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.