Almost like coming home

I’m here—back in Pakistan—and it is almost as if I never left. There is so much that is familiar about Karachi: food, crowded streets, tuk-tuks, sounds and smells. The past two years in Prague have started fading away, which is sort of sad, as I enjoyed them so much. But I find I am glad to be back; almost like coming home.

I joined the U.S. Foreign Service with the intent to live and work in places I would never visit as a tourist. My goal was to really get to know people and cultures that were different from the life I had always known, and I have been true to that goal. Even living in Prague, in the Czech Republic, which is in many ways similar to the United States, was very different from my pre-Foreign Service life in the American South. Americans and Europeans are pretty savvy about health and wellness issues. At least, they know a good deal about it, even if they don’t follow good health practices. But Southeast Asians are often not well educated about safety and health issues. Many of the home remedies and first aid applied in this region are traditions passed down from one generation to another, and they are not always effective traditions.

For instance, during my previous tour in Pakistan, one of our gardeners sustained a deep gash on his lower leg from a chainsaw accident. In an effort to stop the bleeding, his co-worker doused him with the gasoline mixed with oil that was used to power the chainsaw. We rushed him to the hospital for definitive care and, after the surgery, the surgeon called me to ask what that oily substance was in the wound that required such pains to debride?

As a result of that incident, a program was created to train some of the local employees to teach all of the other local employees, in their language and on a regular basis, about basic first aid. I’m pleased to say that the program is still ongoing in Karachi and is taken quite seriously by the workers. I am hearing stories of how family members and neighbors have been helped through the program.

Sharing information about health and safety practices to poorly served populations around the world is one of the most important things we can do. It follows the “teach a man to fish” philosophy, and small successes are really great triumphs.

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.

The sign of the comet

I’ve often said it is the variety in my U.S. Foreign Service job that keeps me enthralled, especially since I seem to have a rather short attention span. In my career, no two posts have even been similar, much less the same. The Czech Republic has been a huge change from my previous developing-country assignments and, with a more typical list of medical complaints, I admit I was getting a bit soft.

Then, the mites arrived! One of our young officers came to me with a profusion of itchy, whelped, pink bites on her posterior thighs. Honestly, I didn’t know what the cause could be, and since the bites were in a defined location, it didn’t seem like a major issue. That was in the morning. When she returned in the afternoon, the bites were weeping, enlarged and had taken on a purple hue. My comfort level dropped to zero, and we arranged for her to see a dermatologist immediately.

The dermatologist was less concerned, because she knew what the cause was—a severe reaction to mites! Mites? Where did they come from, and why now? It is winter in Prague. Do mites attack in winter? A bit skeptical, I forwarded photos to a dermatology consultant in Washington, D.C. His reply was, “Yep, mites.” The dead giveaway was the “comet sign” coming off one of the lesions. (A comet sign is a red streak leading away from the central area). The two dermatologists disagreed on the source. One believed the mites were related to birds, and the other thought they were connected to woodborers, but both were certain the lesions were caused by a severe reaction to mite bites.

This is where my job gets really interesting. If I was in a usual practice in the United States, I would refer my patient to a dermatologist, who would prescribe treatment, and we would be finished with the issue. Not so in the Foreign Service. The ongoing saga of investigating why there are mites in this officer’s home, determining which chemicals are safe—and OSHA approved—to treat the infestation, photographing and cataloging new bites as they have appeared, discussing with various embassy offices about what’s best to do—all have involved me.

I know more about mites today than I knew three weeks ago and more than I ever thought I would need to know. It is fascinating, really! And to the long list of “jack-of-all-trade” tasks the Foreign Service has required of me, I can now add exterminator!

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

If you're from Georgia, I'm from Mississippi!

I haven’t lived in the United States for almost 12 years. I can’t count the number of times a week I am asked, “Where are you from?” or some derivative of that question. I always hesitate before I answer, a habit I dislike, but it is a question that does not have a simple answer, and I’m forced to think before I reply. I have to think about the actual information the asker wants, which can vary quite a bit, depending on circumstances. I realize Americans are, more and more, a mobile society, but the question, “Where do you live?” or “Where are you from?” asked by one American to another has a limited connotation. Not so for the expat.

I spent the first 20 years of my life in Texas, followed by 17 in Tennessee and 10-plus in Mississippi, before I joined the U.S. Foreign Service. Today, I live in the Czech Republic, my legal residence is Tennessee, and I own a house in Mississippi. If I am relatively sure the intent of the question is what part of the United States I call home, and the asker is foreign, I answer “From the South” Most non-Americans have as little understanding of the geography of the United States as Americans do of other countries. I learned early on that most foreigners know New York, Chicago and Los Angeles. Any place else is just a mystery and answering “From the South” seems to satisfy them. In fact, I once spent about 10 minutes on an overseas flight trying to explain to someone that I was going to Mississippi, the state, not Mississippi, the river. He never did get it.

If I am asked the question when I begin work at a new embassy posting, I know they want to know the location of my last post. If I am traveling away from my post and someone asks the question, I always answer with the city of my current residence. About 50 percent of the time, that solves the issue. Sometimes I can have great fun with this, like the time I was in Thailand and answered the question with Pakistan. The young lady behind the counter repeated it twice with a look of amazement on her face but, since the address I had put on the registration form was indeed a Pakistan address, she didn’t argue.

If I meet people from Texas, I always tell them I am, too. I still think of myself as a Texan, even though I have spent two-thirds of my life outside of Texas. I cannot remember ever meeting someone from Mississippi overseas, but if I am introduced to a person from Alabama, Georgia or another southern state, I will counter that I am from Mississippi. And, if some stranger is pushing me about my nationality, and I am uncomfortable with giving the information, I say I am from Nova Scotia. No one knows where it is, how they talk or anything about it—shuts them right up!

Is it any wonder I’m confused?

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

Pink backpacks in Kabul

I have been fortunate enough to serve in 14 embassies with the U.S. Department of State for periods of time ranging from one month to three years (Ghana, Guinea, Afghanistan, Nicaragua, Sierra Leone, Mexico, Uzbekistan, Hungary, Russia, Kosovo, Rwanda, Romania, Pakistan and Czech Republic). I am often asked which of these was my favorite posting, a question impossible to answer. In truth, each has given me memories I cherish, friendships I continue to enjoy and experiences I value. But, if pushed to name one post that was a pivotal experience for me, it would be Kabul, Afghanistan.

I spent 14 months in Kabul in 2003-04 and it was, I think, the best time to be there. The Afghan people were full of hope and promise, the Taliban were weakened and had retreated, and much needed money and skilled personnel were flowing into the country to rebuild the economy and improve living conditions. I was there when the girls were permitted to return to school. On the first day of the term, the streets were full of nicely groomed girls holding hands, smiling and walking briskly toward their classes. I remember a profusion of pink backpacks as I sat in the rear seat of the embassy vehicle, sobbing at the sight.

The city of Kabul was relatively safe then, and I was allowed to meet civilian medical colleagues from other missions and military medical colleagues from the International Security Assistance Forces (ISAF) and the North Atlantic Treaty Organization (NATO), both at secure locations and even at approved restaurants in town. Truly, one of the great delights of my career was the opportunity to collaborate with so many American and foreign military medical professionals. I came out of that experience with an unshakeable regard for the military and utmost respect for the sacrifices they make for us.

U.S. Aid for International Development (USAID) made a commitment to build primary care clinics throughout Afghanistan so that physicians, midwives and community health educators could begin to pull the health system up from the ruin that years of war had created. I was invited to attend the opening of the first such clinic at a village some distance from Kabul.

The citizens of the little village were proud of their new clinic and the medical personnel the government had sent to staff it. I was proud of the U.S. government for making this dream a reality, and honored to be there to witness the villagers’ delight.

After the dedication speeches, the village imam came to ask the USAID representative for another favor. “The children need a school,” he said, through an interpreter. “May we have a place for our children to learn and books to teach them?” I was really struck by this old man and his humble request. Isn’t that what we all want for our children—good health and a future? Is there really anything else that matters, regardless of where on earth you live?

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.

The perfect health care system? I haven’t found it.

Even though I am an expat living in Europe, I am bombarded daily with news of the U.S. health care reform debate that seems to have our country polarized. I have seen so many other health care systems around the world that my viewpoint is probably a bit skewed from what it would be if I still practiced in America.

If there is a perfect system, I haven’t found it. My experiences vary from Guinea and Afghanistan, where there was basically no real health care available, to Mexico, where the range was from excellent to terrible, to the Czech Republic, where the care is on a par with what I would expect in the United States. I am referring to the standard of care, not the process of financing it. How health care is financed—fee for service, socialized, self-pay, etc.—is a wholly different matter, although it is a fact that if someone isn’t paying for health care in a country, it isn’t going to exist.

In Conakry, Guinea, there is one government-run hospital. The hospital is surrounded by a high wall with an iron gate. A patient who comes to the hospital must first pay an entrance fee of a few francs. No francs, no entrance—regardless of the seriousness of the illness or injury. Once inside, the patient will be seen by a physician and, perhaps, be assigned to a bed. The bed will have no sheets, no mattress. If the patient needs these things, the family must bring them. Likewise, if the patient requires any medication or supplies, including surgical supplies, the family must go to a local pharmacy and purchase them and bring them back to the hospital. The hospital carries no medications and no supplies. Not even a Band-Aid.

The patient will be charged a daily rate to cover the “overhead” of the hospital. If he can’t pay each and every day, he will be removed from the hospital. The same is true for the physician’s fee. Physicians must be paid in advance or they will not render services, as they are not paid by the government. This is also true of private clinics and medical offices available throughout the city. Either pay up front or forfeit services. This was the system that was in place when I left Guinea in 2003. If it has changed, it has only been for the worse, as the country has spiraled downward into instability.

Afghanistan’s medical system was decimated by 25 years of war. While I was posted to Kabul, various NGOs, as well as the Ministry of Health, were trying to put together rudimentary care, at least in the capital. My most poignant memory is of one day in 2004 when I learned that 17 mothers or babies had died during childbirth at a maternity hospital in Kabul. These lives were lost because there were not enough personnel at the hospital to take care of the delivering mothers. There was no system of organization at that time and, for whatever reason, most medical personnel assigned to work that day didn’t come. There were no phone lines, and mobile phones were still a rarity, so staff couldn’t alert the hospital that they wouldn’t be there and the hospital couldn’t call in replacements. At that time, Afghanistan had the highest maternal/child mortality rate in the world, so, because of a poor communication system, those 17 lives added to the dismal statistics.

I left Afghanistan in 2004 and spent a couple of months in Sierra Leone, which ended a 10-year civil war in 2001. They, too, had been stripped of a medical system that was insufficient to begin with. In fact, the only hospital in Freetown, the capital, was vacant and shuttered. The government simply had no money for medical care. A few physicians had trickled back into the country after the war and opened offices, but they were only able to provide basic services. Medications and supplies had to be imported, and sources were not reliable. As in Guinea and Afghanistan, severe lack of medical care was a bitter fact of life. I do not know actual statistics, but I feel confident in saying there are many more people in the world who have little or no modern medical care available to them than there are those who do and, while I agree the American system needs tweaking, I’m still very grateful we have it.

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

Interesting people

I continue to visit medical and dental clinics in Prague, as required by my Washington superiors. The purpose is to know options for care that are most in line with our American medical philosophy. This information benefits Americans who work here in an official capacity as well as visiting Americans who call the consular office for our list of medical consultants. I’ve had the opportunity to hear interesting stories along the way, and I frequently find the unexpected.

From 1948 to 1989, the Czechs were under a communist political system. One practitioner I know completed his medical education in Prague in the late 1960s and then defected to the west, eventually ending up in Canada, where he practiced for more than 20 years. He returned to Prague a few years ago to work and reclaim the home of his youth. His story is fascinating as he tells of his struggle to learn English, pass the medical examinations required in Canada and begin a life completely cut off from the rest of his family, who remained in what was then Czechoslovakia. He made huge sacrifices to live a life free of political domination.

I met a physician born in the United States to Czech parents, who defected from communism. He completed his medical education around the time the Czech Communist Party was abolished and decided to come to the Czech Republic to help build the new medical system. He has spent the last 20 years with his foot in both societies. He has a practice in Prague and maintains an attending staff position at an Ivy League teaching hospital in the United States, working at the U.S. location several times a year. Medical residents from the U.S. program have the opportunity to rotate through a linked curriculum he administers in Prague for an overseas study semester.

My young dentist in Prague is an American who married a Czech woman. They met in the United States, where they married, lived and worked but, when their child was born, they decided to move to the Czech Republic to be near her parents. His story is equally interesting because it is the reverse tale. Although he wasn’t escaping a totalitarian government, he did have to learn Czech—a very difficult language—to pass the certifying and licensing examinations. In fact, he was the first English-speaking dentist to achieve licensing in the Czech Republic. And, of course, he had to adapt to a very different medical environment. He has great stories to tell about his experiences; in fact, they all do. Meeting these interesting people and hearing their histories is one of the most interesting parts of my job.

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

How do YOU spell relief?

The snow has been falling intermittently in Prague for two months. The streets and sidewalks are rife with patches of ice that threaten all who trod there. I’ve been doing quite a bit of slippin’ and slidin’ myself, and I’ve had a number of patients come to the medical unit that have been injured from falls. Some have been referred to our local emergency departments or orthopedists for treatment.

This brings me to the topic of pain and, more precisely, pain control. Americans, probably more than any other society on earth, are interested in pain control. We don’t like to hurt, and we believe that unnecessary pain is a violation of our human rights. We have laws that govern pain control measures, and we have developed pain measurement scales to assist providers in properly assessing the level of pain or pain relief.

Many other societies accept pain as incidental to injury and, while they may offer measures of relief, they are not committed to pain eradication whenever possible. Of course, there are many areas of the world where pain medication just doesn’t exist, or it is reserved for the truly severe cases, so pain tolerance is expected.

I’m discovering that the philosophy in the Czech Republic, as in much of Europe, is that pain is to be dampened by using the most moderate means available. That usually means no narcotics. Europeans love NSAIDS (ibuprofen-type medications) and are really slow to suggest narcotics. They also rely on nonpharmacological methods such as ice, heat, breathing techniques, muscle relaxation, music, massage therapy, and the list continues. These important adjuvant measures are used in the United States, too, but usually not for short-term or immediate pain control.

In West Africa, I took a patient with an injured leg to the local emergency department. The X-ray showed a displaced fracture and the orthopedist was called to do a closed reduction. I asked the doc, “What are you going to give her for pain?” He looked puzzled for a moment, then turned to the nurse and said, “Please prepare some tea!”

A very quick and tense conversation followed regarding pain control in this patient, who was now terrified as well as hurting. It was finally decided that I would scurry to my clinic to bring an appropriate pain medication to the hospital for my patient, as all the doc could provide was an NSAID. My patient had pain medication prior to the closed reduction and casting and, while the procedure was still a bit uncomfortable, she did quite well. Oh, yes. She also had tea!

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

Culture shock

Culture shock is a well-known, expected phenomenon in the Foreign Service community. It doesn’t happen to every person with every transfer, and there are degrees of effect, but it is something we warn our patients about whenever they relocate. I am in culture shock.

There are phases to culture shock. The first is the honeymoon, where the new location is pleasing and exciting. Prague is certainly beautiful—amazingly beautiful—but the aspect of Prague that impressed me most in the weeks after I arrived was my ability to walk through the city and have no one pay attention to me. My last three years were in Islamabad, Pakistan. It was too dangerous to freely walk around the city and, in those few places we were allowed to go, a tall, gray-haired (head uncovered), fair-skinned woman walking about was always met with curiosity. Everyone stared! So, for the first six weeks in Prague, I walked for a couple of hours after work—more on the weekends—just because I could and no one would care. It was absolutely liberating.

The second phase of culture shock is negotiation. That's where I am. In this phase, the new living circumstances may cause frustration, anxiety and even anger over differences in language, cultural ethics and available food choices. This is a time of comparison between what was one’s life in contrast to what is one’s life and may lead to mood disturbance or even depression, in extreme cases.

Life in Pakistan was life on the edge, especially the last two years. Somehow, being in the middle of it conferred a sense of control. Now that I have moved on, I am beset by concern for those I left behind, especially my Pakistani friends who are less protected than the diplomatic residents. I feel helpless to do anything but worry, so I worry. I watch the news. I fret when a new incident happens. Recently, the Navy Yard gate in Islamabad was attacked and people were killed. The Navy Yard was one of my favorite places to shop and I felt safe there. In Prague, I feel safe everywhere. That is a very good thing, but now I also feel guilty for enjoying this safety and freedom in Prague when my former colleagues don’t share it.

The final phase is adjustment. When I get to that phase, life in Prague will feel normal to me and Pakistan will be a memory. It isn’t that I will lose my concern for my colleagues who remain in Islamabad, but I will accept that my focus is my life and work in the Czech Republic.

Foreign Service employees may also suffer reverse culture shock when they reenter the United States for a long visit or for a work tour. Returning to the U.S., especially from a country that is very different, can be mind-boggling.

Many years ago, I came home for the birth of my first grandson. I was living in Ghana at the time and, while it is a pleasant country and I enjoyed living there, food choices were quite limited. On my first day back in Mississippi, my daughter sent me to the grocery store with a list that included corn flakes. I stood in the aisle at Kroger looking at what seemed to be dozens of choices of corn flakes—different brands additives and sizes. I simply could not choose because I had grown accustomed to buying the one option available to me, if there was any available at all. Having so many choices was overwhelming! I was forced to call my daughter and request that she name a particular corn flakes item so I could continue shopping. And, yes, she thought I was completely wacky!


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

H1N1

H1N1 has arrived in the Czech Republic. This is a bit more complicated for my clinic than for a clinic in the United States. For one thing, I don’t have H1N1 vaccines. They were ordered months ago for the Foreign Service, but only a tiny fraction has actually been delivered to the Department of State for its overseas staff. I have 20 people who fall into the CDC’s high-risk group and should be vaccinated; some of them are anxious because the vaccine is not available.

The Czech Republic has vaccine only for a limited number of their residents, and they have purchased Pandemrix, which is not FDA approved, so I wouldn’t be able to use it anyway. I do have Tamiflu and Relenza and use them when appropriate. Although we have had employees diagnosed with H1N1, so far, none have been serious, and we are doing our best to keep it that way.

We’ve been busy educating all staff members at the embassy, including local employees who fall under the Czech health system. I’ve tried to impress on everyone that this is a public health issue and not just a private health concern. I’ve delivered information in e-mails, handouts and personal group sessions with the different offices, but the most successful campaign has been the use of a video prepared by the Virginia Department of Health. Whoever thought this up is a genius!

In 2007, when “bird flu” was all the rage, the U.S. Embassy in Islamabad, Pakistan was seeing a large bird die-off on the embassy compound. My clinic arranged for some of these birds—all crows—to be evaluated at a poultry lab and, sure enough, they died of H5N1. At that time, there had been no animal-to-person transmission of avian influenza in Pakistan, but having these multitudes of bird carcasses around the compound was unsettling to people, and a minor crisis was evolving.

Our facilities manager called me one afternoon to announce that a sick hawk was on the compound and asked me what to do. “Leave it alone,” was my sage advice. For the next three hours, I received update calls as this poor bird experienced his death throes! When he finally did expire, he was refrigerated and sent to the poultry lab for diagnosis. He tested negative for H5N1, so they performed an autopsy! Cause of death: pathogenic E-coli. If Mr. Hawk had come to the health unit for his check-in orientation, he would have known to boil it, cook it, peel it or leave it, essential food sanitation advice in Pakistan, and he might still be soaring in the skies!

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

Assimilation in progress!

Encountering a different culture as a tourist doesn’t require true commitment to adaptation. A person on vacation eats in foreigner-friendly places, shops for souvenirs in stores where staff do not view the customer as a “bother,” and learns polite words (please, thank you, etc.) in the language of the country visited, but little else.

Not so for the expatriate who has come to a foreign country to live and work. We are more than guests of our new home country and are expected to assimilate as much as possible. In some countries, going to the grocery store is often more of a nightmare than an adventure. When I was in Russia, where I had no prior language training, I would only purchase things that were visible in the package or that had a picture I recognized. The writing was not only Russian, but in the Cyrillic alphabet, and completely unintelligible to me.

Once, an American co-worker, also a non-Russian speaker, and I decided to lunch in a particular restaurant because they had an English menu. Most restaurants will have a line item in the local language followed by a translation immediately below it in other languages. This establishment, however, had two separate menus, one in Russian and one in English. Our server spoke no English, so my friend and I found what we wanted on the English menu and then located items in the same positions on the Russian menu and pointed out our choices. Ah, you see what’s coming, don’t you? It’s true; the meals we ordered were not at all what we were served. It never occurred to us that the two menus, other than being in different languages, would not be exact duplicates of each other.

I’ve been in the Czech Republic for five weeks now and I’m learning to assimilate. At least the Czech language uses the Roman alphabet and I had seven weeks of language training to give me the bare necessities of communication.

I was in the butcher shop a few days ago and asked, in Czech, for the items I wanted. The lady behind the counter understood me and began preparing my order. I burst with pride when the woman standing next to me turned and said something in a long Czech sentence that I did not understand, but I knew she spoke to me because she thought I could understand. I smiled and nodded, to what I do not know, and she was satisfied.

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