Karachi, here I come

Four young, beefy guys just left my apartment and, while I know this must sound intriguing, there is a simple explanation: They are movers. Once again, it is time to pull up stakes and move somewhere else in the world. For my next adventure, I’m going to Karachi, the largest city in Pakistan and the main seaport on the Arabian Sea.

If you have followed this blog, you know I previously spent three years in Islamabad, the capital of Pakistan, located 710 miles north of Karachi. There is a complex reason why I chose Karachi as my final post, but one important element is that I honestly like the people.

This usually comes as a shock to people who have never been there, especially Americans who interpret the troubled relationship between the United States and Pakistan as anti-Americanism of the Pakistani populace. I’m not a political person, despite the fact I am employed as a diplomat, but I can say with certainty that the problem between the average American and the average Pakistani is that they each know the same thing about the other, which is to say almost nothing. Both groups have formed opinions based on rumors and sensationalized news stories, and the reality is far different from the perception.

Please note I did say average Pakistani, because there is no denying there are radical factions at work in Pakistan, as in many countries. Fortunately, I need only interact with people who are just trying to get through another day, as am I, with no ill will toward anyone else. I can honestly say that, in my previous three years in Pakistan, I never met a single person who was anything less than welcoming and friendly to me. I hope I never do.

This moving ritual that we Foreign Service employees participate in always brings up the question of “Which post did you like best?” I can never really answer that question, because I’ve found something to like about all of them and comparison between embassies is very much an apples-and-oranges dilemma. But I can say what I liked best about each post:

Accra, Ghana was my first taste of Africa, as well as my introduction to Foreign Service life. It was an excellent beginning, as Accra has a vibrant culture, the provincial travel possibilities were marvelous and I developed friendships that are still important to me.

Conakry, Guinea is the place people mean when they say “the end of the earth!” In spite of the poverty and lack of opportunity for the citizens, I met some of the kindest people I have ever known in Conakry.

Kabul, Afghanistan is the zenith of my Foreign Service experiences. I’ve explained why in previous blogs. To summarize, it is where I experienced great professional purpose and enormous pride in American assistance to others in need.

A two-year “roving” tour that took me to nine different countries over four continents during which I learned a person can live for an extended period of time with only two suitcases of material goods. I also had one of the most amazing experiences of my life in Rwanda, as I climbed through a bamboo forest to watch mountain gorillas in their habitat.

I appreciate Islamabad, Pakistan for the art, food and generous hospitality of the people. I also have to say the work-team environment was as close to perfect as I will ever have.

Prague, Czech Republic is a gift of beauty at the foot of Cinderella’s castle. It is almost a fantasy to walk down these cobblestone streets and enjoy the spectacular architecture. I’ve been on a two-year vacation, but shhhh, don’t tell my bosses, okay?

I will depart Prague this week, and I have several weeks of vacation and a couple of weeks of training before I report to Karachi. Please be patient while I take a break. I will be back.

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.

Small miracle

The Western Hemisphere and most of Europe are gripped by the tragic events unfolding in Haiti. Modern media transports those of us who have televisions to the center of the misery and captures us with heartbreaking and touching stories.

I always considered myself a knowledgeable person, but it wasn’t until I joined the Foreign Service and traveled to the, shall we say, more unusual parts of the world, that I realized how little I really knew about life outside of my sphere. I understood American poverty and I understood the chasm that existed between those who have and those who don’t—in North America. After all, I grew up in south Texas and had visited our neighbors to the south many times. I thought I knew.

What I know now is that the events currently taking place in Haiti are occurring all over the world, on a smaller scale, daily. I don’t just mean earthquakes. I’m talking about desperate circumstances, poor nutrition, unsafe water, lack of shelter, and poor medical care. The World Health Organization estimates that one million African children die each year from malaria. That’s just one continent and one disease. To extrapolate is truly disturbing.

And while I now know, and have seen firsthand, some of the terrible conditions people survive, I have also seen small miracles occur, without international coverage or support, that make life better for these unfortunate people. I’ve already mentioned a few, but I want to tell you another.

When I worked in Conakry, Guinea, I was introduced to six nuns of the Missionary Sisters of Charity—the order started by Mother Teresa—who operated a clinic. I began assisting them in small ways. The clinic usually had a full load of 25 inpatients, mostly children 3 years and younger who had nutritional needs.

One day, I received a phone call asking me to come to the clinic to see a sick child but I was unprepared for what I found. A village woman had come to the clinic with a premature infant. She was the infant’s grandmother. The mother of the child needed to stay in the village with her other children. This baby weighed 1 kilogram. I had no experience with preemies and looking at this little boy was like looking at a tiny, skinny doll. I was afraid to touch him. In spite of his small size, he looked pretty good. He was alert, he was feeding well (breastfeeding mothers at the clinic were pitching in) and he had no respiratory problems. But he was only a few days old, and I couldn’t imagine he would survive. In a developed country, this child would be in the NICU for weeks with all sorts of advanced monitoring and treatments. This baby was in an open crib in a room full of sick children, with just a mosquito net between him and certain malaria. If he needed specialized care, it just wasn’t available. The clinic didn’t even have hot water.

I went to the clinic every other day and watched in amazement as this child survived, developed and eventually flourished. When he was 3 months old, he was a plump, smiling and cooing little boy, and his grandmother took him back to the village. I think of him often and wonder if his miracle continued. He would be 8 years old now. I hope he is.

For Reflections on Nursing Leadership, 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.