09 July 2012

Where's the billing department?

On a recent trip to The Indus Hospital in Karachi, I was once again amazed by the extraordinary achievement of a few ordinary people. This is a free hospital completely supported by donations. No one who is seen and treated at this hospital is charged. If a patient wishes to donate a sum of money, it is accepted but they are not informed what their treatment might have cost in a different institution, and there is absolutely no expectation of a donation.

You might think this is a small, neighborhood operation, but you would be wrong. The hospital staff treats upwards of 300,000 outpatients per year and has admissions of about 11,000. And free doesn’t mean low tech, either. Indus offers invasive cardiology, endoscopy, lithotripsy, hemodialysis and all radiology services except MRI, and that will be in service before the end of this year.

Impressed? Well, there is another really amazing fact. Indus is 100 percent paperless! All records and reports—all business—are electronic. Of course, since they have no billing department—can you imagine?—a large need for paper is eliminated right from the start. When one visits a hospital ward at Indus, the robotic medication cart moving down the hall with monitor and keyboard on top should be a quick tipoff. All medications are ordered, tracked and recorded electronically. Every patient service is handled the same way.

How did this amazing institution come to be? A group of like-minded medical and business people decided it was needed and would be so—and now it is. The goal was free but excellent treatment for the poor, and Indus provides both.

I visited Indus because I will be screening our local staff for tuberculosis this fall. We do this on a four-year cycle, because TB is endemic in Pakistan, and it is important to screen for possible infection and to ensure that people are properly treated. The government of Pakistan has a TB treatment program, and the expert resources in the Karachi area belong to The Indus Hospital. My objective was to arrange a referral path, in case our screening indicated any employee needed further testing and, possibly, treatment.

After my tour of the main hospital, I was taken to the TB screening and treatment facility, which is in a separate space from the hospital proper. I really hate to overuse the term “amazed” but, once again, I was. This purpose-built building is ingeniously designed to accomplish infection control.

Karachi’s climate alternates between hot and hotter and there is, on average, 7 inches of rainfall per year. That is only 4.5 inches more than Death Valley’s annual average, so this climate is hot and dry. The TB treatment pavilion uses an open-air concept in which shade coverings that resemble boat sails are positioned horizontally to the ground. Every six feet, a bidirectional fan moves air toward the ground, air that is subsequently circulated up and out through the sails. Because the tubercule bacilli are lighter than air, any that might be exhaled from an infected patient are swept up and out with this efficient ventilation system, thus dispersing the bacilli and rendering them ineffective. In Karachi’s hot, dry climate, this ingeniously designed system is very cost effective. As an added safety factor, patients, staff and visitors all wear surgical masks to further reduce the chance of exposure.

In addition to this hospital-based TB facility, where patients are diagnosed, counseled, tested and treated, there is an extensive community support program. TB patients are given monthly food items for nutritional support, a monthly travel allowance to treatment centers, daily home visits by treatment supporters to monitor drug compliance—they utilize Directly Observed Treatment, or DOT—and to provide ongoing psychological and social support during the term of treatment. It is all without cost to the patient.

Here in Karachi, a city of 20 million in a country with an unstable economy and an average annual wage of approximately $450 per year, ordinary people have come together to do an extraordinary thing. Wow!

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

30 May 2012

Linked in but unhinged!

Whoa! Beware of jet lag. It can cause you to act in strange ways.

I returned two days ago from R & R in the United States. The time difference is 10 hours, and it always takes me a few days to make the switch. Most of the time, I feel like my brain is still hanging out over the Atlantic Ocean while my body is on terra firma in a strange land. The few days are the worst. Yesterday afternoon, I was absolutely goofy from jet lag and struggling to stay awake. Typically, I surf the Net to kill time.

Another time I was jet lagged, this got me in trouble. My laptop DVD drive had conked and, rather than take it to an “iffy” local repair place and expose my personal data to who knows whom, I decided to order an external DVD drive. I took up the quest to find the best bargain on my first day back from leave. A couple days later, I picked up the search again and ordered a drive. A couple weeks after that, my two DVD drives arrived on the same day. TWO? Yes. Though I don’t remember it at all, I had ordered one the first night back when my brain was still on low-function mode.

This morning, my e-mail junk folder was particularly full. There were all these “congratulations” messages from people I know about joining LinkedIn. I have to honestly admit that I really don’t know what LinkedIn is and have resisted all offers to join in the past. Further, it seems that anyone I know and correspond with via e-mail has been notified that I’m now part of the fun. How do these things miraculously occur? I am totally baffled.

I tried to retrace my steps and, yep, I found a LinkedIn request from my brother-in-law. In my jet-lagged stupor, I must have clicked on the little button that has now opened a new world for me, of what I’m still not sure. But I’m going to embrace this adventure and learn to be linked in and, since Jim Mattson, editor of Reflections on Nursing Leadership (RNL), is also in this pond, I’m sure the sailing will be just fine.

For safety’s sake, the next time I return from R & R, I’m going to disable all electronic devices for at least three days. I just can’t trust myself.

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

30 April 2012

I’m so VERY glad we had this time together?

Cultural idiosyncrasies are some of the most entertaining aspects of living overseas, and let me assure you that we Americans are just as entertaining in our cultural habits as anyone on the face of the earth.

Recently, three colleagues of mine—a Pakistani man, a Tanzanian woman and an American woman—were in my office, and the four of us were discussing a work issue. My American colleague was explaining something to our male colleague who, because he would get frustrated by his inability to answer quickly in English, would respond instead in the local Pakistani language of Urdu and have our Tanzanian colleague translate, because she is also fluent in Urdu. As I said, the four of us were discussing a work issue, but it should be noted that I was largely ignoring the entire conversation because I was rapt with the task of clobbering a fly that was bothering me.

I don’t know what it is about flies. Mosquitoes find me boring, and fleas refuse to nibble. I don’t think I’ve ever had a tick bite; perhaps a chigger bite or two, but I am honey to a fly. A fly will travel great distances to buzz around my head and drive me out of my mind. They do it at great personal risk, because I am always intent on truncating their already limited life span.

So, as the conversation ensued, I was paying attention to my buzzing tormentor, ready for an opportunity to strike with the magazine that was rolled up in my hand. At a particularly opportune time in the conversation, the pesky fly chose to land on the edge of my desk, immediately in front of my Pakistani colleague. I reared back and slammed the rolled magazine down on the desk, at which point my friend jumped up from his chair and grabbed both of his earlobes.

There was a moment when the three of us women took in this scene. We each knew I was swatting a fly—actually, I missed—and I was momentarily miffed that my colleague would ever have thought I was aiming at him but, as we looked at him standing and holding his earlobes, we had no choice but to burst into laughter. He joined in but still tightly holding his earlobes.

After we caught our breath and wiped the tears; we had to know: Why was he holding his earlobes?

Ah, it is cultural. Because he was concentrating on the conversation and the translation that was taking place, he wasn’t paying attention to my hunt for the fly. When I slammed the rolled-up magazine down on the desk, his immediate reaction was to think he had somehow said something wrong or insulting and that I was showing my displeasure. I understood why, to get out of the way of my magazine, should it strike again, he had jumped up, but the earlobes? Turns out it is a demonstration of apology in the Sindhi culture. My friend didn’t know what he was apologizing for but his reaction was instinctive and, given the circumstances, very funny.

We have now spent several days adapting this newly learned skill to our toolkit. We’ve decided a mild insult warrants pulling on one lobe, à la Carol Burnett, and that a more serious offense should have both lobes wagging in supplication. My Pakistani friend, on the other hand, has a newfound dislike of flies. Cross-cultural assimilation at its best!

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

03 April 2012

Mr. Wolfe had it right!

Thomas Wolfe wrote a novel titled You Can’t Go Home Again, and the phrase has become a metaphor for “You can’t recreate the past.” For the last three weeks, I’ve worked in the health unit of U.S. Embassy Islamabad, a place where I spent three of the best years of my career, and I’ve discovered Mr. Wolfe had it right!

I was pleased to receive the invitation to cover for a staffing gap in Islamabad. I still have many friends there, both in the health unit and in the city, and it was an opportunity to renew relationships. I was met at the airport by an embassy driver who remembered me and exclaimed, “Madam, you’ve come home!” It actually felt that way, so familiar and comfortable.

But time has not stood still, and the health unit has grown and become even busier than when I was there. Some of the medical resources have changed, and I had to brush up on new consultants and new facilities. I stopped by a free-standing diagnostic center to see a colleague, and we had a cup of tea and cookies, but it became obvious we really didn’t have much to say to one another. We’ve both moved on and don’t share common ground beyond a past fondness.

The embassy facility itself has changed, and I needed directions to new locations of the various service centers. New construction has greatly changed the layout of the embassy grounds. It was almost the same, but not quite; familiar, yet different.

I was busy. There were lots of patients to see, including three patients to hospitalize, while I was there. That is quite a different pace from Karachi, and I enjoyed the challenge of sweeping out the recesses of my medical knowledge and enjoying a vibrant practice style again.

At the end, I boarded the plane to Karachi with some relief. I have a new home, a new routine, and Thomas Wolfe is right. I really can’t go home again.

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

09 March 2012

For tincture of time, there's no copay.

If you follow this blog, you know I’ve been missing for a bit. I am thankful to my buddy, Betty Ulrich, who penned the last entry, and I couldn’t agree more with her description of medical facilities we see in various parts of the world and how fortunate we are to have U.S. medical care.

So where have I been? Well, I went home for a few weeks to see my family, and then I attended a medical conference before returning to Karachi. Since then, I’ve been in somewhat of a funk! Is that word still used, or am I dating myself?

This is a very common problem in the Foreign Service (FS). We call it “culture shock,” but I think the name is a bit misleading. There is a period of time, usually three to six months after transfer to a new post, when an individual feels somewhat disconnected to the new environment, perhaps longs for the city and friends he or she has left behind and experiences anxiety or doldrums. Clinically, people show up on my doorstep complaining of insomnia, gastric disturbances, lethargy or nervousness. Symptoms are nearly always nonspecific, and a treatment of benign neglect is all that is warranted. I advise a person to eat well, exercise, get a good night’s sleep, do something that interests them in off hours and, usually, that is all it takes. “Tincture of time,” we call it.

No one is immune, no matter how many times the moving process is experienced. Early in my FS career, I was sure I would reach a point when culture shock didn’t occur. I was wrong. It has manifested itself in very different ways, depending on the circumstances, but it has always happened.

When I left Ghana, I really missed the friendships I had created and the many local people I had grown to love. When I left Guinea, I pined for the islands offshore that were such a wonderful place of respite. When I left Afghanistan, I had a haunting feeling of things left undone. When I left Pakistan (the first time), I was plagued by concern for the colleagues that remained.

This time, I think the hardest thing is being away from my children and grandchildren, and this only became an issue with this latest visit home. My grandson Cade, the little guy who used to describe his grandmother as living in a box, because he most frequently saw me on the computer screen via Skype, has the part of Michael in the community theater’s presentation of Peter Pan. I won’t be there, and I’m still deciding if that is acceptable to my vision of who a Nana should be.

When I knew I wouldn’t have the mindset to blog for a while, I wrote to Jim Mattson, editor of Reflections on Nursing Leadership, the magazine for which I write this blog. I told him I was suffering from jet lag, a cold and a bad attitude, and we both agreed the first two would resolve quickly, but the last malady could present a problem. I think the cure is near.

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

30 January 2012

Reflections from stateside

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

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

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

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

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

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

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

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

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

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

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

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

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

05 January 2012

Do you know TED?

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

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

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

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

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