22 December 2010

Turkey, ham or carp?

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.

16 December 2010

You’re going where?

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.

01 December 2010

Thanks, Jim!

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.

22 November 2010

Home sweet shipping container

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.

04 November 2010

Pink backpacks in Kabul

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.

20 October 2010

Thumbs up for the Scots

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.

14 October 2010

Weighing in on vaccinations

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 be
en 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.

24 September 2010

One Saturday night in Pakistan

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.

10 September 2010

Meet me at The Savoy

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.

24 August 2010

A man's best friend

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.

16 August 2010

And this is a SLOW week!

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.

02 August 2010

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

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.

20 July 2010

Fans, fountains and fruit

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.

13 July 2010

Disabled doesn’t mean unable

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.

30 June 2010

A place at the table

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.

16 June 2010

Question to ponder

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.

08 June 2010

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

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 maximu
m 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.

27 May 2010

Only when stressed

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.

18 May 2010

They haven't forgotten

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.

13 May 2010

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

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.

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.

03 May 2010

When personal overlaps with professional

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.

26 April 2010

Truly remarkable people

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.

15 April 2010

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

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.

05 April 2010

Too much of a good thing

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.

29 March 2010

A good thing

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.

23 March 2010

The hero whose name I don't remember

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 clini
c 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.