Getting my eyes Czeched

For some months now, I’ve noticed my vision becoming less sharp. I finally decided to see if a bit of LASIK surgery might be a possible solution and scheduled an appointment with Prague’s premier LASIK center at a local hospital.

The appointment started off in the opposite direction I had hoped for when I was told the ophthalmologist with whom I had the appointment was not in and that his associate would see me. After a few minutes wait, a lovely young woman came in to speak with me and asked questions about my medical and visual history. I thought she was the nurse. She was the associate.

A few minutes later, I was ushered into the examination room where the young doctor did an eye exam. She quickly informed me that LASIK would not help me, and I needed to meet with her colleague. She thereupon personally walked me up to the next floor, where I met an equally young and lovely lens implantation specialist. In spite of the fact that I’m a medical provider, I can be a bit slow on the uptake. I was still of the mindset that we were talking about improving my vision which, in my mind, was a simple matter of loss of visual acuity due to aging.

The second ophthalmologist told me all about this wonderful multifocal lens that would improve my ability to read, without the Dollar Store readers I’ve used for years. “Yea!” I thought. I would love to ditch the readers. She then took me into her examination room and started with the same basic eye exam I had one floor below.

At some point, I threw out the question, “I guess LASIK would not work for me?”

“No” she said, “it will not correct the cataract.”

Cataract! What? Where did that come from? I immediately said, “I’m too young for a cataract!”

“Obviously not,” came her reply.

I was still trying to absorb this information when the young lady, now peering into my dilated right pupil, said “Oh!”

I do medical examinations and, as hard as I try, sometimes that “Oh!” just slips out. It usually isn’t good.

Now, the doctor is speaking Czech to her assistant. Next, the assistant is on the phone, and then we are moving hurriedly to another office. I asked what the “Oh!” was about. The doc tells me she thinks she sees a hole in my retina, and I’ll need retinal laser surgery.

“When?”

“Now!”

My goodness, the Czechs move quickly! This time, the retinal specialist is a rather ordinary-looking man who, though quite pleasant and reassuring, does mean things to my eyeballs as he looks for holes. After about 10 minutes of misery, he announces that my retinas are not perfect, but they are good enough and—drum roll—NO HOLES! “No laser today,” he says.

By now, I am so relieved I don’t have a hole in my retina I don’t even care that I have a cataract. Back we go to the second office, where the informed consent for cataract surgery and several bits of paperwork for pre-surgery testing are prepared. Alas, I am told that, because my retina is not perfect, I can only have the monofocal lens and will still have to rely on readers. They scheduled me for cataract surgery in three weeks, and I left the office with the typed medical report in my hand, just two hours after I arrived in the ophthalmology department.

Beat that!

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

Advanced practice nursing is an option?

In the Czech educational system, a public school student can choose to concentrate studies along a technical or professional path beginning at age 14, or what we in the United States consider high school. For instance, a student accepted to a health-career school would have a curriculum that follows a scientific and biological course, with clinical experiences in health care. After four years, the student can decide to pursue nursing, medical or allied health programs at the university level, go a completely different direction with university studies, or simply enter the workforce.

This past week, I was invited to speak at a health-career school in a neighboring community on the subject of health care in the United States. My audience was comprised of third- and fourth-year students, ages 17 to 18. The students submitted questions in advance, which gave me an idea of the type of information they were interested in.

They wanted to know a bit about me; where I went to school, where I had worked and in what section of the hospital. In fact, the assumption was that all my experience was in a hospital setting. In the Czech Republic, there are few nursing jobs outside hospitals, so, when I mentioned the many different roles nurses fill in the U.S. system, the students were quite surprised. I also identified and explained available levels of nursing education, including advanced practice possibilities, and this came as a downright shock to the students. They had never heard of an expanded nursing role, even though it exists in Europe with practitioners in the United Kingdom, the Netherlands, Sweden and Switzerland.

I had been warned that Czech students are not interactive, and I should not expect them to engage in dialog. However, the discussion about opportunities in nursing and advanced practice spurred many questions and interaction that surprised the class teacher. She admitted, once the discussion had ended, that she was amazed at the amount of interest the students had expressed and how engaged they were with questions. I hope I planted a seed of curiosity in my audience that may lead them to explore the many ways nurses can contribute to the health of their nation. The possibilities are exciting.

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

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.

We got something right!

One of my responsibilities, when moving to a new post, is to assess local medical resources. Most cultures are more formal than the American culture, so there are official introductions, sometimes the exchange of small gifts, often tea or coffee, and polite chatting before we get down to the business of me asking, “What can you do for the official Americans in your country?” Not in those words, of course, but that is the real purpose. I will visit the hospital or clinic and ask nosey questions to determine if the facility is acceptable to me, and those I serve.

I continue to be surprised by the hidden jewels I find in the most unexpected of places around the world. I remember the husband-wife MD team—Harvard residencies—working in a truly backwater clinic in Rwanda and, in Guinea, the tropical disease expert from Germany. I have never served anywhere that I couldn’t find at least a few excellent physicians.

Nursing is another matter. Frankly, most of the countries in which I have worked undervalue the nursing discipline, and a few—Guinea and Afghanistan come to mind—don’t recognize the discipline at all. Nursing in these places is an OJT technician job with little formal training and no respect. In more modern countries, nursing usually requires formal education but falls short of the critical thinking required in countries with the highest standards of nursing care.

I recently had dinner with a German nurse who was lamenting that nurses in her country, while highly educated, were underutilized as integral members of the health care team. She was intrigued by advanced practice nursing and commented on the ways in which the German system could benefit from such a program. Finally, she said, “You Americans have really got it right!” Now, there’s a comment I never hear. I usually have to listen to all the things we Americans have wrong.

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

Prologue to my blog

The advertisement in the nursing journal said, “Deliver primary care to U.S. government employees working in embassies overseas.” That was enough to catch my attention! I was a 40-something single mother with a great nurse practitioner job in Biloxi, Mississippi, but I had a nagging suspicion that there was more to be had if I looked for it. Soon, I was going through the long and frustrating process of applying for the position of foreign-service health practitioner with the U.S. Department of State.

That was 10 years ago and, in subsequent years, I have enjoyed long assignments in Ghana, Guinea, Afghanistan and Pakistan with shorter tours to Mexico, Russia, Hungary, Uzbekistan, Rwanda, Kosovo and Honduras. I am assigned—with consideration of my preference—to a U.S. embassy community to deliver patient care in the medical unit, usually as the sole provider, but sometimes with a State Department physician. The patient load is the run-of-the-mill primary care stuff with some interesting twists along the way. Some are location-specific, such as parasites, malaria, or “acid” bug burns. Some are scary acute-care problems (MIs, cancers and orthopedic nightmares) that my clinic diagnoses, stabilizes—using local resources, when available—and transfers to a medevac center or to tertiary care in the United States.

It isn’t all direct patient care. I am responsible for testing embassy water quality, evaluating food sanitation practices of embassy kitchens, scrutinizing local public health issues that might affect our embassy population, emergency preparedness, health education of the embassy staff and a variety of issues that are in some way related to the health and well being of embassy personnel. It is never boring and I marvel at the range of knowledge I have acquired since taking this job.

The off-work possibilities are boundless. I’ve spent New Year’s Eve in Red Square, ridden horseback to Egypt’s Great Pyramids, climbed through a bamboo forest to photograph mountain gorillas and been a lazy bum on some of the most beautiful, and isolated, beaches in the world.

I’ve met amazing people at every location and learned that, no matter the region or the language, we are all more alike than we are different. I have also seen the poverty, lack of education and poor health care the majority of the world suffers. It devastates me, but I have been able to offer small assistance by volunteering at a children’s center or supporting a local hospice.

Of course, there are some negatives to this employment. While I have attended the major events in my grown children’s lives, such as weddings, I’ve missed just about all of the daily life events. Webcams and Skype phone calls help my seven grandsons remember my face and voice between visits home, but I miss not being with them more often. My youngest daughter traveled with me until 2003, when she returned to the United States for university. Now, I live and travel unaccompanied and sometimes feel out of touch with the U.S. culture, and my family and friends. Still, I know how truly fortunate I have been to reside and work in the world at-large. It isn’t for everyone but it has been a dream-come-true for me.

I recently completed a three-year assignment in Pakistan, an amazing experience. After returning to Washington, D.C. for two months of language training, I’ve now moved to my new assignment, Prague, the capital of the Czech Republic. The past 10 years have taken me to mostly rough, medically underserved locations. For the next three years, I will be in the heart of Europe, and I wonder what that assignment will hold for me. In this blog, I will share my discoveries and adventures and reflect on past ones. I hope you’ll join me.

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