Journey to Middle-earth

I think the biblical scholars have it wrong when they propose that the Garden of Eden was located between the Tigris and the Euphrates. I’ve just returned from a driving tour of the South Island of New Zealand, and I’m pretty sure that’s the real Eden.

I’ve been to the North Island previously and, while I had been told the South was even more beautiful, it was hard to imagine in advance what I actually saw once there. Followers of the movie trilogies, “The Hobbit” and “The Lord of the Rings,” based on books with the same titles by J.R.R. Tolkien, will understand that the South Island of New Zealand is “Middle-earth,” as all of the movies have been filmed there.

Of course, as all movies do, the videographers have toyed with nature and created imaginary scenes that aren’t really there; but the majesty of the mountains, the purity of the water—and its often-turquoise color—is not video editing. It is a simply amazing place! Top that off with the exciting adventure of seeing fur seals, yellow-eyed penguins, albatross and sperm whales in their own habitats, in nature without fences (other than to keep people out) and it makes for one bang-up trip.

It is not easy to get to New Zealand, which may explain how it stays pristine and minimally affected by man, but it is certainly worth the effort to get there. I heartily recommend it to anyone wanting to experience the freshest air, purest water, cleanest towns and friendliest people you are likely to see anywhere on earth.

Back here in Karachi

I don’t consider myself a teacher. I’ve shared information before with colleagues, as we all do, but teaching as an occupation is something I’ve never felt drawn to or suitable for. The consulate has embarked on a program to improve English skills of willing employees, using a combination of professional and volunteer teachers. I am a volunteer.

Every Wednesday from 3:30 to 4:30 p.m., two other volunteers and I look into the eager faces of 43 gentlemen with varying English skills ranging from none to minimum, and we try to teach and encourage them. We have a syllabus for beginning English, which seems rather advanced to me, as it assumes some previous introduction to English words. We play games with them to instill the desired idea. For example, we demonstrate walking forward and walking backward, and we try to help them understand the difference between “I am Karachi” and “I am from Karachi.”

First, we worked on was greetings. We pointed out, for instance, that the answer to “Good morning” is not “Fine,” which is the common response we receive to greetings given on the compound. It is a particular joy when we can see by our students’ expressions that the light bulb has gone on, and they really get the difference. The excitement is contagious, because local employees seek out English speakers with whom to practice their newfound skills. It has added levity between us that did not exist before and, in a place such as Karachi, where life is mostly tense, this is a very good thing.

One of my fellow teachers explained to our class that, in the United States, we do not usually address colleagues using Miss and Mister plus their first name. (She is obviously not from the Deep South.) She encouraged the students to call us by our first names, as we do each other or, if they believed a more formal approach was necessary, to use Miss or Mr. and the last name.

A few days later, one of the young members of the class, who is working very hard on improving his English, pulled me aside for a chat. He repeated what the other teacher had said about addressing people and then said to me, “I have respect for you and, because you are an old woman, I must call you Ms. Judie. Is that okay?”

Next, I think we will work on political correctness!

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.

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.

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