ran through my mind that this was a situation I had not anticipated and with which I was not completely comfortable. While I saw no indication of hostility, I also know it only takes one person with ill intent to turn a situation violent.

I quickly considered my options. I didn’t want to turn around, as that would put my back to the crowd. Instead, I did what every good southern woman from the United States would do in that situation. I smiled my biggest smile, waved at the crowd and kept moving forward to the residence, reaching it without incident.

Later, I learned that the crowd came with buses and people had climbed on top of the buses to see into the compound, thus giving me the impression they were standing above the wall. And the initial estimate of several hundred turned out to be several thousand, though that was not obvious from the numbers I saw levitating above the wall.

I have caught a lot of ribbing from my colleagues for waving at the protesters, and more than a few have suggested that the “waving” I perceived was, perhaps, less than friendly. I choose to remember my version of the event. It is the southern way.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Food for thought

2011-09-22T15:05:00.002-04:00

One of the things I love most about working in the U.S. Foreign Service is the variety of health issues I have to deal with. Each new post brings a fresh challenge, a new opportunity to learn and, frankly, a different way to make changes that have a lasting influence. Most of us choose a nursing career to have a positive impact on the lives of others, and my job offers very creative ways to fill that need.

I am the first Foreign Service medical officer to be assigned to Karachi. There is a wonderful RN who has been here for years and has done an amazing job of getting the needed accomplished but, as a sole practitioner, she was limited in the projects she could attack. I am now in the office, as well as an administrative assistant, and we are on the prowl to stamp out common health problems.

One of the major issues at this post has been food-borne illness. Kitchen checks and food-handler classes failed to make a significant dent in the number of people with GI complaints. For the past six weeks, a small part of my day—each day—is looking at food safety issues. This is not new. Almost every Foreign Service medical officer has responsibility for food safety at his or her post, but the depth of responsibility differs vastly, depending on the post’s location and size.

I have five commercial-style kitchens to evaluate and approximately 30 food workers spread among them. Despite my previous experience, which I considered advanced, I’ve turned over a whole new leaf in food safety, pun intended! There is a mantra that Foreign Service people recite: Wash it, peel it, cook it or don’t eat it. And that is good advice, but not the whole picture. I bet most people have never thought of the many opportunities food has to make a person ill.

I have to consider where the food comes from and how it has been handled prior to purchase. If the meat is fresh, there is possible contamination, such as salmonella for chicken and eggs, E. coli for beef and vegetables or, more commonly, vegetables contaminated with the protozoa Giardia.

Once the food is purchased, our kitchens are expected to clean it with the intent to rid the food of harmful organisms. In this part of the world, this is usually done with salted water, but our standards do not accept that as sufficient, so cultural sensitivity is required when asking our cooks to do something different than they do in their own homes.

The food is now properly cleaned. Are we done? Not on your life, pun intended. Now it has to be stored at the proper temperature. That means assuring freezers register no more than 4 degrees Fahrenheit and refrigerators no more than 38 F. But what about a place where the electricity is unstable and power fluctuates between the grid and a generator, sometimes multiple times a day. This is murder to a motor and the fridge that was functioning properly yesterday may be at 60 degrees today. We require cooks to record the temperature of these units daily, but think of how difficult it is to understand the concept of proper cold storage when you don’t have cold storage in your home? I recently found a freezer where the worker had dutifully recorded the temperature of 27 degrees for three days running but didn’t understand the significance of this “danger zone” temperature and hadn’t notified Maintenance of the problem.

OK, so we have properly functioning storage and now the food is prepared into meals. Am I twiddling my thumbs at this point? No, I’m out there with my handy-dandy, infrared thermometer, truly one of the coolest inventions on earth, checking to be sure the salads are being served cold and the hot foods are hot. So now, sigh, my job is finally done!

Hmm, what about the flies? What about the hygiene of the dinnerware, glassware, tableware? What about the hands of the servers? Are any of the staff workers ill with a communicable disease? Is the lassi (a lovely local drink) really made with pasteurized yogurt, or did some raw tuberculosis-tainted yogurt sneak in?

I’m sure I have colleagues who would say they did not go into medicine to focus on food safety issues, and I never imagined this as part of my forte, either. We really take this for granted in the Western world. But I don’t live and work in the Western world, and I have to tell you, I am struttin’ my stuff right now. I haven’t had a bad belly come through my health unit door in about 10 days, and my staff and I are kings of the consulate! No pun intended!

But, dengue fever is on the rise, up 15 percent over last week in the city. That will be another story.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Almost like coming home

2011-09-12T14:27:00.002-04:00

I’m here—back in Pakistan—and it is almost as if I never left. There is so much that is familiar about Karachi: food, crowded streets, tuk-tuks, sounds and smells. The past two years in Prague have started fading away, which is sort of sad, as I enjoyed them so much. But I find I am glad to be back; almost like coming home.

I joined the U.S. Foreign Service with the intent to live and work in places I would never visit as a tourist. My goal was to really get to know people and cultures that were different from the life I had always known, and I have been true to that goal. Even living in Prague, in the Czech Republic, which is in many ways similar to the United States, was very different from my pre-Foreign Service life in the American South. Americans and Europeans are pretty savvy about health and wellness issues. At least, they know a good deal about it, even if they don’t follow good health practices. But Southeast Asians are often not well educated about safety and health issues. Many of the home remedies and first aid applied in this region are traditions passed down from one generation to another, and they are not always effective traditions.

For instance, during my previous tour in Pakistan, one of our gardeners sustained a deep gash on his lower leg from a chainsaw accident. In an effort to stop the bleeding, his co-worker doused him with the gasoline mixed with oil that was used to power the chainsaw. We rushed him to the hospital for definitive care and, after the surgery, the surgeon called me to ask what that oily substance was in the wound that required such pains to debride?

As a result of that incident, a program was created to train some of the local employees to teach all of the other local employees, in their language and on a regular basis, about basic first aid. I’m pleased to say that the program is still ongoing in Karachi and is taken quite seriously by the workers. I am hearing stories of how family members and neighbors have been helped through the program.

Sharing information about health and safety practices to poorly served populations around the world is one of the most important things we can do. It follows the “teach a man to fish” philosophy, and small successes are really great triumphs.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

I’m ba-a-ck ... I think

2011-08-17T10:24:00.001-04:00

I hurt all over! No, it isn’t flu, it is “crash and bang!” There are several postings around the world where U.S. Foreign Service personnel are at an increased risk for things, such as mob mentality, kidnapping or targeted terrorism. If we are assigned to such a post, we are tasked to complete a defensive driving course, the idea being that we out-drive the threat and get to safety. My Pakistan assignment requires me to take this course.

We are taken to a racetrack in the boonies to drive worn-out police cars way too fast. I probably wouldn’t complain if it was just speeding, though I am truly a granny driver. No, we have to drive through water so we can skid and try to stop the inevitable donut-spin that comes if you don’t brake absolutely correctly! We must ram an almost done-for vehicle into the front, then the back, of a totally done-for vehicle, to move the thing out of our path.

Then there is the exercise of driving forward at about 40 mph, stopping as quickly as possible, backing up using mirrors and doing a rapid Y-turn so you are going back the way you came. I don’t get motion sickness easily, and I’m not a whiney person, but I am sure whining over this experience.

The requirement is 100 percent participation, so when I place my hand over my stomach and turn my green face toward the instructor, he simply asks, “Do you need to hurl before we continue?” Considering that my abdominal contents are unsure which way to face forward and that’s it’s 100 degrees,, yes, that is exactly what I must do.

My three days of vehicular terror are over. I had such a nice weekend planned, but now it consists of moving from the tub of hot water, where my very sore muscles are trying to un-spasm, to the couch, where I lay quietly, trying to convince my stomach that life is back to normal. Before this experience, people would tell me “crash and bang” was great fun. Just goes to prove, once again, one size does not fit all!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Karachi, here I come

2011-06-15T09:34:00.005-04:00

Four young, beefy guys just left my apartment and, while I know this must sound intriguing, there is a simple explanation: They are movers. Once again, it is time to pull up stakes and move somewhere else in the world. For my next adventure, I’m going to Karachi, the largest city in Pakistan and the main seaport on the Arabian Sea.

If you have followed this blog, you know I previously spent three years in Islamabad, the capital of Pakistan, located 710 miles north of Karachi. There is a complex reason why I chose Karachi as my final post, but one important element is that I honestly like the people.

This usually comes as a shock to people who have never been there, especially Americans who interpret the troubled relationship between the United States and Pakistan as anti-Americanism of the Pakistani populace. I’m not a political person, despite the fact I am employed as a diplomat, but I can say with certainty that the problem between the average American and the average Pakistani is that they each know the same thing about the other, which is to say almost nothing. Both groups have formed opinions based on rumors and sensationalized news stories, and the reality is far different from the perception.

Please note I did say average Pakistani, because there is no denying there are radical factions at work in Pakistan, as in many countries. Fortunately, I need only interact with people who are just trying to get through another day, as am I, with no ill will toward anyone else. I can honestly say that, in my previous three years in Pakistan, I never met a single person who was anything less than welcoming and friendly to me. I hope I never do.

This moving ritual that we Foreign Service employees participate in always brings up the question of “Which post did you like best?” I can never really answer that question, because I’ve found something to like about all of them and comparison between embassies is very much an apples-and-oranges dilemma. But I can say what I liked best about each post:

Accra, Ghana was my first taste of Africa, as well as my introduction to Foreign Service life. It was an excellent beginning, as Accra has a vibrant culture, the provincial travel possibilities were marvelous and I developed friendships that are still important to me.

Conakry, Guinea is the place people mean when they say “the end of the earth!” In spite of the poverty and lack of opportunity for the citizens, I met some of the kindest people I have ever known in Conakry.

Kabul, Afghanistan is the zenith of my Foreign Service experiences. I’ve explained why in previous blogs. To summarize, it is where I experienced great professional purpose and enormous pride in American assistance to others in need.

A two-year “roving” tour that took me to nine different countries over four continents during which I learned a person can live for an extended period of time with only two suitcases of material goods. I also had one of the most amazing experiences of my life in Rwanda, as I climbed through a bamboo forest to watch mountain gorillas in their habitat.

I appreciate Islamabad, Pakistan for the art, food and generous hospitality of the people. I also have to say the work-team environment was as close to perfect as I will ever have.

Prague, Czech Republic is a gift of beauty at the foot of Cinderella’s castle. It is almost a fantasy to walk down these cobblestone streets and enjoy the spectacular architecture. I’ve been on a two-year vacation, but shhhh, don’t tell my bosses, okay?

I will depart Prague this week, and I have several weeks of vacation and a couple of weeks of training before I report to Karachi. Please be patient while I take a break. I will be back.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Eye witness

2011-05-31T11:47:00.006-04:00

I have recently been on the receiving side of patient care. My cataract surgery was a complete success, and I am surprised—no, amazed—how much brighter my world looks now.

I reported to the eye clinic at a local hospital one morning last week. My ophthalmologist, who looks like she belongs in high school rather than a hospital, did a quick eye exam to determine if I was an acceptable surgery risk and then sent me off to the outpatient surgery section. There, I was met by two lovely young nurses, Petra and Jane, who explained that they each spoke a little English and that, together, would get me ready.

They were so helpful and pleasant I was sorry I caused them extra effort with my language requirements. I changed into scrubs, had my name plastered on the front of my shirt on a piece of tape so they wouldn’t forget who I was, and was led into the surgery-suite waiting area. There, one of them appeared every 10 minutes to put different medicated drops in my eye.

I’ve traveled a good bit of the world and one thing I’ve always marveled at is, no matter how friendly a society is or is not toward Americans, everyone—and I do mean everyone—likes American music. So there I am sitting in this room, surrounded by several Czechs waiting for eye surgery, and I’m listening to American country music.

After I completed several rounds of eye drops, I was transferred to the operating room, positioned for surgery and draped out. I have a bit of claustrophobia. It isn’t one of those run-screaming-out-of-the-room things but rather a nervous tension. I knew I was going to have a drape over my face, and I was a little concerned about this, but I shouldn’t have been. I only had a moment to worry about being covered up before the instruments started coming toward my eye. For the rest of the short procedure, I gave no thought to being enclosed. I was too focused on the needles and the sucker thing I was watching attack my eyeball.

I readily admit there was no pain! And, to prepare me, my ophthalmologist explained everything that was happening. The nurses were great, comforting and reassuring me, and one even held my hand. It was not a bad experience; it was a strange experience! I’ve never had eye surgery before, but I have had surgery in the United States and I can honestly say that the surgeon, staff and facility met any expectation I would have had at home. I would not hesitate to recommend them.

I’m now in the recovery phase, which has been surprisingly easy. I had no post-operative pain at all, only a patch on my eye for 24 hours. The patch came off and—voilà—bright, clear vision! I’m channeling Bob Marley lately as I sing, “I can see clearly now.”

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Getting my eyes Czeched

2011-05-23T12:13:00.007-04:00

For some months now, I’ve noticed my vision becoming less sharp. I finally decided to see if a bit of LASIK surgery might be a possible solution and scheduled an appointment with Prague’s premier LASIK center at a local hospital.

The appointment started off in the opposite direction I had hoped for when I was told the ophthalmologist with whom I had the appointment was not in and that his associate would see me. After a few minutes wait, a lovely young woman came in to speak with me and asked questions about my medical and visual history. I thought she was the nurse. She was the associate.

A few minutes later, I was ushered into the examination room where the young doctor did an eye exam. She quickly informed me that LASIK would not help me, and I needed to meet with her colleague. She thereupon personally walked me up to the next floor, where I met an equally young and lovely lens implantation specialist. In spite of the fact that I’m a medical provider, I can be a bit slow on the uptake. I was still of the mindset that we were talking about improving my vision which, in my mind, was a simple matter of loss of visual acuity due to aging.

The second ophthalmologist told me all about this wonderful multifocal lens that would improve my ability to read, without the Dollar Store readers I’ve used for years. “Yea!” I thought. I would love to ditch the readers. She then took me into her examination room and started with the same basic eye exam I had one floor below.

At some point, I threw out the question, “I guess LASIK would not work for me?”

“No” she said, “it will not correct the cataract.”

Cataract! What? Where did that come from? I immediately said, “I’m too young for a cataract!”

“Obviously not,” came her reply.

I was still trying to absorb this information when the young lady, now peering into my dilated right pupil, said “Oh!”

I do medical examinations and, as hard as I try, sometimes that “Oh!” just slips out. It usually isn’t good.

Now, the doctor is speaking Czech to her assistant. Next, the assistant is on the phone, and then we are moving hurriedly to another office. I asked what the “Oh!” was about. The doc tells me she thinks she sees a hole in my retina, and I’ll need retinal laser surgery.

“When?”

“Now!”

My goodness, the Czechs move quickly! This time, the retinal specialist is a rather ordinary-looking man who, though quite pleasant and reassuring, does mean things to my eyeballs as he looks for holes. After about 10 minutes of misery, he announces that my retinas are not perfect, but they are good enough and—drum roll—NO HOLES! “No laser today,” he says.

By now, I am so relieved I don’t have a hole in my retina I don’t even care that I have a cataract. Back we go to the second office, where the informed consent for cataract surgery and several bits of paperwork for pre-surgery testing are prepared. Alas, I am told that, because my retina is not perfect, I can only have the monofocal lens and will still have to rely on readers. They scheduled me for cataract surgery in three weeks, and I left the office with the typed medical report in my hand, just two hours after I arrived in the ophthalmology department.

Beat that!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Spice girl

2011-05-05T11:24:00.005-04:00

I have just returned from two weeks in the United States to welcome my newest—and eighth—grandson. He is a great little guy, peaceful and even-tempered, and, considering that his next older brother is a real handful, I hope he stays that way, in deference to his mom.

Lately, I have been corresponding with a couple of people who are interested in what my job entails. I’ve been asked to recount my "typical" day, and I’ve given a great deal of thought about what a typical day is for me. However, there is a big picture to my job, and it can’t be answered as easily as one might think.

First of all, typical, in the sense of the types of patients I see in the clinic, depends a great deal on where that clinic is located. State Department embassy medical units are located worldwide, so health risks differ from location to location. While there might be an allergy or influenza season in any location, acid bug, malaria, dengue or Japanese encephalitis risk only occurs in some locations. However, most patients are seen for basic primary-care causes, just as in a U.S. clinic, but the daily patient load is less, as our responsibilities are broader than patient care.

Patient safety and health issues also vary by location. For example, the risk of gastroenteritis in Southeast Asia, and the community education required to prevent it, far surpasses the risk in Western Europe. When I was in Southeast Asia, evaluation for and treatment of food-borne disease was a daily event. In Prague, I have never discussed food-borne disease with a patient; it isn’t required.

My typical day in some posts might include a visit to the embassy cafeteria kitchen to observe and reinforce proper food storage and preparation practices. Our North American standards of food service are a mystery to food workers in much of the world, and it falls to the post medical unit to enforce the standards we expect.

A frequent task is evaluation of medical resources to use as consultants for the embassy community. In the majority of these cases, a continuing relationship and rapport must be nourished by frequent contact, visits with the consultant and sponsorship of social events. Medical associations in the United States are largely pure business while, in a great deal of the rest of the world, successful business requires social interaction like "tea and biscuits" to keep the relationship active.

In the beginning, I found this very difficult. I was used to calling a consultant and immediately launching into information about a patient. I've learned to be more sensitive to the cultural needs of the practitioners I call, which usually requires discussion of niceties first—"How are you? How is the family? How was your recent trip to X?"—before I launch into the medical conversation.

A typical day for me includes meetings—management, country team, emergency action committee and other committees of various sorts. I may be the medical officer, but my official duties cover many things that aren't medical at all. I admit I’m not a fan of meetings, but they are a necessary part of the job.

If variety is truly the spice of life, I have a very spicy life. Just the way I like it.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Not the place for cost cutting

2011-04-15T12:57:00.010-04:00

If you have been watching the health news, you may have seen statistics released by the World Health Organization for stillbirths across the globe. Congratulations to Finland, which has the lowest rate at one per 1,000 births. Pakistan, a county I have lived in, has the second highest rate at 47 stillbirths per 1,000 births.

In 2008, I was invited to join a group of USAID (United States Agency for International Development) staff traveling to Kashmir to oversee a women’s health project. I jumped at the chance, even though it required traveling in a helicopter (I hate them), because we are not usually allowed to go to Kashmir. As disputed territory between Pakistan and India, it is not considered “secure.” So, the opportunity to see part of this district was too good to pass up.

The purpose of the project is to strengthen essential obstetric care in the district of Bagh, where 64 percent of deliveries occur without skilled attendants. There was no obstetric physician in all of Bagh, a district of 2 million people, until USAID paid to locate one—yes, that is ONE—there. To provide pre- and postnatal care to the mothers of the Bagh district, local nurses are trained to be professional midwives. They are located in rural areas where the preponderance of unattended births occur. One in every 74 deliveries is fatal for a mother in Pakistan versus 1 in 4,800 in the United States, so the program has tremendous potential. This is a two-year education program and very professional. I visited two rural health clinics, one where training was in process that day on how to prevent and treat post-delivery hemorrhage.

These clinics, housed in prefab buildings, have no running water. Hand washing stations were created using a system comprised of metal jugs, and instrument sterilization is done by boiling or by soaking the instruments in disinfectant. In addition to providing a place to deliver babies, these clinics, which were amazingly clean and tidy, provide health care to the general population.

Operating at low cost and with high return, such programs are fiscally efficient. WHO’s recent release of stillbirth statistics emphasizes the need for continued education in maternal-child health care in the poorest parts of the world. I do hope that cost cutting proposed by First World countries to tackle their budget problems does not include decreasing these effective, fiscally efficient programs. I’ve seen first hand the benefit they provide.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Advanced practice nursing is an option?

2011-03-28T20:33:00.009-04:00

In the Czech educational system, a public school student can choose to concentrate studies along a technical or professional path beginning at age 14, or what we in the United States consider high school. For instance, a student accepted to a health-career school would have a curriculum that follows a scientific and biological course, with clinical experiences in health care. After four years, the student can decide to pursue nursing, medical or allied health programs at the university level, go a completely different direction with university studies, or simply enter the workforce.

This past week, I was invited to speak at a health-career school in a neighboring community on the subject of health care in the United States. My audience was comprised of third- and fourth-year students, ages 17 to 18. The students submitted questions in advance, which gave me an idea of the type of information they were interested in.

They wanted to know a bit about me; where I went to school, where I had worked and in what section of the hospital. In fact, the assumption was that all my experience was in a hospital setting. In the Czech Republic, there are few nursing jobs outside hospitals, so, when I mentioned the many different roles nurses fill in the U.S. system, the students were quite surprised. I also identified and explained available levels of nursing education, including advanced practice possibilities, and this came as a downright shock to the students. They had never heard of an expanded nursing role, even though it exists in Europe with practitioners in the United Kingdom, the Netherlands, Sweden and Switzerland.

I had been warned that Czech students are not interactive, and I should not expect them to engage in dialog. However, the discussion about opportunities in nursing and advanced practice spurred many questions and interaction that surprised the class teacher. She admitted, once the discussion had ended, that she was amazed at the amount of interest the students had expressed and how engaged they were with questions. I hope I planted a seed of curiosity in my audience that may lead them to explore the many ways nurses can contribute to the health of their nation. The possibilities are exciting.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The sign of the comet

2011-03-17T12:16:00.010-04:00

I’ve often said it is the variety in my U.S. Foreign Service job that keeps me enthralled, especially since I seem to have a rather short attention span. In my career, no two posts have even been similar, much less the same. The Czech Republic has been a huge change from my previous developing-country assignments and, with a more typical list of medical complaints, I admit I was getting a bit soft.

Then, the mites arrived! One of our young officers came to me with a profusion of itchy, whelped, pink bites on her posterior thighs. Honestly, I didn’t know what the cause could be, and since the bites were in a defined location, it didn’t seem like a major issue. That was in the morning. When she returned in the afternoon, the bites were weeping, enlarged and had taken on a purple hue. My comfort level dropped to zero, and we arranged for her to see a dermatologist immediately.

The dermatologist was less concerned, because she knew what the cause was—a severe reaction to mites! Mites? Where did they come from, and why now? It is winter in Prague. Do mites attack in winter? A bit skeptical, I forwarded photos to a dermatology consultant in Washington, D.C. His reply was, “Yep, mites.” The dead giveaway was the “comet sign” coming off one of the lesions. (A comet sign is a red streak leading away from the central area). The two dermatologists disagreed on the source. One believed the mites were related to birds, and the other thought they were connected to woodborers, but both were certain the lesions were caused by a severe reaction to mite bites.

This is where my job gets really interesting. If I was in a usual practice in the United States, I would refer my patient to a dermatologist, who would prescribe treatment, and we would be finished with the issue. Not so in the Foreign Service. The ongoing saga of investigating why there are mites in this officer’s home, determining which chemicals are safe—and OSHA approved—to treat the infestation, photographing and cataloging new bites as they have appeared, discussing with various embassy offices about what’s best to do—all have involved me.

I know more about mites today than I knew three weeks ago and more than I ever thought I would need to know. It is fascinating, really! And to the long list of “jack-of-all-trade” tasks the Foreign Service has required of me, I can now add exterminator!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Six days in Malta

2011-03-03T16:55:00.010-05:00

I have just returned from six days in Malta. It would be a great spot to vacation, but I was there strictly for work. The U.S. Department of State Office of Medical Services, known in governmentese as MED, sent a psychiatrist and me to support Americans being evacuated out of Libya. Before they could be evacuated to Malta, 300 of these evacuees spent two harrowing days aboard a ferry anchored in the port of Tripoli, while they waited for seas calm enough to travel. This group included children, pregnant women and elderly people, all of whom were at higher risk for such travel. They slept on the floor three nights, ate mostly snack food and had no shower facilities.

On the third day, they were finally cleared to travel to Malta and then motored through high seas and rough water. Most were seasick and exhausted when they, at last, arrived. Still, considering that experience and all they went through prior to reporting to the ferry, when tensions in Tripoli were high and the situation was increasingly dangerous, they all looked remarkably good.

I believe the emotional trauma was the worst of the suffering. People left their homes and nearly everything else behind, perhaps never to see them again. They left Libyan friends and colleagues to an uncertain future. They left beloved pets that were not allowed to travel on the ferry. I heard of at least one family that witnessed people being shot in the street. Their children were clearly distressed. The psychological healing will take some time.

Fortunately, there were no serious illnesses or injuries on the vessel. The physical complaints were mostly the effects of exhaustion, seasickness and the benign, nonspecific physical symptoms that follow the decrease of stress hormones after they have been elevated for an extended period of time.

I have worked through crisis situations before, but never an evacuation. I was extremely impressed with its planning and execution. The staff of the American embassy in Malta really did their homework, and I don’t believe they left a single contingency unexplored. In addition, the Maltese government provided relief workers, ambulances and supplies, and the Maltese Red Cross provided personnel and equipment for escort. The whole episode was a finely tuned operation that went off without a hitch, which was very encouraging since the American-chartered vessel was the first to arrive. Other followed that evening and in succeeding days.

PHOTO: U.S. Ambassador to Malta Douglas W. Kmeic welcomes evacuees from Libya as they exit the ferry. Michael Avina, photographer.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

I'm sure I am where I am!

2011-02-17T18:20:00.011-05:00

My hard drive crashed. That’s a major headache for anyone, but add the oddity of being overseas, and it becomes a major migraine.

Fortunately, my computer is still under warranty. I called the company, which is U.S. based but has an offshore service center. The technician, a very nice man, put me and my blue-screen computer through several diagnostic procedures and then announced that my hard drive had, indeed, crashed and would have to be replaced. The company would send me a new one, and within 10 days of its arrival I needed to return the old one. If I didn’t return the defective drive within 10 days, I would receive a bill for the new one.

I explained that, although I have a U.S. address, I don’t live in the United States and, thus, it takes more time for me to receive mail. Besides, the East Coast was in the middle of several storms, which always slows military-diplomatic mail. Even after I explained it several times, the young man had no idea what I was talking about. He kept repeating that I was giving him a U.S. address, so I could not be in Europe. Finally, we both called a truce and ended the conversation.

Three days later, the phone calls began. I have Skype and a U.S. telephone number that rings on my computer in Prague. A company representative—not the technician I spoke with originally—began calling daily to see if I had received the new hard drive. I explained the situation to him and, no, I had not received the disk. He repeated the U.S. address where the package had been delivered and signed for. Yes, I said, but that is a forwarding address, and now the package gets forwarded to me in Europe. He repeated the address again and reminded me that the package had been signed for, but finally agreed he would give it a day or two and check back.

For the next several days, I came home to voice mails from him—at least it was the same guy—reminding me that the package had been signed for at the address I had provided and that I should call the 800 number and leave a message. I did, once again leaving a detailed message about how this mail-forwarding business works.

Again we spoke, and he told me 10 days had passed since my receipt of the drive, because he had confirmation of delivery, and he wanted to know if I was experiencing any trouble. He seemed very suspicious when I told him I didn’t have the drive, because it had not yet arrived. I went back over my story about the mail-forwarding process. He countered that I had called and left a message for him from a U.S. phone number. The unspoken charge? I could not be in Europe because I have a U.S. address and a U.S. phone number that I both answer and call from. Clearly I am in the United States!

Uncle!

PS: I now have the new hard drive and the phone calls have, mercifully, stopped.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Evaluation season

2011-01-28T12:08:00.005-05:00

Job performance evaluations are a normal part of a practitioner’s life. The norm is to be evaluated on our medical work, of course, but this skews a bit when working as a U.S. Foreign Service nurse practitioner. In the Foreign Service, the evaluation season theoretically begins on 15 April and ends a month later, when all evaluations are to be in Washington for processing and review. This year, the already-complex system has been “electronically enhanced” to make the procedure run in a more linear, proficient manner, so, of course, we have to start much earlier. To this end, a human-resources expert came to post to teach us the new system.

Each employee, regardless of her or his actual job, has a rater and a reviewer, selected on the basis of organizational hierarchy. I am the chief of my section—medical—so my rater is the management officer, who is responsible for the embassy’s administrative function. His boss, the deputy chief of mission, who is ultimately responsible for the function of all departments of the embassy, is my reviewer. It should be noted that neither of these great guys has any idea what I do medically.

It is incumbent upon the employee to provide the rater and reviewer with a list of accomplishments that can be highlighted in the evaluation. Most of my nonmedical colleagues can speak in specifics, but I must speak in generalities or risk treading on patient confidentiality. I can offer vague statistics that are medically related or, if something is widely known, such as when the bombing happened in Islamabad, I can offer my rater more specific details. But, usually, my evaluations barely touch on the practice of medicine and I am rated more on administrative issues. There is an exception. Once, during each assignment, a regional medical officer or regional medical manager must submit a supplementary evaluation, which does address medical practice and skill.

On the surface, it might appear that there’s a lack of accountability, but that’s not really true. In Foreign Service lingo, it is called “corridor reputation,” which provides the real scoop on how an employee handles his or her responsibilities, and it has a very real effect on that person’s career. If there are problems, it will be known.

So, back to the training provided by the human-resource specialist. To illustrate how far the Foreign Service has come in performance evaluation, she handed out the single-sheet form used in 1949 for all employees. There were 16 areas of evaluation, each containing only four phrases. The rater was asked to underline the one phrase that was most descriptive and cross out the line regarded as least descriptive. Some of my favorite choices are:

He talks too much.
He lacks breadth of view.
He is careless in his personal habits.
He is too much of an individualist.
He lacks aggressiveness.
He is ingratiating.

And my personal favorite:

He does not wear well as one knows him better!

I’m grateful to say that the evaluation process has progressed light years from this type of appraisal. One other thing: Note that all the phrases begin with he. In 1949, women did not serve in the U.S. Foreign Service. That change might be the greatest advancement of all!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

If you're from Georgia, I'm from Mississippi!

2011-01-14T13:08:00.006-05:00

I haven’t lived in the United States for almost 12 years. I can’t count the number of times a week I am asked, “Where are you from?” or some derivative of that question. I always hesitate before I answer, a habit I dislike, but it is a question that does not have a simple answer, and I’m forced to think before I reply. I have to think about the actual information the asker wants, which can vary quite a bit, depending on circumstances. I realize Americans are, more and more, a mobile society, but the question, “Where do you live?” or “Where are you from?” asked by one American to another has a limited connotation. Not so for the expat.

I spent the first 20 years of my life in Texas, followed by 17 in Tennessee and 10-plus in Mississippi, before I joined the U.S. Foreign Service. Today, I live in the Czech Republic, my legal residence is Tennessee, and I own a house in Mississippi. If I am relatively sure the intent of the question is what part of the United States I call home, and the asker is foreign, I answer “From the South” Most non-Americans have as little understanding of the geography of the United States as Americans do of other countries. I learned early on that most foreigners know New York, Chicago and Los Angeles. Any place else is just a mystery and answering “From the South” seems to satisfy them. In fact, I once spent about 10 minutes on an overseas flight trying to explain to someone that I was going to Mississippi, the state, not Mississippi, the river. He never did get it.

If I am asked the question when I begin work at a new embassy posting, I know they want to know the location of my last post. If I am traveling away from my post and someone asks the question, I always answer with the city of my current residence. About 50 percent of the time, that solves the issue. Sometimes I can have great fun with this, like the time I was in Thailand and answered the question with Pakistan. The young lady behind the counter repeated it twice with a look of amazement on her face but, since the address I had put on the registration form was indeed a Pakistan address, she didn’t argue.

If I meet people from Texas, I always tell them I am, too. I still think of myself as a Texan, even though I have spent two-thirds of my life outside of Texas. I cannot remember ever meeting someone from Mississippi overseas, but if I am introduced to a person from Alabama, Georgia or another southern state, I will counter that I am from Mississippi. And, if some stranger is pushing me about my nationality, and I am uncomfortable with giving the information, I say I am from Nova Scotia. No one knows where it is, how they talk or anything about it—shuts them right up!

Is it any wonder I’m confused?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

A Red Square New Year's

2011-01-03T18:49:00.012-05:00

A new year is upon us. Years seem to turn over much faster now than when I was a child. How I spend my New Year’s Eve directly reflects my stage in life, as I suspect it does for most people.

When I was a young adult, it was all about the big party, dressing up and celebrating with a large, sometimes raucous, crowd. As a young mother, my New Years’ Eves were spent in the company of couple-friends, eating and playing the latest parlor-game sensation. The TV was on in the background, just to make sure we didn’t miss the stroke of midnight. When that magic moment arrived, we quickly passed hugs and “Happy New Year” greetings, and then it was back to the game. As my children entered high school, New Year’s suddenly became about them—what they were doing, who they were with, and their safety—while I watched celebratory events around the world on TV and waited for them to return home.

For the past 15 years or so, New Year’s Eve usually concludes, for me, somewhere around 10 p.m. My mother used to say, “Whatever you do on January 1st, you will do all year long!” I use that as an excuse to beg off attending any late parties on New Year’s Eve, because I need to be well and rested on January 1, so I can enjoy the same throughout the year (wink).

An exception was December 31 of 2005. I was in Moscow and it was cold, with lots of snow on the ground. Two medical-unit colleagues and I decided we would walk down to Red Square to people-watch. The Kremlin was holding a huge outdoor party in the Square but it was by invitation only, and we were not invited. We arrived at the Okhotny Ryad shopping center, which is a large underground mall just outside the entrance gates to Red Square. The street crowd was massive—many thousands, just milling around, drinking and singing. At the ground-level entrance to the mall, a park and recreation area, soldiers stood in a semi-circle, shoulder to shoulder. One of us decided we should try to get in, so we made our way to the front and flashed our diplomatic badges. Voilà! The guard let us pass.

We were feeling pretty cocky until we realized that, behind the barrier of guards, was another barrier in front of the gate to Red Square. We boldly marched forward and got in the line, but when we made it to the front, our diplomatic badges didn’t pass muster and we were denied access. Darn!

We found a vantage point to watch the activity but, as we were still outside the walls of Red Square, we had no inkling of what was happening on the Square. Then we noticed an opening in the wall, off to the side from the main entrance. A few people, walking on a path that led to the opening, disappeared into the Square. There appeared to be no guards at all. Well, you just know we had to give it a try and, once we made our way to that path and through the portal in the wall, there we were inside Red Square on New Year’s Eve!

The rest of the evening was truly magical. President Putin addressed the crowd on a big screen set up to the side of a stage, where entertainers sang and danced. Fireworks burst over Saint Basil’s Cathedral, probably loud enough to disturb poor old Lenin, who was laid out in his glass box across the way. I have no idea how the invited guests were chosen, but the variety of languages spoken was like a mini Tower of Babel. People sang and danced and generally had a great time, my friends and I among them, considering our selves very fortunate to be enjoying the party rather than experiencing the disgrace of having been caught gate-crashing!

Happy New Year!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Turkey, ham or carp?

2010-12-22T12:55:00.003-05:00

When I was growing up in Texas, our family tradition was to have turkey for Thanksgiving and ham for Christmas. That might have been related to my mother’s Ohio upbringing, since most of my friends had turkey for both holidays, except for my friend Kathy.

Kathy’s grandmother was Mexican, and their family's Christmas tradition was tamales. The grandmother, who could never say my name and always called me Beulah, would prepare a hog’s head and keep it in a big tub in the pantry. She would spend hours in the kitchen making the masa to go on the cornhusks, and then chop off meat from the hog’s head to fill the tamales. I always looked forward to Christmas visits to Kathy’s house, and tamales are still one of my favorite foods.

My mother was, at best, an adequate cook, and she passed on to me her lack of interest in spending time in the kitchen. So our Christmas ham was usually a canned ham, which, as I remember, was just a rung or two above Spam. When I married and had a family to feed on Christmas Day, I discovered spiral-cut honey hams and continued the tradition until the last little Pruett had left the nest. I don’t believe I’ve had a ham in my house since.

Czechs have a traditional Christmas meal, too. If I asked you to guess what it is, you couldn’t, unless you happen to be Czech, as it is carp soup and roasted duck. I’m not a fan of duck, but I would eat it if it were on the table. But carp? I just haven’t been brave enough to try that yet. I do like fish and I especially like catfish, and they are pretty ugly creatures, so I’ve surprised myself that my reluctance to try carp is based on how unattractive they are. That, plus I know that goldfish are carp, and it just doesn’t seem right to eat a family pet.

But Czechs are all about Christmas carp and, a few days before Christmas, you will find vendors on most streets with big vats of water and live carp swimming in them. A buyer will indicate the carp he or she wants, and the vendor catches and prepares it right there on the street. The poor carp, who was chatting with his tub buddies just a moment ago, is now on a chopping block with a cleaver aimed at beheading him. The blood literally runs in the street, and it is quite unappetizing for me.

I will be spending Christmas in Prague this year but, perhaps, it is time to look for a ham.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

You’re going where?

2010-12-16T13:08:00.005-05:00

I've asked my colleague, Mary E. "Betty" Ulrich, RN, MSN, ANP-BC, FNP, to write a guest posting for today's blog entry. Betty, also a member of the Honor Society of Nursing, Sigma Theta Tau International, is a retired U.S. Army major who wasn’t through with public service and brought her considerable experience and expertise to the U.S. Foreign Service. — Judie

I don’t know how folks functioned in the U.S. Foreign Service before the advent of the personal computer. Every year, about a third to half of embassy staff members prepare to rotate to the next blue horizon. That goes for the medical crew, as well. We bid on a job list that is anxiously awaited every year and then get down to the business of learning geography all over again. Not every U.S. embassy has a health unit, so we are not in tune to every country, but we don’t do too badly.

I was working for the State Department about a year before it dawned on me that we don’t bid on country assignments but capitals. So, when you are looking at a list and it says, Yaoundé, you’d better look it up before you put it on your list. Many of you will know Berlin, Rome, Frankfurt and Beijing, but what about Lilongwe, Antananarivo, Ulaanbaatar, Chisinau, Quito or Cartagena? Okay, you may know Cartagena, if you are a Michael Douglas “Romancing the Stone” movie fan.

So, every year, the medical folks help those who are bidding on jobs—sometimes on the other side of the world—to assure that medical assets required by the bidder’s family are available at the new posting. Easier said than done! Over the years, a system of evaluating and writing down medical contacts and sources of excellent care has evolved into a massive worldwide I’ve-got-you-covered list. So Jamie, who has asthma and wants to go to an air-polluted environment, will need a very good pulmonologist who, by the way, speaks English well enough so that her mother, whose native tongue is French, will understand.

This whole topic evolved as a patient—and friend—walked into the office the other day and said her husband had gotten the job of his dreams in Lusaka.

“Great!” I said. “Hmmm,” I was thinking quietly, “where in the world? Okinawa? Japan? Southeast Asia?” No, my friends, none of the above. It’s the lovely country previously known as Zambia.

Now, what part of Africa is that in? Get out the maps, which a seasoned Foreign Service officer has bookmarked on the desktop. The usual thoughts race through the old gray cells: Malaria? Yellow fever? Diarrhea? Food sources? Typhoid? Etc, etc.

Well, this is going to take some education to pull off the medical-advice portion of a briefing for Lusaka. Like I said, I don’t know what medical providers did before the computer!

— Betty Ulrich, U.S. Foreign Service NP, medical rover, Washington, D.C. (for now)

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Thanks, Jim!

2010-12-01T13:07:00.004-05:00

I rarely get to go to the United States for holidays and this Thanksgiving was no exception. But don’t feel too sorry for me because, while there was no turkey and dressing, I spent my holiday playing with friends in Paris. Three other Foreign Service ladies and I met in Paris for the long weekend, arriving on Wednesday and returning to our respective posts on Sunday.

I’ve been to Paris previously but this was an opportunity to see things I had not seen before and to do something I’ve long thought about. I spent seven hours one day at the Louvre, even eating lunch there. For those of you who have been to the Louvre, you know that seven hours isn’t enough time to see all of even one section—and there are three sections! But I was alone, and that meant I did not have to compromise. I saw exactly what I wanted and spent as much time as I needed to thoroughly check out my interests. I didn’t even go by the Mona Lisa. Heresy!

But what I did do, something that had been lurking in the back of my mind for some time, only took a few minutes and still has me smiling—and singing—days later. My friend Judy and I found our way to the Père Lachaise Cemetery, a veritable maze of tombs, monuments and cobblestone paths leading to hidden treasures of history, some a millennium old, and the very nondescript grave of James Douglas Morrison, better known as Jim Morrison of the Doors.

A small group of gawkers was there, very quiet and respectful. I was seized with an uncontrollable desire to sing “Come on baby, light my fire,” and most of the others joined in. Truthfully, I went there with this plan in mind but almost chickened out when I saw other people. But there I was, standing at the feet of Jim, and breaking into song seemed appropriate, even necessary. It was a great, if short, moment and the memory is still tickling my fancy days later.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Home sweet shipping container

2010-11-22T15:40:00.007-05:00

I have had a steady stream of visitors since I’ve been in Prague. To be fair, I haven’t worked many places people were eager to visit, and Prague is the crème de la crème of my locations, so it is understandable that this would be a popular place to visit me.

I anticipated visitors, a bit more spread out perhaps, but I messed that up when I announced that my tour in Prague would be two years rather than three. (I will depart Prague in June of 2011.) That added pressure to tell those who want to visit me and share this beautiful city to “come on.” Luckily, I have a second bedroom in my apartment, so there is a place to house visiting friends.

Housing is an interesting subject in the U.S. Foreign Service. In almost all posts, we are assigned housing based on family size, seniority and job requirements. Some of my colleagues must entertain contacts in their homes, so that may net them a larger place. There are firm rules concerning housing assignments at post and a housing committee ensures that the rules are followed. I have served on those committees several times.

Housing assignments can be disputed and there are often solid reasons why someone should be allowed a housing change. However, my favorite memories of housing disputes are from Afghanistan. At that time, all housing consisted of repurposed metal shipping containers—a single room 7 feet wide by 20 feet long. Each resident had a 3-foot wide bathroom, a metal bunk bed, a student desk with chair and a dorm-sized microwave and refrigerator. The walls were plastic and the floor vinyl. This is what everyone had regardless of rank or position.

Ah, but it was the location that became the disputed issue. People would jockey for housing (called hooches) depending on what location was most important to them. A person might prefer to be closer to the cafeteria or nearer the embassy, while others wanted to be on the back of the property and away from the noise. Personally, I considered myself fortunate to be close to the laundry trailer, especially during inclement weather.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Pink backpacks in Kabul

2010-11-04T18:31:00.003-04:00

I have been fortunate enough to serve in 14 embassies with the U.S. Department of State for periods of time ranging from one month to three years (Ghana, Guinea, Afghanistan, Nicaragua, Sierra Leone, Mexico, Uzbekistan, Hungary, Russia, Kosovo, Rwanda, Romania, Pakistan and Czech Republic). I am often asked which of these was my favorite posting, a question impossible to answer. In truth, each has given me memories I cherish, friendships I continue to enjoy and experiences I value. But, if pushed to name one post that was a pivotal experience for me, it would be Kabul, Afghanistan.

I spent 14 months in Kabul in 2003-04 and it was, I think, the best time to be there. The Afghan people were full of hope and promise, the Taliban were weakened and had retreated, and much needed money and skilled personnel were flowing into the country to rebuild the economy and improve living conditions. I was there when the girls were permitted to return to school. On the first day of the term, the streets were full of nicely groomed girls holding hands, smiling and walking briskly toward their classes. I remember a profusion of pink backpacks as I sat in the rear seat of the embassy vehicle, sobbing at the sight.

The city of Kabul was relatively safe then, and I was allowed to meet civilian medical colleagues from other missions and military medical colleagues from the International Security Assistance Forces (ISAF) and the North Atlantic Treaty Organization (NATO), both at secure locations and even at approved restaurants in town. Truly, one of the great delights of my career was the opportunity to collaborate with so many American and foreign military medical professionals. I came out of that experience with an unshakeable regard for the military and utmost respect for the sacrifices they make for us.

U.S. Aid for International Development (USAID) made a commitment to build primary care clinics throughout Afghanistan so that physicians, midwives and community health educators could begin to pull the health system up from the ruin that years of war had created. I was invited to attend the opening of the first such clinic at a village some distance from Kabul.

The citizens of the little village were proud of their new clinic and the medical personnel the government had sent to staff it. I was proud of the U.S. government for making this dream a reality, and honored to be there to witness the villagers’ delight.

After the dedication speeches, the village imam came to ask the USAID representative for another favor. “The children need a school,” he said, through an interpreter. “May we have a place for our children to learn and books to teach them?” I was really struck by this old man and his humble request. Isn’t that what we all want for our children—good health and a future? Is there really anything else that matters, regardless of where on earth you live?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Thumbs up for the Scots

2010-10-20T12:48:00.006-04:00

One of the things I like most about Prague is that it surprises me! I can’t think of a month that has passed without some occasion or insight that has either surprised or delighted me. I’ve already written about many of them and, now, men in skirts!

While I’ve never been to Scotland, I have seen men in kilts before, rarely, and usually in association with a parade and bagpipes. But this past week, I noticed an abundance of men in skirts on the streets. Some were walking alone, some were in groups and, over a couple of days, the numbers grew until I thought there must be some kind of national Scottish holiday these men were honoring. Finally, I asked my buddy at the Irish pub where I frequently eat lunch, “Why all the men in kilts?”

He explained that there was a futbol—soccer to us Yanks—game in Prague between the Czechs and the Scots, and all these fine men in kilts were here to cheer on their team. A visiting friend was lucky enough to see a group of these fans as they hung out on the famous Charles Bridge—the perfect photo op!

They are gone now. The Czechs won the match 1-0 and are now second behind Spain in their group, competing toward the semifinals of the 2012 European Futbol Championship. I’m glad the Czechs won, as this is my adopted home for now, but I give a huge thumbs up to the Scots who were so supportive of their team that they outnumbered the Czechs two to one at the match. That is a terrific fan base. I will miss seeing them around.

Photo by Marianne Drain

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Weighing in on vaccinations

2010-10-14T13:08:00.009-04:00

It is influenza vaccine season, and I spend a good deal of time trying to encourage my patients to accept vaccination. I firmly believe in the benefit of any vaccination for communicable disease, and I frequently have to defend my position.

Young parents are concerned about drugs administered to their children. As a mother and grandmother, I understand their worry about risk versus benefit. Statistics are hard to find, but the National Vaccine Injury Compensation Program (U.S. Department of Health and Human Services) indicates that, on average, 100 claims of childhood deaths per annum are possibly attributable to vaccine administration. These are claims, not necessarily fact, but there is no doubt that vaccines do result in death or harm for a minuscule number of vaccine recipients each year. Of course, if one of those unfortunate persons is a member of your family, it is a tragedy of undeniable magnitude and cannot be minimized.

I am old enough to remember the advent of modern vaccines. I remember standing in line at my local elementary school with my parents, waiting to get my sugar cube with the pink medicine. That was the beginning of the polio vaccine. This memory is attached to another one, about my mother’s friend.

My mother and I would visit this lady in her home, where she lived in a round metal tube, lying on her back. A machine attached to the tube made a whoosh sound every few seconds. My mother told me this was an “iron lung,” but it would be years before I understood its significance. I knew she had polio, and she seemed remarkably normal to me as she spoke and laughed with visitors, observing them in a mirror attached to the tube above her head. I’m not sure I understood she was always in that tube.

When I was in first grade, there was a girl my age that lived on my block but, because she was blind, went to a different school. Before she was born, her mother had rubella. In the late 1980s, I made several trips with a medical team to the Caribbean island of St. Vincent. Each year, we would provide medical care to students attending a school for the blind and/or deaf, who were also victims of their mother’s rubella infections. The measles vaccine has been available in the United States since the early 1960s, and U.S. incidence of measles-caused congenital illness has been largely overcome, while the developing world is still suffering the effects that vaccine can prevent.

The risk in developed countries, while lessened, is still there. Just this month, the World Health Organization (WHO) announced that its goal of eliminating rubella and congenital rubella syndrome had been moved from 2010 to 2015, primarily because of small, vaccine-averse populations.

When parents ask for my opinion of the risk of vaccines, I don’t equivocate. I tell them about my mother’s friend in the iron lung and the other effects of vaccine-preventable disease I have witnessed firsthand. I remind them that the last case of smallpox was in 1977, the direct result of a global vaccine effort to eliminate what WHO terms “one of the most devastating diseases known to humanity.” But I also tell them the choice is theirs and that it should be an informed decision based on history and science, rather than personal apprehension. It is a serious choice.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

One Saturday night in Pakistan

2010-09-24T12:18:00.010-04:00

It was two years ago this month on—for me—a typical Saturday night. It was about 8 p.m., and I was sitting on my sofa watching TV when the noise came and the apartment windows shook so hard I thought they would explode. I immediately ran to the radio and called the Marine on duty to tell him I was standing by, because I knew that—whatever this was—it was really bad.

Almost immediately, my cell phone rang. It was the physician I worked with at the U.S. Embassy’s health unit in Islamabad. We quickly formed a plan. I was to call the other nurse practitioner and ask her to go to one hospital while he went to another. Their goal would be to seek out injured Americans. Since I lived on the embassy compound, and was about 30 seconds away from the medical unit, I would go there, in case anyone came. Before I could get my shoes on, the Marine called to say that injured were coming through the gates, and they would be escorted to the medical unit.

My professional history included more than two decades in emergency departments and intensive care units, so I was prepared for the chaos that emergencies always bring. But this night would stand out as unique in my experiences. The initial injured that were arriving had sustained minor injuries, abrasions and scratches from flying debris. People were also arriving who had not been at the location of the bomb. Some came to assist, some to look for friends, and some because they were in shell shock from the enormity of the event and weren’t sure where else to go.

The blast was from a truck bomb in front of the Marriott Hotel. The resulting explosion killed 60 people and injured nearly 300 more. The blast concussion blew out windows and doors in much of the surrounding area, and some of the people coming to the medical unit were victims of that effect.

For the first hour, until the medical unit RNs could be escorted in, I worked as the lone medical provider. Several Marines came to help and were instrumental in taking names, triaging wounds, handing out water and bringing supplies to the exam rooms. However, the atmosphere was uncannily orderly. People spoke in hushed voices and wept silently. And, as I would go to the front room to seek the next victim I could assist, those waiting had already sorted out who might need to be next and patiently waited their turns.

A gentleman I did not know, and never saw again, came to answer the phone and relay messages. When a badly injured man was brought in, and it was apparent he needed immediate critical attention, I had only to announce the need for someone to accompany him to the hospital in the embassy’s ambulance. Immediately, a serviceman volunteered.

By the second hour, the other NP and the clinic’s three RNs had come, as well as a physician’s assistant who was in the area. We all worked steadily: cleaning wounds, suturing, dressing, comforting. A second critically injured person was diagnosed and we sent him off to the hospital.

Around 11 p.m., I received a call from a consular officer that a gravely injured American had been located at a government hospital. I left with the ambulance and another military volunteer—“I can’t let you go by yourself, ma’am”—to assess the situation. The man was badly injured and in shock. He had been partially stabilized but needed a head CT, which could not be done at the present facility. I used my very best diplomatic skills to thank the staff for all they had done and moved the injured man to our ambulance so we could take him to a facility with a CT. This hospital, not equipped for trauma cases, was a terrible scene, as many injured and dead had been transported there, and the staff was doing the best they could under appalling circumstances.

At 6 a.m. the following morning, I finally went to my apartment to catch a couple hours’ sleep, then headed back to the medical unit to see victims in follow-up, or new ones with minor injuries who came to be checked out. My physician colleague had spent the entire night at the hospital and finally went home when one of the clinic RNs came to relieve him. The other NP went to the morgue to sit with deceased Americans until the air transport arrived. On Monday, we would all be in the clinic for regular work responsibilities.

I have many times reflected on that Saturday night. I still marvel at the orderliness, the compassion for one another and the solidarity of everyone who came to the health unit that evening, in spite of the horrific event that brought them there. I would not call it fate or providence, but it was one of the few times in my life that I knew, without a doubt, I was exactly where I was meant to be and doing what I was meant to do.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Meet me at The Savoy

2010-09-10T11:58:00.006-04:00

When it comes to food, I’m a consumer, not a connoisseur. I enjoy a wide variety of foods and have very few dislikes. When I was in Czech language class, the instructor asked me to list my favorite foods so she could teach me the names. I told her all I really needed to know was the word for liver. As long as I can avoid liver, I’ll be just fine.

Of course, I have learned Czech words for various foods, as I have to recognize them on the grocery shelf. But my repertoire need not be very extensive, as I refuse to cook. To clarify, yes, I do on occasion actually throw something in a pot or a pan and turn on the heat, but it is very basic cooking. No recipes, no fancy ingredients, no slicing, no dicing or extensive preparation time. When my last child flew the coop, I had been cooking for 30 years, and I decided that was long enough. My kitchen is permanently closed.

Because I like almost any food or ethnic style of cooking, I don’t get overly excited about most dishes. And, gratefully, I’ve never really been a sweets or dessert eater. My one real weakness is ice cream but, even then, I never buy it for home and seldom eat it when out. At least, that used to be true.

There is a restaurant in Prague called The Savoy. The main reason I have gone there in the past is because the ceiling of the restaurant is hand-painted and truly a beautiful sight. I’m not all that crazy about the menu, but they have a nice soup and a huge variety of teas, and I do like trying different teas. Recently, friends and I went to The Savoy for dessert. It is known for having delicious pastries but, since I don’t really like pastries, I ordered the Savoy Sundae.

A bowl was placed in front of me that contained two small scoops of rich chocolate and one scoop of vanilla laced with a hint of strawberry, all perched on a marzipan. Surrounding the ice cream was real whipped cream drizzled with a chocolate sauce and topped with cherry compote. A garnish of biscotti and a dark chocolate disk completed this unbelievable concoction.

I really don’t have the words to describe my reaction to the burst of flavors that took place in my mouth while eating the Savoy Sundae. I am hard pressed to explain why this gastronomic delight has me creating reasons to take colleagues or visiting friends to The Savoy to enjoy the beautifully painted ceiling, and oh, perhaps, a Savoy Sundae while there. I fear this may be an addiction in the making.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

A man's best friend

2010-08-24T14:24:00.002-04:00

Sometimes, information from odd sources comes together at the perfect time to effect a great good. I view these as minor miracles and am always grateful for the cosmic assistance.

I had a patient who believed he was suffering from empty-nest syndrome. His last child had departed for university and he was blue, often on the verge of tears, he said. He was also finding it hard to sleep. He visited me for some advice but was not amenable to any medicinal intervention, and there isn’t much a practitioner can do about the complaint of fatigue. I offered the usual naturalistic recommendations and reassured him that tincture of time is a great healer.

I saw him frequently around the embassy and usually asked how things were going for him, since I expected, as the days turned into weeks, that his sleep and mood would improve. But they didn’t. One day, we were chatting in a hallway and he mentioned that his dogs had been acting very strange at night and were adding to his sleeplessness. He told me that, when his child left home, he began letting the family dog sleep in his room and now, several times a night, the dog would jump on the bed, bark and wake him up. As soon as he spoke, the dog would lie down and be quiet.

Immediately, an article I had read about how dogs can sense medical dangers popped into my mind. Call it a hunch or an inspiration, but I instantly asked if he snored. Yes, he said, his child often complained about how loudly he snored. Returning to my office, I sent him the Epworth Sleepiness Scale and, wow, his score was very high! That was enough to get him scheduled in the sleep lab for evaluation of possible sleep apnea.

My colleague and his dog are now having peaceful nights, thanks to the CPAP that treats his severe sleep apnea. And, perhaps because of the passage of time, or maybe because he gets adequate oxygenation at night, his blue moods and fatigue are long gone.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

And this is a SLOW week!

2010-08-16T11:52:00.005-04:00

Another week has ended and, because it is summer vacation time and post transfer season, my clinic has been operating at a slower pace. I enjoy the occasional slumps, because they give me time to accomplish administrative work I’ve been putting in my “round tuit” file, catch up on journal reading and reflect a bit on what I’m doing.

Today’s reflection highlighted the virtual practice, of which I am part, and the global resources I enjoy. In my former U.S. practice, if I wished to discuss a case, I usually walked down a hall to speak with a fellow medical provider. Occasionally, I would phone a colleague about a particular patient but, almost certainly, that colleague was someone I would see face to face within a short time to continue the collaboration.

Most of my postings with the U.S. Foreign Service have been as a single provider, so when I require consultation, I pick up a phone to call medical staff people in Washington, D.C. or in another country. For example, this week I’ve collaborated by phone or e-mail with colleagues in Washington, Budapest and Kyiv. I’ve also discussed medical-supply problems with colleagues in Islamabad, Pretoria and Abu Dhabi, and worked through an administrative question with my counterpart in Bucharest. And this is a slow week!

I admit I am impressed with how truly universal and “virtual” this form of practice is. I take it for granted that the diabetes expert I rely on is in Jakarta, the neurologist is in Frankfurt and the pediatric guru is in Budapest. And, like a city toss, next year we could all be in a different location, but still readily available to each other and the patients we serve.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

See the USA in a Chevrolet ... wait a minute, this is Prague!

2010-08-02T08:00:00.001-04:00

Even though I live on the third floor of an apartment building located on one of Prague’s main streets, traffic noise is usually like white noise to me, excepting the occasional ambulance. But when I heard the successive revving engines, I immediately recognized it as something unusual. I looked out my window to see—a long line of Corvettes.

Corvettes? One after the other they came up the street and, when it continued for several minutes, I realized this was not just a quirky occurrence. Down to the street I went to see—as far as I could see in both directions—Chevrolet Corvettes!

Police had stopped the traffic so the spectacle could continue, unimpeded, to its destination, wherever that might be. People lined the sidewalks, pointing at various vehicles that impressed them and taking photos. For a full 20 minutes after I arrived at street level, they passed. There were vintage models and new ones, hardtops and convertibles, of every imaginable color, driven by men and women, some with a passenger and others alone. All the drivers and passengers looked rather serious and largely ignored the curious crowds on the sidewalks. Except for the drivers who were compelled to rev up their engines and jerk their vehicles forward by a foot or two, it was more like a funeral procession than a parade.

The scene was quite surreal. First of all, I am absolutely sure I have not seen any Corvettes traveling around Prague since I’ve been here. Secondly, the mighty Corvette, symbol of American automotive ingenuity and the most “macho” of sports cars, really stood out when contrasted to Prague’s cobble-stoned streets and ancient buildings. And, of course, despite the fact that this vehicle is distinctly American, here, in the heart of Europe, were a couple hundred of them passing.

I have since learned that the 10th International Corvette Meeting is this weekend, when proud Corvette owners from all over Europe come together to flex their engines and share their pride of ownership. I am still smiling from this unexpected treat.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Fans, fountains and fruit

2010-07-20T11:33:00.013-04:00

Prague is in the middle of a heat wave. The temperatures have been in the mid 80s for a week and, for a city with an average summer temperature of 74 degrees, I guess that is a bit warm. Air conditioning is virtually unknown in Prague. The few establishments that have it proudly display large, bold “Air-Conditioned!” signs to draw in wilting visitors. Fans and open windows are the methods most used to cool businesses and homes, and most restaurant dining is done alfresco, on any patch of outdoor space available.

Just across from my apartment is a very nice fountain. As I walked home from work a few nights ago, I saw many people in bathing suits—adults, not children—sitting in the fountain basin and lying around on the surrounding grass. I had to look twice to be sure I was really seeing that. Odd, I thought. The next day, same thing, and it has continued.

I can think of no water fountain that I’ve seen in the southern United States where citizens are allowed to frolic in the basin. To be fair, these Czechs weren’t frolicking, either. They were either sitting in the water, or dipping in and then going back to the grass. It was purely a method to cool down.

In thinking back over the many countries I have worked in and those that had fountains, I could only recall one other country where I’ve seen people inside a fountain. In Mexico City, the U.S. Embassy is just down Reforma Avenue from the fountain of Diana the Huntress. This is a quite large and very beautiful fountain and, for reasons I never understood, protesters for various causes would frequently come to the fountain, completely disrobe and splash around as a form of civil defiance. We would receive notices the day before these planned demonstrations and be advised to stay away from the fountain area, but there was never any violence or police action—just a bunch of nude people cavorting around Diana’s statue. Perhaps municipal fountains should be open to citizens to enjoy the cooling waters on a hot summer day, just not in the nude.

Strawberries, cherries and peaches. Oh, my! Summer has enveloped the local market with wonderful fruit. I returned to the United States in May for several weeks and left behind in Prague the sweetest, most succulent strawberries it had ever been my pleasure to enjoy. Sad was I that they would be gone on my return, as I assumed a short strawberry season as in the United States. Surprised was I when I realized there were still scads of strawberries to be had upon arriving back in Prague. So I asked, “When does the strawberry season end?” September! Because the Czech Republic has a cooler clime, strawberries grow all summer long. Yeah! I’m in paradise. The cherries are abundant right now, as are plums and peaches. Those, of course, do have a finite season, so I’m eating all I can while I can. Just one more reason to love living in Czech land!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Disabled doesn’t mean unable

2010-07-13T14:58:00.001-04:00

I work with a young Czech RN who, because of an equestrian accident, is a paraplegic. She is an excellent nurse, still honing her craft, but with a zeal for knowledge and new skills that puts most professionals to shame. She is everything a nurse should be: compassionate, intelligent, skilled, astute and amiable. Her patients like her, but more importantly, they respect and trust her.

She drives a hand-gear vehicle, kayaks, snow skis and hand bicycles. She always was, and remains, a jock, adapting every sport she can to the constraints of her physical capacity. I know of no one at our embassy that views her as unable. Of course, she has some limitations, but don’t we all, one way or another? I think Americans have made significant progress in overcoming bias or stigma toward people who are different. The Czechs need to work on that, too.

Unfortunately for my colleague, the Czech Republic is a difficult place for people with physical limitations. To be sure, a large part of the problem is that buildings are very old here and, because of laws that prevent destruction of these precious structures, most can’t be adapted for improved handicapped access.

A law is in place that ensures adequate access for new buildings, but there just aren’t that many new buildings and the law doesn’t address problems in getting to them. Parking places for handicapped are woefully inadequate and, in many of the most popular spots, absent. Sidewalks are rough and don’t have ramps for wheelchair traffic. Bathroom doors aren’t wide enough, stalls aren’t wheelchair accessible, and there are often no elevators. The excellent public transportation system provides only minimal access for wheelchairs, making them virtually useless.

The worst insult to my very capable colleague is the prevalent public opinion that she is somehow less because she doesn’t walk. She often recounts the disbelief she gets when she meets someone new and says she is a practicing registered nurse. “But how?” they respond, as if all nursing duties require functioning legs! Yes, our clinic has made some accommodation, but truly little was required. And all those things I mentioned above that a good nurse should be are managed just fine from a sitting position.

I know that this situation will be cured with time. America started working on this issue decades ago. The Czechs will address it as well. In the meantime, my colleague is employed in an American clinic where she is treated with respect and equality and granted the opportunity to continue the work she loves.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

A place at the table

2010-06-30T11:45:00.005-04:00

One of the thorniest issues in modern medicine is the use of or, more accurately, the overuse of antibiotics. I see primary care patients in my U.S. Embassy clinic, but when the illness warrants it, these patients are referred to local medical specialists for a higher level of care.

Last winter, I became concerned about antibiotics prescribed for patients I referred. For instance, I referred a young child with a viral chest infection. Despite everyone agreeing it was viral, she was given antibiotics for several weeks, anyway. I realize there is room for a medical practitioner to prescribe antibiotics when there is the possibility of secondary infection. And I know I’m on slippery ground in second-guessing what a medical specialist thinks is appropriate. But I still had a lingering question in my head: Is this the best thing to do for my patients?

I discussed several cases with my supervisor, who is a physician posted to Warsaw. He had some questions, too. So, it was decided I would speak with the physicians from the local clinic, to whom we refer most patients, just to get a feel for what their thought processes were and to be sure our American patients weren’t pushing for prescriptions. Patients do that all the time!

Schedules initially interfered, so the proposed meeting just recently took place. It was far more cordial than I anticipated. Although one of the pediatricians present didn’t say anything at all, and I have a hunch his thoughts were not available to influence one way or the other, the majority of the physicians were open and more than willing to discuss the issue. We agreed that both sides would communicate better about patients and their treatment, a really useful arrangement.

So, what is noteworthy about this meeting? I am a nurse practitioner working in a country that does not have nurse practitioners. These doctors understand I am not a physician, and I’m sure they are more than a little confused about how, as an advanced practice nurse, I have a license to practice medicine, but they understand that I do, indeed, evaluate and treat medical conditions.

In developing countries, my credibility lies in my attachment to the U.S. Embassy. Medical colleagues in developing countries have the opinion that if the United States sanctions it, it must be okay. In the Czech Republic, a medically modern society in the European Union, the fact that I am a U.S. diplomat gets me social invitations but very little else.

It has been a week since the meeting, and I’m still marveling over me sitting in a room with several physicians, with whom I only have a referral relationship, having a good chat about appropriate antibiotic use and what we can all do—together—to ensure our shared patients get the best treatment. I like the way this is going!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Question to ponder

2010-06-16T12:03:00.002-04:00

In my previous posting, I mentioned the guide, Danny, who took me to the Mountain Gorilla Reserve in Rwanda. There were just the two of us in his Land Rover on the three-hour trip each way, so we had plenty of time to get to know one another. On the return drive, I asked Danny about the 1994 genocide where more three quarters of a million people, mostly Tutsi, were slaughtered. The rivers literally ran red with blood. Danny is a Tutsi and he told me a story of great courage.

In 1994, he was in his early 20’s with a wife and a 2-year-old daughter. He lived in Kigali but the rest of his family lived in rural Rwanda. On the night the radio instructions to kill Tutsi’s was broadcast, Danny’s neighbor, a Hutu, came to his house and told him he wanted to hide Danny’s family to protect them. Danny’s family went with this man to his cornfield and they hid there for three months. Every few days, the neighbor brought them food and water, at great risk to his own safety. When they were finally able to go home safely, Danny learned that, other than a teenage cousin who was away in Uganda when the genocide began, his entire family and his wife’s family were dead—more than 20 men, women and children.

Following the genocide, Danny had worked hard to build a successful business and give his three children a good life. When I asked him what he had told his children about the genocide, I was surprised to learn he had not spoken to them about it at all. He said they learned the history in school, but that he was waiting for the time when his children were “ready” to hear the worst of his story and mature enough to consider the question he would put to them.

Danny remembered that hundreds of thousands of ordinary people were faced with a choice. One choice was to comply with instructions and do something terribly wrong—kill innocent people, including family members and neighbors. The other choice was to acknowledge the evil and refuse to participate. Danny said there were many people he considered good people who picked up their machetes and went out and murdered as instructed, because they feared for their own lives or the lives of their family if they did not follow the order. There were also people, like his Hutu neighbor, who refused to do what they knew was wrong and many of them were killed for helping the Tutsis or for resisting the genocide.

So the question Danny said he will put to his children is, “If faced with a decision such as this in life, which person will you be?” Danny believed most people think they would be on the side of good but, until this decision actually faces a person, one cannot know for sure!

I will remember our conversation for a lifetime and I tell it often. Danny’s story is the most heartrending example I know of how ordinary people can do extraordinary things—for good or evil!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Where does an 800-pound gorilla sit? Anywhere it wants to.

2010-06-08T10:01:00.023-04:00

Four years ago, I experienced one of the most magical and meaningful experiences of my life. I was in Kigali, Rwanda for a three-month tour and was lucky enough to find a last-minute ticket to the Mountain Gorilla Reserve, a real triumph since these spaces are sold out a year in advance. I contacted a recommended guide, Danny, to drive me to the reserve the day before our 7 a.m. hike into the forest. I would spend the night before the trek at the Gorilla’s Nest Hotel.

You may remember something about Dian Fossey and her fight to save the mountain gorillas from poachers in the 1970s and ‘80s. Her death in 1985 brought the publicity needed to stop the near extinction of these remarkable creatures. Her work inspired the book and 1988 movie, Gorillas in the Mist. Today, the gorillas are out of danger, well protected, well funded and a fitting living memorial to Fossey’s life and work.

The current families of gorillas living in the mountains have grown up in the wild but, during their lifetimes, their forest has always included humans. While humans are not allowed to interact directly with the gorillas, they continue to study and track them. There are five gorilla families on the Rwanda side of the reserve and, every day of the year, eight humans are allowed to visit each family for a maximum of one hour.

When you arrive at the reserve, you are assigned one of the families. Wherever that family is foraging for the day is the goal of the hike. For me, it was approximately a two-hour hike up a very wet and muddy trail through the bamboo forest. It was miserable. More than once, I wondered if it was worth the effort. Then, unexpectedly, a small gorilla swung out of a tree, careened over the back of one of the guys in the group and ran off. That started the vocalizations and the rustling in the bamboo, and we realized we had arrived.

First, we came on the silverback. Wow, he was huge! Calmly chomping on bamboo, he barely even looked at us, but we knew he knew we were there, and we were acutely aware he was in total charge of his area. Standing in a straight line—eight visitors and two reserve workers—we watched and snapped pictures. We had been told not to talk, as that can agitate the gorillas. This was not a gorilla we wanted to agitate. Other than camera sounds, we were absolutely silent.

After about 10 minutes, he started through the forest. Before we ran into the silverback, one of the guides had to chop through the forest with a machete to make a way. Once we were following the silverback, there was no more need to cut a trail. As he moved through the forest, the bamboo was trampled under him and we just followed the cleared path.

Eventually, the silverback came to a small clearing and flopped down. Within a couple of minutes, three females—one with an infant—and three juniors came into the same clearing and settled around the big guy. For the next 40 minutes, we watched and took pictures. We could hear other gorillas in the bamboo, but no more came to join the group. The juniors played and tumbled, and the females groomed each other. Our group stood about 5 feet from the silverback, with the females behind him. The juniors were anywhere they wanted to be, including inches from us, as they played. It was remarkable.

Before setting off on this expedition, I had high expectations but it was more than I could ever have imagined. For half of the reward, I would have climbed twice as high and still been awe-struck.

These creatures, along with their few cousins that live across Rwandan border in Uganda or the Congo are the only mountain gorillas in the world. If you ever find yourself in this part of Africa, do not pass up the opportunity to make this incredible journey.

I like to classify my exceptional travel experiences in terms of being Top 10. The mountain gorillas are Top 5, no contest. Seeing them was magical. Next time, I’ll tell you about another meaningful part of this trip.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Only when stressed

2010-05-27T14:19:00.004-04:00

One of my responsibilities, using U.S. Department of Transportation guidelines, is to evaluate local employees who drive embassy vehicles. Ninety percent of the drivers evaluated are men who are 100 percent worried that they won’t pass and will be suspended from driving, which rarely happens. Hypertension is usually the biggest health issue that presents in these physicals and, regardless of the actual BP reading, the drivers always blame it on “white coat syndrome.” Most of the time, the initial conversation goes something like this.

Me: I see your blood pressure is a little high today. Do you have high blood pressure?
Driver: No, I’m just nervous to be here.
Me: Really, there is no reason to be nervous. Do you take any prescription medication?
Driver: No, unless my doctor gives me something.
Me: Has your doctor given you anything recently?
Driver: I have those little pills I take when I need to.
Me: What are those pills for?
Driver: For when I get stressed, like now, and my blood pressure goes up, but I don’t have blood pressure problems unless I’m stressed.
Me: How often do you take those pills?
Driver: Well, my doctor told me to take them every day, but I only take them when I’m stressed or I know I’m going to be nervous.
Me: So, you are being treated for high blood pressure?
Driver: Yes.

OK, now we are getting somewhere!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

They haven't forgotten

2010-05-18T11:19:00.010-04:00

Europeans, especially eastern Europeans, honor pivotal WWII events annually. Allied troops marched into what was then Czechoslovakia in May of 1945 and, under the command of General George S. Patton, liberated the Czechs from Nazi occupation. Even though the Czechs fell under USSR domination after the war was over, they still view American forces with fondness.

The kickoff for the month’s many memorial events held around the Czech Republic for this, the 65th anniversary of the liberation, was held in Prague on Friday, April 30. There was a parade of WWII military vehicles and several dozen Czech citizens dressed in the uniforms of Allied-forces troop personnel. The parade wound its way through Prague and ended in front of the American embassy where a 1940s-style swing band was playing themed music. It wasn’t a huge event; there were perhaps 300 people in attendance. Still, it is gratifying to be an American and experience the appreciation that is still held for Americans who left their shores to defend the freedom of other peoples. It is especially welcome to those of us who serve our government in foreign countries, since there is a fair amount of anti-Americanism overseas, and we are more often on the receiving end of disrespect. The big band music was icing on the cake.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Nine things I've learned since coming to the Czech Republic

2010-05-13T14:15:00.012-04:00

I’m in my seventh month in Prague, the weather has warmed to pleasant spring perfection and I’m really enjoying this beautiful European city. I’ve been in the Foreign Service long enough to know each location has its particular culture and individual points of interest, so I’ve been reflecting on what I’ve learned since I’ve been in the Czech Republic.

1) Some people in Prague walk faster than I do. This may seem odd to you, but it is the first place I have ever lived where people on the street routinely pass me. I walk especially fast; not intentionally, it is just what I do. My 6-foot 4-inch son, who has a very long stride, doesn’t walk as fast as I do and asks me to slow down. I have been places where people look at me oddly, wondering where the fire is, I suppose, as I scoot past. Here, I am frequently outpaced, and I love it.

2) Prague is the sixth most visited city in Europe but only about 8 percent of tourists are American. I guess that means Prague is a best-kept secret from Americans but, believe me, other countries’ citizens love to come here. The CR is full of Europeans, South Americans and Asians.

3) Czechs are not friendly until after you say hello. Maybe this is a holdover from the insecure times of communism, but Czechs generally don’t make any eye contact with someone they don’t know, whether on the street or in a store. But the minute the other person says, “Dobrý den (hello),” that reserve melts away and he or she becomes open and friendly.

4) The Czech language is HARD! I think there is a reason only 11 million people speak this language, and it isn’t just because there are only 11 million Czechs! I have learned to get by in Czech when I order a meal or go to the grocery, but I will never be able to hold a simple conversation.

5) Czechs over 30 are not particularly interested in learning English. They were required to learn Russian or German—languages of occupying forces—and they are nationalistic about maintaining the Czech language. Who can blame them? I believe their thinking is, because they live in the Czech Republic and have their own language, foreigners who visit or come to live should make the accommodation to get by in the local language. I agree! We Americans think the same way. I just wish Czech wasn’t so hard.

6) Most Czech women are in the normal weight range. This is probably because almost all Czechs participate in a broad range of sports, but I have a sneaking suspicion it is also because refrigerators are tiny. Keeping the fridge stocked requires several trips a week to the market, on foot. I only feed one person, and I know my physical activity has increased just from grocery shopping. Additionally, once I’ve done the shopping and have lugged the groceries back to my apartment, I’m not too interested in eating.

7) Flowers are important. Prague is a city, but it blooms. Flower shops (květiny) are no more than two blocks away, no matter where you are in Prague. Citizens take great pride in displaying plants and flowers, and bouquets are a common gift. It really adds to the ambiance.

8) Czechs love tea! This was a total surprise to me. The CR is famous for its beer and Budweiser Budvar Brewery, home of the original Budweiser beer, is here, but tea shops with exotic teas from around the world are common. Many restaurants have a special tea menu with dozens of choices. By the way, local beer is often less expensive than tea, coffee or colas!

9) Finally, until 1989, every Czech baby had to be named from an official list of names. Legally, a non-Czech first name was not permitted on a birth certificate, and this tradition had been in place for centuries. Each name—male or female—had a “name” day on the calendar, and name days were celebrated rather than birth days.

No doubt, as I live here longer, I’ll learn more interesting facts about my temporary home. But I think the most important thing I’ve learned about Prague is—I’m happy living here.

Photos:

Top: Astrological clock

Bottom: Tyn Church, Old Town, Prague

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

When personal overlaps with professional

2010-05-03T12:47:00.004-04:00

I suppose being in practice in the Foreign Service is akin to working in a small town—a very small town. While a few embassy populations are quite large, with more than a thousand staff members and families, most are well below the 500 mark. I am responsible for the occupational health needs of fewer than 200 people in Prague, plus another hundred local staff.

This means my patients are also my colleagues and friends. It is not uncommon for me to have lunch or dinner with someone I treat in the clinic the same week. Rarely are we in a situation where we provide care for people we don’t see frequently outside of the health unit, even if it is just passing in a hallway.

I have always had mixed feelings about this unusual practice environment, as having such a close relationship with one’s patients has both advantages and disadvantages. Under this system, my feeling of responsibility for a patient’s medical outcome is both professional and personal. My medical colleagues and I have to maintain clinical objectivity at the same time we have a very special interest in the people we are treating.

Recently, one of my patients has been very ill and has required advanced medical care within the Czech health system. I am thankful there is such competent care available in Prague, but the length and severity of the illness has cost me many tossing-and-turning nights. I worry and wonder if all the people making decisions in this case—myself included—are making the right decisions. From the beginning, there has been a high chance of complications, and I am acutely aware that, if things don’t go well, my embassy colleagues might look at me with a critical eye. But that isn’t the cause of my fidgety sleep. I have tremendous regard and respect for my patient, and it is that personal connection that causes the angst!

At my first post—Accra, Ghana—I was forced to hospitalize a septic 3-year old. The parents were on their initial overseas assignment and had been in country for exactly one month. The mom was a lovely young lady who stood about 5 foot 2. After admitting the baby to the hospital and initiating IV infusion of the drugs that were going to save her, the mom turned to me, literally grabbed me by the shirt and pulled my face down to hers. “Don’t let my baby die!” she cried.

That was the first time I felt the full force of the responsibility this practice can bring. Unfortunately, it hasn’t been the last time but, in that case, the child did well and left the hospital in less than a week, her mother having never left her side.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Truly remarkable people

2010-04-26T12:36:00.013-04:00

In my previous posting, I reported on the desperate lack of medical care some countries face. I would like to offer some balance by recognizing some inspiring people I’ve encountered in these dismal medical circumstances.

I consider myself extremely fortunate to have been assigned to Kabul in 2003-04. The capital of Afghanistan was safer then, and I was able to network with NATO medical providers—all military—as well as some Afghan medical personnel. Since then, the security situation in Kabul has deteriorated and my successors have been confined to the embassy compound. As a result, they’ve missed excellent opportunities to meet some truly remarkable people.

Dr. Farid was educated in England during the Soviet war in Afghanistan. A man of good sense would have stayed in England and forged a comfortable life for himself. Why come back to a country that was embroiled in war, had a failed medical system and offered nothing but hard work, disappointment, frustration and poor financial return on his education?

But Farid is a rare man, and return he did. He stayed through the end of the war and remained when the Taliban came. He stayed because his people needed medical care and most doctors were not staying. He had a ramshackle clinic in Kabul that would make most Americans flee just at the sight of it. But inside the clinic were other Afghan doctors he had recruited who believed as he did. These doctors had gone abroad for solid educations, but had returned to Afghanistan to do the best they could to help the helpless.

Farid was a happy man, but he fully realized the sacrifices he had made. When I asked him if any of his six children would follow him into medicine, he shook his head and said they all recognized what a hard life it had been and wanted something better for themselves and their families.

Some months ago, I spoke to an American contractor working in Kabul. He knew Farid and told me he is still hanging on, still striving to make a difference in the medical care of his community. Against all odds, he continues to hope and aspire.

Dr. Faquir Amin was an epidemiologist who never let war or evil steer him off course, either. His life’s work was fighting leishmaniasis and tuberculosis of the skin, two conditions that are endemic in Afghanistan. He particularly worried about the disfigurement of young girls, because it can make them unmarriageable. If one is illiterate, one needs a supporter, and girls must look good to get offers of marriage.

Amin’s clinic was the best of what could then be found in Afghanistan. He was fortunate to have foreign researchers who came to study these diseases, and they gave him the supplies he needed to run a good clinic. He even had solar panels on the roof to provide clean electricity for the lab computers and equipment, at a time when the only electricity available was through generators.

The U.S. Army offered him a financial grant to assist his work. Their first offer was to give him cash to purchase whatever his clinic needed. He declined the offer. No, he said, money was a responsibility and sometimes could be a temptation. He would rather tell the colonel what he needed and let her donate the items. I was standing there when he said it. She and I were amazed. Are there really people who refuse cash? Amin did.

Watching Amin was watching a man who loved people and wanted only to alleviate their suffering. His clinic treated anyone who came, free of charge. His most ardent desire was to eradicate leishmaniasis, a wholly unreasonable wish since, to do so, would require the complete elimination of the disease’s host, the sand flea. The immensity of this task was no deterrent to Amin. If he still practices, I know he continues to work toward this end, and those nasty little sand fleas better watch out.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

The perfect health care system? I haven’t found it.

2010-04-15T00:43:00.004-04:00

Even though I am an expat living in Europe, I am bombarded daily with news of the U.S. health care reform debate that seems to have our country polarized. I have seen so many other health care systems around the world that my viewpoint is probably a bit skewed from what it would be if I still practiced in America.

If there is a perfect system, I haven’t found it. My experiences vary from Guinea and Afghanistan, where there was basically no real health care available, to Mexico, where the range was from excellent to terrible, to the Czech Republic, where the care is on a par with what I would expect in the United States. I am referring to the standard of care, not the process of financing it. How health care is financed—fee for service, socialized, self-pay, etc.—is a wholly different matter, although it is a fact that if someone isn’t paying for health care in a country, it isn’t going to exist.

In Conakry, Guinea, there is one government-run hospital. The hospital is surrounded by a high wall with an iron gate. A patient who comes to the hospital must first pay an entrance fee of a few francs. No francs, no entrance—regardless of the seriousness of the illness or injury. Once inside, the patient will be seen by a physician and, perhaps, be assigned to a bed. The bed will have no sheets, no mattress. If the patient needs these things, the family must bring them. Likewise, if the patient requires any medication or supplies, including surgical supplies, the family must go to a local pharmacy and purchase them and bring them back to the hospital. The hospital carries no medications and no supplies. Not even a Band-Aid.

The patient will be charged a daily rate to cover the “overhead” of the hospital. If he can’t pay each and every day, he will be removed from the hospital. The same is true for the physician’s fee. Physicians must be paid in advance or they will not render services, as they are not paid by the government. This is also true of private clinics and medical offices available throughout the city. Either pay up front or forfeit services. This was the system that was in place when I left Guinea in 2003. If it has changed, it has only been for the worse, as the country has spiraled downward into instability.

Afghanistan’s medical system was decimated by 25 years of war. While I was posted to Kabul, various NGOs, as well as the Ministry of Health, were trying to put together rudimentary care, at least in the capital. My most poignant memory is of one day in 2004 when I learned that 17 mothers or babies had died during childbirth at a maternity hospital in Kabul. These lives were lost because there were not enough personnel at the hospital to take care of the delivering mothers. There was no system of organization at that time and, for whatever reason, most medical personnel assigned to work that day didn’t come. There were no phone lines, and mobile phones were still a rarity, so staff couldn’t alert the hospital that they wouldn’t be there and the hospital couldn’t call in replacements. At that time, Afghanistan had the highest maternal/child mortality rate in the world, so, because of a poor communication system, those 17 lives added to the dismal statistics.

I left Afghanistan in 2004 and spent a couple of months in Sierra Leone, which ended a 10-year civil war in 2001. They, too, had been stripped of a medical system that was insufficient to begin with. In fact, the only hospital in Freetown, the capital, was vacant and shuttered. The government simply had no money for medical care. A few physicians had trickled back into the country after the war and opened offices, but they were only able to provide basic services. Medications and supplies had to be imported, and sources were not reliable. As in Guinea and Afghanistan, severe lack of medical care was a bitter fact of life. I do not know actual statistics, but I feel confident in saying there are many more people in the world who have little or no modern medical care available to them than there are those who do and, while I agree the American system needs tweaking, I’m still very grateful we have it.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Too much of a good thing

2010-04-05T12:45:00.004-04:00

Unfortunately, the spring equinox did not bring warm weather to Prague, but we are having sunny days and there is no more snow, so I’m quite happy. It is windy and there are scattered showers. I’m not very fond of wet, windy and cold weather but, if the sun shines, it is tolerable, and I was so ready for sun.

Even if the weather is not cooperating, there are plenty of other signs that spring is in the air. Europeans are known for being great lovers of dogs, and the sidewalks have suddenly come alive with dog walkers. The downside is that not all dog owners are responsible, and I have to watch my feet as carefully now as I did when ice was on the sidewalks. It also makes me wonder where all these dogs were during the winter months?

The sidewalks have become treacherous for another reason, too. Preschool kids are out en masse on their wheeled toys, and most moms are less than attentive about where the kids are going or whom they are running over. I literally had to jump sideways this week when a tot whirled his vehicle around, right into my path. It was jump or fall right over him, and I was pretty sure hitting the cobblestones would do me a lot more damage than it would him. I hollered, “Prosim!” (please), which his mother totally ignored as she walked right past me and shooed him forward.

The local eateries have put café tables out on the sidewalks, and the street and park benches are full of people soaking up the sun. A few crocuses are peeking their heads through the barren ground. The park behind my apartment has suddenly burst with activity as people enjoy the outdoors. This includes the young—and not so young—lovers, who seem to be on every street corner and doorway, and in the back of each tram. They are, as my dad would have said, “Makin’ whoopee!” I’m no prude but I ask you, Is it safe to make out on an escalator in a department store?

But the biggest change—one I’m fairly sure portends the first thing I won’t like about living in Prague—is the throngs of tourists. There were tourists when I arrived in October and there were lots of them over the Christmas holidays, but now. Oh my, are there tourists! They are everywhere, even on my street, which really isn’t a tourist area at all. On any given day, I wonder if Italy or Spain has closed their doors, because I’m reasonably sure all the Italians and the Spanish are in Prague.

Walking home after work has become a challenge, because the sidewalks are filled with strolling people who obviously have all the time in the world and believe they’ve rented the pavement for the day. The tourist areas of the old city are impossible to maneuver, as I discovered this past Friday when it took me 45 minutes to make a 20-minute walk to my dentist’s office. Local colleagues tell me that every Praguer who is able to do so leaves Prague in August, because vacationing Germans flood the city. I’ve already started perusing the city map to plan which areas of the suburbs I’ll be discovering for the next six months, as I endeavor to stay clear of the maddening crowds.

Ah Prague, the better to know ye!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

A good thing

2010-03-29T13:36:00.004-04:00

One of my favorite tasks as a Foreign Service medical officer is to mentor new-hire colleagues. This usually starts with an email from my director, asking if I am available to mentor a new employee, who is being posted to my region. I consider it an honor to be asked and a responsibility to be taken seriously. The purpose is to assist the practitioner in learning the Department of State administrative system, which, as you might imagine, is very different from a typical U.S. medical practice. Most of the mentoring occurs via e-mail or phone but may include a site visit as well.

My current mentee is posted to Kiev, Ukraine, and I recently made a site visit. My colleague is a young mother of two. Spousal employment can be a huge issue for many Foreign Service officers but this is a non-issue for my mentee, as her husband’s work can be done from home via the Internet. However, she is concerned about how overseas life might affect her children, since the lifestyle is so very different from growing up in the United States.

I brought my daughter overseas when she was 14, a terrible age to move a child from the known to the unknown, and we were fortunate it worked out so well. She had a personality that was open to exploration, and she was especially accepting of different cultures. Her first foreign school included a student body representing 34 countries. There is no doubt that it was a learning experience for her, far beyond the actual academic curriculum. Her senior year was spent boarding at a high school in Rome, and my concern that the year would not hold the wonderful memories usually attached to a senior year were unfounded. In fact, her dearest friends, eight years after graduation, are young women she formed a bond with in Rome and who have continued to be central relationships in her life.

I have tried to reassure my mentee that her children will most likely do just fine changing environments every two to three years. Not every Foreign Service child adapts and thrives, but the majority of them do. In fact, Foreign Service kids are some of the most adaptive and confident I’ve ever known. And, as my daughter will attest, the question, “Where are you from?” can make a Foreign Service kid the most interesting person in the room. That is usually a good thing.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

The hero whose name I don't remember

2010-03-23T12:32:00.010-04:00

In my last post, I mentioned Greg Mortenson, a modern-day hero to the people of northern Pakistan, whose story has been widely publicized. I cannot fail to also tell the story of the Pakistani doctor who is responsible for medical care in the Shigar Valley, where one of Mortenson’s schools for girls is located.

My friend, Debbie, and I walked into the local clinic on a Saturday morning. We visited because, as medical providers, we were curious about the services offered in this very remote area of the mountains of Pakistan, where there are no modern conveniences. Women wash clothes in the river, there is no running water or sewage and electricity is dependent on generators, which means the overwhelming majority of those who live there have no electricity.

We were warmly welcomed in the clinic’s outer waiting area, and an attendant, who spoke no English, hurried off to get the doctor. The physician, probably in his late 30s, invited us into his office and offered us tea. I am ashamed to say I do not remember his name, because it deserves remembering. We explained who we were and he cordially told us—his English was quite good—about his life. Notice, I didn’t say he told us about his practice. That’s because we quickly learned that the practice of medicine is his life—it is clearly not a job.

This man, the government-stationed physician, is responsible for the 15,000 people of his area and the only formally educated medical person in the Shigar Valley. His staff consisted of local people who had received on-the-job training to assist him in caring for his patient load. His wife and children live at the clinic with him, and he works every day of the year!

While we talked, his assistant brought in patients, who were totally accommodating of our presence. In their language, they told the doctor their complaints. After briefly examining them, he wrote notes on small pieces of paper, which he handed to the assistant. He explained that he was writing down what treatment to give or medicine to dispense. There was a steady stream of people of all ages coming through the door to his office. The nearest hospital is 2 1/2 hours away and inaccessible four to five months of the year, when the roads and mountain passes are closed by heavy snowfall. This doctor takes care of what he can and comforts the patients and families when all he can offer is compassion.

He kindly offered us a tour of the clinic. There were women’s and men’s inpatient wards and treatment rooms for minor surgical procedures or deliveries. There was a small pharmacy and a very basic laboratory. Furnishings were old and meager, but the place was amazingly clean. We asked him if the clinic accepted donations of medicine or medical supplies. No, he said. Needs of government clinics were provided for by the Ministry of Health, and they were specifically forbidden to accept any outside assistance.

Undoubtedly, there will never be a book written about this man, but he is also a hero to the people of northern Pakistan and another fine example of what one person can do. I really wish I could remember his name.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

What can one person do?

2010-03-15T16:25:00.017-04:00

For diplomats, travel within Pakistan is severely limited. However, the far north region remains secure and, outside of the snow months—November to March, visiting is entirely possible, though not entirely reliable.

It is a one-hour flight from Islamabad to either the northern side of the Karakoram mountain range of the Himalayas and the green Hunza Valley, or to the eastern side of the range and the stark gray beauty of the Skardu and Shigar Valleys, and the raging Indus River. Booking a flight in either direction is easy. Getting on the flight, or getting on a flight back, is the challenge. The planes fly into and out of these valleys by visual means only and, in these high mountains, visibility changes from one hour to the next. I’ve had many colleagues who were stuck on one side or the other for several days, unable to return until the weather cleared. I was never that fortunate.

Both of these areas draw mountain climbers from all over the world, although the security situation in Pakistan has hurt the sport tremendously since 2001. These are not classic tourist areas. There are comfortable—though basic—places to lodge, the air is crystal clear and the food is hearty, although it would not be termed cuisine. Hikers can safely backpack to remote locations and camp and, while very little English is spoken, local people are adept at understanding what a visitor needs and are always willing to assist.

It was on a visit to the eastern side and Shigar Valley that my friend Debbie and I came upon a little school building with a yard full of happy, giggling girls. This tiny village doesn’t see many visitors and the girls were extremely excited by our presence. The head teacher welcomed us to the school and offered a tour. So, in and out of the neat little classrooms we went, looking at artwork and taking note of writing exercises on the blackboards and completed math pages. One young girl offered to read to me from her English book, so we sat on the steps as she expertly read a story. I noticed a photo on the desk of a Western-looking family who, the teacher explained, was the school’s benefactor. It was only later that I understood the significance of that photo.

If you have not read the book, Three Cups of Tea, please do. It is the story of Greg Mortenson, an American RN and former mountain climber who saw a need in the mountains of Pakistan and made it his life’s work to educate the illiterate children, especially girls, of the northern regions. It was one of Mortenson’s schools that my friend and I visited that day, and it is one of the most meaningful memories of my time in Pakistan.

Mortenson’s foundation, Central Asia Institute, strives to promote peace through education and by improving the place of girls in society. In November 2009, Mortenson was awarded the Archon Award by the Honor Society of Nursing, Sigma Theta Tau International at its 40th Biennial Convention. I have read that he has twice been nominated for the Nobel Peace Prize, an honor he surely deserves, as he has more than answered the age-old question, “What can one person do?” As one person, Greg Mortenson has created miracles and changed lives, and is an American hero in Pakistan.

Additional resources:
Convention highlights—Monday, 2 November. (2009). Reflections on Nursing Leadership, 35(4). Retrieved 15 March 2009 from http://www.reflectionsonnursingleadership.org/Pages/Vol35_4_FTS_Convention_day3.aspx

Mattson, J.E. (2009). Through his mother’s eyes: Jerene Mortenson talks about the work of Greg Mortenson. Reflections on Nursing Leadership, 35(4). Retrieved 15 March 2009 from http://www.reflectionsonnursingleadership.org/Pages/Vol35_4_Mattson_JMortenson.aspx

Mattson, J.E. (2009). Wrong turn at the Braldu. Reflections on Nursing Leadership, 35(3). Retrieved 15 March 2009 from http://www.reflectionsonnursingleadership.org/Pages/Vol35_3_Mattson_Mortenson.aspx

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Viva Italia!

2010-03-09T11:24:00.008-05:00

Today was a beautiful, sunny day—a real treat during this mostly gray-skies time of year in Prague. I took the opportunity to hop a tram, followed by the metro, to go to a distant shopping area and explore that vicinity of the city.

Before I joined the Foreign Service, I spent my entire life in southern United States. Mass transit really doesn’t exist in the South, other than a rather limited system in Atlanta, so being involved with some of the world’s largest and most sophisticated mass-transit systems has been of real interest to me, both in technology and in the culture of mass travel.

Most of my metro/tram experience has been in Europe, but I was also a frequent rider of the Mexico City metro, while serving in that post. Frankly, most of my colleagues wouldn’t ride the Mexico City metro, for fear of pickpockets or of being squashed to death. The latter was a real possibility, as I quickly discovered one rush hour when I witnessed a young woman trying to exit the train and be literally picked up by the oncoming rush of people and pushed back into the car. I hoped she was able to get off at the following stop.

My favorite thing about living in Moscow was the metro system. This system is HUGE! It is dependable, inexpensive and has the most artistic stations I’ve ever seen. I spent many weekends just traveling the metro and taking pictures of station decorations, which was strictly forbidden but not enforced. There are tours of the Moscow subway stations—I took one just to learn more about the history—and coffee-table picture books of the most ornate.

The culture of mass transit in Moscow is interesting. There is a set etiquette for travel, and it includes being straight-faced and, preferably, quiet. If one must speak to another passenger, it is to be done at a whisper and as quickly as possible. And one should never ever smile, nod or make eye contact with other travelers.

In contrast is travel on the Rome metro, where jabbering travelers might be entertained by a fellow commuter(s) who breaks out in song—usually opera—for a few minutes, and then finishes to raucous clapping. While Rome stations are not particularly ornate, in comparison to Moscow stations, their displays of Roman antiquities are a real plus.

In Bucharest, I sometimes traveled on the new and modern metro, usually with only a few other passengers. The line is rather limited, but so expensive that most people couldn’t afford to travel. Sure kept those cars clean and shiny, though.

In Budapest, the stations were underground shopping malls with food courts, stores, flower shops and travel agencies—sort of one-stop shopping while going to or from home. I mostly used the trams in Budapest, and I don’t think I was ever on one that wasn’t standing-room-only, which became an issue when tram police jumped on to check tickets. People without tickets would start pushing to the other end of the car, hoping to get off at the next stop before getting caught and fined. It was great entertainment, if I could get out of the way.

The metro and trams in Prague are modern and quite utilitarian, and the system is widespread. The most important thing is, they are punctual with a great frequency schedule. Unlike our neighbors to the far northeast, people happily chat and smile at each other, though not so much to strangers. On my tram ride back home today, our car was serenaded by a group of three young men—visiting Italians!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Interesting people

2010-03-01T11:49:00.003-05:00

I continue to visit medical and dental clinics in Prague, as required by my Washington superiors. The purpose is to know options for care that are most in line with our American medical philosophy. This information benefits Americans who work here in an official capacity as well as visiting Americans who call the consular office for our list of medical consultants. I’ve had the opportunity to hear interesting stories along the way, and I frequently find the unexpected.

From 1948 to 1989, the Czechs were under a communist political system. One practitioner I know completed his medical education in Prague in the late 1960s and then defected to the west, eventually ending up in Canada, where he practiced for more than 20 years. He returned to Prague a few years ago to work and reclaim the home of his youth. His story is fascinating as he tells of his struggle to learn English, pass the medical examinations required in Canada and begin a life completely cut off from the rest of his family, who remained in what was then Czechoslovakia. He made huge sacrifices to live a life free of political domination.

I met a physician born in the United States to Czech parents, who defected from communism. He completed his medical education around the time the Czech Communist Party was abolished and decided to come to the Czech Republic to help build the new medical system. He has spent the last 20 years with his foot in both societies. He has a practice in Prague and maintains an attending staff position at an Ivy League teaching hospital in the United States, working at the U.S. location several times a year. Medical residents from the U.S. program have the opportunity to rotate through a linked curriculum he administers in Prague for an overseas study semester.

My young dentist in Prague is an American who married a Czech woman. They met in the United States, where they married, lived and worked but, when their child was born, they decided to move to the Czech Republic to be near her parents. His story is equally interesting because it is the reverse tale. Although he wasn’t escaping a totalitarian government, he did have to learn Czech—a very difficult language—to pass the certifying and licensing examinations. In fact, he was the first English-speaking dentist to achieve licensing in the Czech Republic. And, of course, he had to adapt to a very different medical environment. He has great stories to tell about his experiences; in fact, they all do. Meeting these interesting people and hearing their histories is one of the most interesting parts of my job.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Grandma in a box

2010-02-20T13:09:00.003-05:00

I live in a computer. At least, that’s what my 18-month-old grandson, Price, thinks. Yesterday, my daughter in Orlando sent me a precious video of Price standing in front of the computer monitor, pointing and saying, “Nana!” It is there, in that small square, that he sees me the most. I play tickle with him by waving my fingers at the webcam and blowing kisses his way. He leans in to hug the monitor and then looks confused that it looks like me, but isn’t me. I want to reach out and grab him, but we aren’t at the “Scotty, beam me up” phase of our scientific progress yet. Webcam is definitely the next best thing.

Living overseas has many challenges. Maintaining a family life with those in the United States is one of them. When I joined the Foreign Service in the late 1990s, technology—especially communication technology—was still very basic. There was email, of course, but no Facebook, blogs, webcam or Voice over Internet Protocal (VoIP). The special-occasion phone calls were very expensive and mail (via the U.S. diplomatic pouch system) was slow. The only thing that has remained the same is the pouch.

Another significant change for me is my family framework. During the early years, my four older children were all single and in university. They didn’t have much time to communicate and, frankly, not a lot of interest. If I managed to talk to them every other month and saw them once a year, that was OK. We were all busy with our individual lives and, because my youngest child was with me overseas, I still had a family core.

Then, in quick succession came the weddings, followed by the change that rocked my world—grandchildren. The birth of each little boy—there are seven now—tugged my heart a bit more and, I believe, gave my grown children a different perspective about staying in closer touch with me, too. The difficulties of frequent communication became more apparent to us all, and while webcams had become available by then, I didn’t have computer access that could support one.

When I moved to Islamabad in 2006, I could finally sign up for VoIP and use a webcam. My then youngest grandson, Trevor, who previously would have nothing to do with me on home visits because I was a stranger to him, learned who I was and would happily babble to me over the Internet. Now, when I would visit, he came to me easily. When my next grandson, Caden, was born, he grew up seeing me on webcam and never viewed me as a stranger at all. His mother would announce as I was leaving from a visit, “Nana is going back into her box!” and the transition was smooth. Little ones are amazing like that.

I fully understand how much this advance in technology has helped me stay satisfied with my Foreign Service career and life out of the United States. I feel like I am part of my children and grandchildren’s lives on a more personal level and, as a result, any guilt I might have of choosing to be so far away is largely assuaged. It is a tough choice to move to the other side of the world from one’s family and friends. I am very grateful to have the benefit of technology to bridge the distance.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

How do YOU spell relief?

2010-02-12T06:00:00.003-05:00

The snow has been falling intermittently in Prague for two months. The streets and sidewalks are rife with patches of ice that threaten all who trod there. I’ve been doing quite a bit of slippin’ and slidin’ myself, and I’ve had a number of patients come to the medical unit that have been injured from falls. Some have been referred to our local emergency departments or orthopedists for treatment.

This brings me to the topic of pain and, more precisely, pain control. Americans, probably more than any other society on earth, are interested in pain control. We don’t like to hurt, and we believe that unnecessary pain is a violation of our human rights. We have laws that govern pain control measures, and we have developed pain measurement scales to assist providers in properly assessing the level of pain or pain relief.

Many other societies accept pain as incidental to injury and, while they may offer measures of relief, they are not committed to pain eradication whenever possible. Of course, there are many areas of the world where pain medication just doesn’t exist, or it is reserved for the truly severe cases, so pain tolerance is expected.

I’m discovering that the philosophy in the Czech Republic, as in much of Europe, is that pain is to be dampened by using the most moderate means available. That usually means no narcotics. Europeans love NSAIDS (ibuprofen-type medications) and are really slow to suggest narcotics. They also rely on nonpharmacological methods such as ice, heat, breathing techniques, muscle relaxation, music, massage therapy, and the list continues. These important adjuvant measures are used in the United States, too, but usually not for short-term or immediate pain control.

In West Africa, I took a patient with an injured leg to the local emergency department. The X-ray showed a displaced fracture and the orthopedist was called to do a closed reduction. I asked the doc, “What are you going to give her for pain?” He looked puzzled for a moment, then turned to the nurse and said, “Please prepare some tea!”

A very quick and tense conversation followed regarding pain control in this patient, who was now terrified as well as hurting. It was finally decided that I would scurry to my clinic to bring an appropriate pain medication to the hospital for my patient, as all the doc could provide was an NSAID. My patient had pain medication prior to the closed reduction and casting and, while the procedure was still a bit uncomfortable, she did quite well. Oh, yes. She also had tea!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Blow out the candle!

2010-02-04T16:47:00.003-05:00

How, you might wonder, do I manage a patient with a medical problem that can’t be handled at my post? This is actually quite common at many embassies and not just those with poor, local medical care. Some very modern places in the world do have a medical viewpoint that is culturally different from Americans and, when necessary, we medevac to a location more in keeping with our standards or expectations. Of course, the majority of medevacs are for conditions that cannot be medically treated due to lack of appropriate local resources.

The type of medevac depends on the patient and the problem. Sometimes, the patient travels on commercial transportation alone, sometimes with a non-medical or medical attendant and, in the most severe circumstances, we call in an air ambulance. During my career, I’ve had patients who have required each kind.

You might think that the person who is able to travel alone would cause me the least angst, but that isn’t a given. Consider the mid-40s gentleman who, after six months of feeling not quite right, was evaluated by his family doctor while in the United States on leave. A chest X-ray was suspicious and a CT was ordered but, before the report was sent, he returned to post in Kabul, Afghanistan. This gentleman brought a letter into my clinic that had arrived via DHL.

The letter started with “Take this to your medical provider immediately” and, as I read, I saw the term “dissecting, ascending aortic aneurysm.” These are not words a nurse practitioner wants to read, ever, but particularly not in the middle of a war zone with limited options for emergency care. After many phone calls of consultation, the decision was made to fly the patient back to the U.S. for surgery—on regular transport. Imagine both my surprise and relief when I received a message some 30 hours later that the patient was at Duke University Hospital prepping for surgery after an uneventful flight.

The only case of Guillain-Barre I’ve ever seen occurred when I was serving in Conakry, Guinea. While my patient’s ascending paralysis was making its way up his torso, I was calling in the air ambulance. Unfortunately, air ambulance support to a remote place like Conakry can take a lot of time and, in this case, more than 24 hours. I moved the patient to the hospital nearest the airport where there were people—but precious little else—to help me take care of him. The internist overseeing the patient’s care moved the anesthesia machine into the room in case he required respiratory support, as there was no ventilator in the hospital. But, much of the time there was no electricity in the hospital either, so an Ambu bag was brought in as well!

After we settled the patient in the room, the internist brought in a candle and a tape measure. He proceeded to measure 18 inches out from the patient’s mouth, then lit the candle and asked the man to blow out the flame. He did. This, the internist said, was proof that his pulmonary function was adequate. As long as our patient could blow out the candle each hour, we would not have to intubate (put in a breathing tube). Every hour, for the next 20-plus hours, either the internist or I dutifully lit the candle and our patient dutifully blew it out. By the time the air ambulance arrived, my patient only had use of his head, neck, shoulders and upper arms, but he could still blow out the candle! I have no idea if this procedure is actually founded in good science, but I can tell you that this hourly exercise was immensely calming both to my patient and me during an otherwise very scary situation.

When the flight crew arrived and I reported off, I couldn’t help but notice the confusion on the face of the attending physician when I explained that our patient had been able to extinguish a candle flame at 18 inches throughout our wait for the air ambulance. I’ve tucked this little pearl of information into the recesses of my brain, in case I’m ever in a similar circumstance and need a rudimentary means of assessing respiratory effort. I’m happy to wait.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Small miracle

2010-01-25T11:30:00.006-05:00

The Western Hemisphere and most of Europe are gripped by the tragic events unfolding in Haiti. Modern media transports those of us who have televisions to the center of the misery and captures us with heartbreaking and touching stories.

I always considered myself a knowledgeable person, but it wasn’t until I joined the Foreign Service and traveled to the, shall we say, more unusual parts of the world, that I realized how little I really knew about life outside of my sphere. I understood American poverty and I understood the chasm that existed between those who have and those who don’t—in North America. After all, I grew up in south Texas and had visited our neighbors to the south many times. I thought I knew.

What I know now is that the events currently taking place in Haiti are occurring all over the world, on a smaller scale, daily. I don’t just mean earthquakes. I’m talking about desperate circumstances, poor nutrition, unsafe water, lack of shelter, and poor medical care. The World Health Organization estimates that one million African children die each year from malaria. That’s just one continent and one disease. To extrapolate is truly disturbing.

And while I now know, and have seen firsthand, some of the terrible conditions people survive, I have also seen small miracles occur, without international coverage or support, that make life better for these unfortunate people. I’ve already mentioned a few, but I want to tell you another.

When I worked in Conakry, Guinea, I was introduced to six nuns of the Missionary Sisters of Charity—the order started by Mother Teresa—who operated a clinic. I began assisting them in small ways. The clinic usually had a full load of 25 inpatients, mostly children 3 years and younger who had nutritional needs.

One day, I received a phone call asking me to come to the clinic to see a sick child but I was unprepared for what I found. A village woman had come to the clinic with a premature infant. She was the infant’s grandmother. The mother of the child needed to stay in the village with her other children. This baby weighed 1 kilogram. I had no experience with preemies and looking at this little boy was like looking at a tiny, skinny doll. I was afraid to touch him. In spite of his small size, he looked pretty good. He was alert, he was feeding well (breastfeeding mothers at the clinic were pitching in) and he had no respiratory problems. But he was only a few days old, and I couldn’t imagine he would survive. In a developed country, this child would be in the NICU for weeks with all sorts of advanced monitoring and treatments. This baby was in an open crib in a room full of sick children, with just a mosquito net between him and certain malaria. If he needed specialized care, it just wasn’t available. The clinic didn’t even have hot water.

I went to the clinic every other day and watched in amazement as this child survived, developed and eventually flourished. When he was 3 months old, he was a plump, smiling and cooing little boy, and his grandmother took him back to the village. I think of him often and wonder if his miracle continued. He would be 8 years old now. I hope he is.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Unpacking history

2010-01-20T10:19:00.005-05:00

Today is moving-in day for me. I arrived in Prague in October but my HHE (household effects) were just delivered. I had a much smaller shipment that arrived from Islamabad in October, so I’ve been perfectly content living with what I have, and I have dreaded this day for several months now. I need to give you the background on the problem.

Allow me to introduce you to one of the oddities of Foreign Service life. We move—a lot! Our standard tours are one to three years, depending on the difficulty of the location. While our housing is provided, and almost always furnished, personal items, household goods, kitchenware, books, etc. move with us. Some posts are in areas where standard goods are difficult, if not downright impossible, to buy. If we are moving to one of those “hardship” posts, we are also granted a consumables allowance, which is an additional weight to use for products we will need while we are at that post and are not likely to find locally.

In 2001, I transferred to Conakry, Guinea in West Africa. Conakry is one of those “hardship” posts where a consumables allowance is essential. Guinea is a country incredibly rich in resources with a long-standing corrupt government that has kept the people in abject poverty. Fortunately, people don’t usually starve there because food grows abundantly, but the people are starved for everything else. As a result, goods and services are largely unavailable.

I was supposed to be in Conakry until 2004 and I brought with me ample goods to see me through. I’ve learned that I do quite well on local food, so most of my consumables are things such as paper products and cleaning supplies. One can really tell a lot about a person’s preferences from seeing what is chosen for consumables. Let your imagination be your guide: disposable diapers, wine and beer, ethnic foods, various canned goods, etc. For me, it is American paper products. They can’t be beat! If you have ever used non-American toilet paper, you know what I mean.

Unexpectedly, I was offered a move to Kabul, Afghanistan for the spring of 2003, more than a year before I was supposed to leave Guinea. I jumped at the opportunity and began the preparation of moving. But there was a catch. Housing in Kabul consisted of a 17-foot by 8-foot metal shipping container, and I was only allowed to ship 500 pounds of goods and bring two suitcases. So everything I had in Guinea that was non-perishable was put into storage for me by the Department of State.

My plan was to do the one-year tour in Kabul and then go to another regular post, but again I was offered my dream job—worldwide rover. My things stayed in storage for the second and third year while I worked temporarily in nine different locations, filling in staffing gaps. In fact, the things I had shipped to Kabul were now in storage, too, as I was down to two suitcases—period!

As providence would have it, for my next posting I chose Islamabad, again one of those limited-household-effects posts, and all I was able to move was the stored goods from Kabul. I stayed in that one-year post for three years! This brings me to today. This morning the belongings that have been stored since 2003 were delivered to my apartment.

I have been opening boxes all day, discarding things I wondered why I packed at all, trying to find a place in my limited storage space for other things I know I don’t need. I’m even getting nostalgic over a few items. When I opened a box filled with dinnerware my son gave me years ago, I choked up. And when I came across a couple of items that had belonged to my daughter, I sat down for a good cry. Perhaps nearly seven years of not having my real life with me was too long. I need reminders of my history to reassure me and help me remember who I really am and where I came from, not just things that chronicle where I’ve been.

Some of the boxes have been real surprises with contents I actually don’t remember at all. Several times today I have said, to no one present, “Where did this come from?” Fortunately, I like most of what I’ve found.

And then I came upon the consumables. I won’t bore you with the details, but I will tell you this. For the rest of my life, I will never again have to buy paper towels.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Culture shock

2010-01-08T14:54:00.004-05:00

Culture shock is a well-known, expected phenomenon in the Foreign Service community. It doesn’t happen to every person with every transfer, and there are degrees of effect, but it is something we warn our patients about whenever they relocate. I am in culture shock.

There are phases to culture shock. The first is the honeymoon, where the new location is pleasing and exciting. Prague is certainly beautiful—amazingly beautiful—but the aspect of Prague that impressed me most in the weeks after I arrived was my ability to walk through the city and have no one pay attention to me. My last three years were in Islamabad, Pakistan. It was too dangerous to freely walk around the city and, in those few places we were allowed to go, a tall, gray-haired (head uncovered), fair-skinned woman walking about was always met with curiosity. Everyone stared! So, for the first six weeks in Prague, I walked for a couple of hours after work—more on the weekends—just because I could and no one would care. It was absolutely liberating.

The second phase of culture shock is negotiation. That's where I am. In this phase, the new living circumstances may cause frustration, anxiety and even anger over differences in language, cultural ethics and available food choices. This is a time of comparison between what was one’s life in contrast to what is one’s life and may lead to mood disturbance or even depression, in extreme cases.

Life in Pakistan was life on the edge, especially the last two years. Somehow, being in the middle of it conferred a sense of control. Now that I have moved on, I am beset by concern for those I left behind, especially my Pakistani friends who are less protected than the diplomatic residents. I feel helpless to do anything but worry, so I worry. I watch the news. I fret when a new incident happens. Recently, the Navy Yard gate in Islamabad was attacked and people were killed. The Navy Yard was one of my favorite places to shop and I felt safe there. In Prague, I feel safe everywhere. That is a very good thing, but now I also feel guilty for enjoying this safety and freedom in Prague when my former colleagues don’t share it.

The final phase is adjustment. When I get to that phase, life in Prague will feel normal to me and Pakistan will be a memory. It isn’t that I will lose my concern for my colleagues who remain in Islamabad, but I will accept that my focus is my life and work in the Czech Republic.

Foreign Service employees may also suffer reverse culture shock when they reenter the United States for a long visit or for a work tour. Returning to the U.S., especially from a country that is very different, can be mind-boggling.

Many years ago, I came home for the birth of my first grandson. I was living in Ghana at the time and, while it is a pleasant country and I enjoyed living there, food choices were quite limited. On my first day back in Mississippi, my daughter sent me to the grocery store with a list that included corn flakes. I stood in the aisle at Kroger looking at what seemed to be dozens of choices of corn flakes—different brands additives and sizes. I simply could not choose because I had grown accustomed to buying the one option available to me, if there was any available at all. Having so many choices was overwhelming! I was forced to call my daughter and request that she name a particular corn flakes item so I could continue shopping. And, yes, she thought I was completely wacky!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Win-win

2010-01-04T12:09:00.011-05:00

It has been the holiday season in Prague and, as in most northern European cities, numerous small log-cabin-type buildings have been erected at most major plazas, and merchants have been selling crafts and Christmas goods. Originally, I thought this was the purpose of the markets, but I now know better. The real reason for the markets is to drink beer, grog and mulled wine and to eat pastries and sausage. The shopping is just for entertainment during eating and drinking rest breaks.

Recently, I visited an interesting specialty hospital in Prague. This hospital specializes in adult cardiac, neurosurgical and planned abdominal, vascular, orthopedic and GYN surgery. They have no conventional emergency department and they don’t accept trauma cases. The hospital is also heavily involved in surgical research.

My intent was to quickly view the outpatient diagnostic departments and perhaps see a med/surg floor, but the executive office, which had advance notice of my visit, arranged a presentation in the cardiac catheterization lab. Specifically, I was ushered into the electrophysiology lab, where a patient was undergoing right-atrial mapping for prospective ablation therapy.

I had atrial ablation in 2005, so I was interested in comparing the facility in Prague with the U.S. facility that treated me. The Prague lab is super high-tech with robotics and a magnetic catheter-guidance system that has just become available in the United States. I do believe my electrophysiologist in Memphis would be drooling over this lab set up.

The opposite end of this scale would be the National Cardiothoracic Centre in Accra, Ghana. It was my privilege to meet the founder of this, the first cardiac surgery program in all of West Africa, while I was posted to Ghana. Frimpong Boateng, MD, left his native Ghana in the 1970s to study surgery in Germany. After 10 years abroad, he returned to his home country to offer life-saving cardiac surgery where there had been none and, in 1989, with considerable support from members of the German medical establishment, opened the National Cardiothoracic Centre in Accra. For 20 years, he has struggled to keep his life’s work moving forward and has survived insufficient facilities, a dearth of funding and even occasional loss of electrical backup during surgery. The center regularly accepts patients from neighboring countries and primarily repairs valvular and congenital heart disorders for persons who would have no options if the center didn’t exist.

I have not been to this hospital in many years but I am confident that Boateng and his group of dedicated colleagues continue to provide valuable health care under the most difficult of circumstances and without all the fancy bells and whistles I saw this week. Don’t misunderstand. I am as impressed by the potential of the high-tech interventions and the practitioners who advance our knowledge through research as I am by the surgeon who is saving lives under stringent circumstances. Ultimately, in both cases, the practice of medicine benefits and lives are bettered. I think we call this win-win.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

H1N1

2009-12-21T11:45:00.005-05:00

H1N1 has arrived in the Czech Republic. This is a bit more complicated for my clinic than for a clinic in the United States. For one thing, I don’t have H1N1 vaccines. They were ordered months ago for the Foreign Service, but only a tiny fraction has actually been delivered to the Department of State for its overseas staff. I have 20 people who fall into the CDC’s high-risk group and should be vaccinated; some of them are anxious because the vaccine is not available.

The Czech Republic has vaccine only for a limited number of their residents, and they have purchased Pandemrix, which is not FDA approved, so I wouldn’t be able to use it anyway. I do have Tamiflu and Relenza and use them when appropriate. Although we have had employees diagnosed with H1N1, so far, none have been serious, and we are doing our best to keep it that way.

We’ve been busy educating all staff members at the embassy, including local employees who fall under the Czech health system. I’ve tried to impress on everyone that this is a public health issue and not just a private health concern. I’ve delivered information in e-mails, handouts and personal group sessions with the different offices, but the most successful campaign has been the use of a video prepared by the Virginia Department of Health. Whoever thought this up is a genius!

In 2007, when “bird flu” was all the rage, the U.S. Embassy in Islamabad, Pakistan was seeing a large bird die-off on the embassy compound. My clinic arranged for some of these birds—all crows—to be evaluated at a poultry lab and, sure enough, they died of H5N1. At that time, there had been no animal-to-person transmission of avian influenza in Pakistan, but having these multitudes of bird carcasses around the compound was unsettling to people, and a minor crisis was evolving.

Our facilities manager called me one afternoon to announce that a sick hawk was on the compound and asked me what to do. “Leave it alone,” was my sage advice. For the next three hours, I received update calls as this poor bird experienced his death throes! When he finally did expire, he was refrigerated and sent to the poultry lab for diagnosis. He tested negative for H5N1, so they performed an autopsy! Cause of death: pathogenic E-coli. If Mr. Hawk had come to the health unit for his check-in orientation, he would have known to boil it, cook it, peel it or leave it, essential food sanitation advice in Pakistan, and he might still be soaring in the skies!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

We got something right!

2009-12-11T13:03:00.004-05:00

One of my responsibilities, when moving to a new post, is to assess local medical resources. Most cultures are more formal than the American culture, so there are official introductions, sometimes the exchange of small gifts, often tea or coffee, and polite chatting before we get down to the business of me asking, “What can you do for the official Americans in your country?” Not in those words, of course, but that is the real purpose. I will visit the hospital or clinic and ask nosey questions to determine if the facility is acceptable to me, and those I serve.

I continue to be surprised by the hidden jewels I find in the most unexpected of places around the world. I remember the husband-wife MD team—Harvard residencies—working in a truly backwater clinic in Rwanda and, in Guinea, the tropical disease expert from Germany. I have never served anywhere that I couldn’t find at least a few excellent physicians.

Nursing is another matter. Frankly, most of the countries in which I have worked undervalue the nursing discipline, and a few—Guinea and Afghanistan come to mind—don’t recognize the discipline at all. Nursing in these places is an OJT technician job with little formal training and no respect. In more modern countries, nursing usually requires formal education but falls short of the critical thinking required in countries with the highest standards of nursing care.

I recently had dinner with a German nurse who was lamenting that nurses in her country, while highly educated, were underutilized as integral members of the health care team. She was intrigued by advanced practice nursing and commented on the ways in which the German system could benefit from such a program. Finally, she said, “You Americans have really got it right!” Now, there’s a comment I never hear. I usually have to listen to all the things we Americans have wrong.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Assimilation in progress!

2009-12-03T07:00:00.002-05:00

Encountering a different culture as a tourist doesn’t require true commitment to adaptation. A person on vacation eats in foreigner-friendly places, shops for souvenirs in stores where staff do not view the customer as a “bother,” and learns polite words (please, thank you, etc.) in the language of the country visited, but little else.

Not so for the expatriate who has come to a foreign country to live and work. We are more than guests of our new home country and are expected to assimilate as much as possible. In some countries, going to the grocery store is often more of a nightmare than an adventure. When I was in Russia, where I had no prior language training, I would only purchase things that were visible in the package or that had a picture I recognized. The writing was not only Russian, but in the Cyrillic alphabet, and completely unintelligible to me.

Once, an American co-worker, also a non-Russian speaker, and I decided to lunch in a particular restaurant because they had an English menu. Most restaurants will have a line item in the local language followed by a translation immediately below it in other languages. This establishment, however, had two separate menus, one in Russian and one in English. Our server spoke no English, so my friend and I found what we wanted on the English menu and then located items in the same positions on the Russian menu and pointed out our choices. Ah, you see what’s coming, don’t you? It’s true; the meals we ordered were not at all what we were served. It never occurred to us that the two menus, other than being in different languages, would not be exact duplicates of each other.

I’ve been in the Czech Republic for five weeks now and I’m learning to assimilate. At least the Czech language uses the Roman alphabet and I had seven weeks of language training to give me the bare necessities of communication.

I was in the butcher shop a few days ago and asked, in Czech, for the items I wanted. The lady behind the counter understood me and began preparing my order. I burst with pride when the woman standing next to me turned and said something in a long Czech sentence that I did not understand, but I knew she spoke to me because she thought I could understand. I smiled and nodded, to what I do not know, and she was satisfied.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Prologue to my blog

2009-11-25T08:30:00.003-05:00

The advertisement in the nursing journal said, “Deliver primary care to U.S. government employees working in embassies overseas.” That was enough to catch my attention! I was a 40-something single mother with a great nurse practitioner job in Biloxi, Mississippi, but I had a nagging suspicion that there was more to be had if I looked for it. Soon, I was going through the long and frustrating process of applying for the position of foreign-service health practitioner with the U.S. Department of State.

That was 10 years ago and, in subsequent years, I have enjoyed long assignments in Ghana, Guinea, Afghanistan and Pakistan with shorter tours to Mexico, Russia, Hungary, Uzbekistan, Rwanda, Kosovo and Honduras. I am assigned—with consideration of my preference—to a U.S. embassy community to deliver patient care in the medical unit, usually as the sole provider, but sometimes with a State Department physician. The patient load is the run-of-the-mill primary care stuff with some interesting twists along the way. Some are location-specific, such as parasites, malaria, or “acid” bug burns. Some are scary acute-care problems (MIs, cancers and orthopedic nightmares) that my clinic diagnoses, stabilizes—using local resources, when available—and transfers to a medevac center or to tertiary care in the United States.

It isn’t all direct patient care. I am responsible for testing embassy water quality, evaluating food sanitation practices of embassy kitchens, scrutinizing local public health issues that might affect our embassy population, emergency preparedness, health education of the embassy staff and a variety of issues that are in some way related to the health and well being of embassy personnel. It is never boring and I marvel at the range of knowledge I have acquired since taking this job.

The off-work possibilities are boundless. I’ve spent New Year’s Eve in Red Square, ridden horseback to Egypt’s Great Pyramids, climbed through a bamboo forest to photograph mountain gorillas and been a lazy bum on some of the most beautiful, and isolated, beaches in the world.

I’ve met amazing people at every location and learned that, no matter the region or the language, we are all more alike than we are different. I have also seen the poverty, lack of education and poor health care the majority of the world suffers. It devastates me, but I have been able to offer small assistance by volunteering at a children’s center or supporting a local hospice.

Of course, there are some negatives to this employment. While I have attended the major events in my grown children’s lives, such as weddings, I’ve missed just about all of the daily life events. Webcams and Skype phone calls help my seven grandsons remember my face and voice between visits home, but I miss not being with them more often. My youngest daughter traveled with me until 2003, when she returned to the United States for university. Now, I live and travel unaccompanied and sometimes feel out of touch with the U.S. culture, and my family and friends. Still, I know how truly fortunate I have been to reside and work in the world at-large. It isn’t for everyone but it has been a dream-come-true for me.

I recently completed a three-year assignment in Pakistan, an amazing experience. After returning to Washington, D.C. for two months of language training, I’ve now moved to my new assignment, Prague, the capital of the Czech Republic. The past 10 years have taken me to mostly rough, medically underserved locations. For the next three years, I will be in the heart of Europe, and I wonder what that assignment will hold for me. In this blog, I will share my discoveries and adventures and reflect on past ones. I hope you’ll join me.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International