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.

Go fly, kite!

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

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

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

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

Black kite

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

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

Evaluation season

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

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

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

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

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

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

And my personal favorite:

• He does not wear well as one knows him better!

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

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

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.

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.

Unpacking history

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

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

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

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

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

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

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

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

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

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

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