20 February 2010

Grandma in a box

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.

12 February 2010

How do YOU spell relief?

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.

04 February 2010

Blow out the candle!

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.