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.

Spice girl

I have just returned from two weeks in the United States to welcome my newest—and eighth—grandson. He is a great little guy, peaceful and even-tempered, and, considering that his next older brother is a real handful, I hope he stays that way, in deference to his mom.

Lately, I have been corresponding with a couple of people who are interested in what my job entails. I’ve been asked to recount my "typical" day, and I’ve given a great deal of thought about what a typical day is for me. However, there is a big picture to my job, and it can’t be answered as easily as one might think.

First of all, typical, in the sense of the types of patients I see in the clinic, depends a great deal on where that clinic is located. State Department embassy medical units are located worldwide, so health risks differ from location to location. While there might be an allergy or influenza season in any location, acid bug, malaria, dengue or Japanese encephalitis risk only occurs in some locations. However, most patients are seen for basic primary-care causes, just as in a U.S. clinic, but the daily patient load is less, as our responsibilities are broader than patient care.

Patient safety and health issues also vary by location. For example, the risk of gastroenteritis in Southeast Asia, and the community education required to prevent it, far surpasses the risk in Western Europe. When I was in Southeast Asia, evaluation for and treatment of food-borne disease was a daily event. In Prague, I have never discussed food-borne disease with a patient; it isn’t required.

My typical day in some posts might include a visit to the embassy cafeteria kitchen to observe and reinforce proper food storage and preparation practices. Our North American standards of food service are a mystery to food workers in much of the world, and it falls to the post medical unit to enforce the standards we expect.

A frequent task is evaluation of medical resources to use as consultants for the embassy community. In the majority of these cases, a continuing relationship and rapport must be nourished by frequent contact, visits with the consultant and sponsorship of social events. Medical associations in the United States are largely pure business while, in a great deal of the rest of the world, successful business requires social interaction like "tea and biscuits" to keep the relationship active.

In the beginning, I found this very difficult. I was used to calling a consultant and immediately launching into information about a patient. I've learned to be more sensitive to the cultural needs of the practitioners I call, which usually requires discussion of niceties first—"How are you? How is the family? How was your recent trip to X?"—before I launch into the medical conversation.

A typical day for me includes meetings—management, country team, emergency action committee and other committees of various sorts. I may be the medical officer, but my official duties cover many things that aren't medical at all. I admit I’m not a fan of meetings, but they are a necessary part of the job.

If variety is truly the spice of life, I have a very spicy life. Just the way I like it.

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

Not the place for cost cutting

If you have been watching the health news, you may have seen statistics released by the World Health Organization for stillbirths across the globe. Congratulations to Finland, which has the lowest rate at one per 1,000 births. Pakistan, a county I have lived in, has the second highest rate at 47 stillbirths per 1,000 births.

In 2008, I was invited to join a group of USAID (United States Agency for International Development) staff traveling to Kashmir to oversee a women’s health project. I jumped at the chance, even though it required traveling in a helicopter (I hate them), because we are not usually allowed to go to Kashmir. As disputed territory between Pakistan and India, it is not considered “secure.” So, the opportunity to see part of this district was too good to pass up.

The purpose of the project is to strengthen essential obstetric care in the district of Bagh, where 64 percent of deliveries occur without skilled attendants. There was no obstetric physician in all of Bagh, a district of 2 million people, until USAID paid to locate one—yes, that is ONE—there. To provide pre- and postnatal care to the mothers of the Bagh district, local nurses are trained to be professional midwives. They are located in rural areas where the preponderance of unattended births occur. One in every 74 deliveries is fatal for a mother in Pakistan versus 1 in 4,800 in the United States, so the program has tremendous potential. This is a two-year education program and very professional. I visited two rural health clinics, one where training was in process that day on how to prevent and treat post-delivery hemorrhage.

These clinics, housed in prefab buildings, have no running water. Hand washing stations were created using a system comprised of metal jugs, and instrument sterilization is done by boiling or by soaking the instruments in disinfectant. In addition to providing a place to deliver babies, these clinics, which were amazingly clean and tidy, provide health care to the general population.

Operating at low cost and with high return, such programs are fiscally efficient. WHO’s recent release of stillbirth statistics emphasizes the need for continued education in maternal-child health care in the poorest parts of the world. I do hope that cost cutting proposed by First World countries to tackle their budget problems does not include decreasing these effective, fiscally efficient programs. I’ve seen first hand the benefit they provide.

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.

Six days in Malta

I have just returned from six days in Malta. It would be a great spot to vacation, but I was there strictly for work. The U.S. Department of State Office of Medical Services, known in governmentese as MED, sent a psychiatrist and me to support Americans being evacuated out of Libya. Before they could be evacuated to Malta, 300 of these evacuees spent two harrowing days aboard a ferry anchored in the port of Tripoli, while they waited for seas calm enough to travel. This group included children, pregnant women and elderly people, all of whom were at higher risk for such travel. They slept on the floor three nights, ate mostly snack food and had no shower facilities.

On the third day, they were finally cleared to travel to Malta and then motored through high seas and rough water. Most were seasick and exhausted when they, at last, arrived. Still, considering that experience and all they went through prior to reporting to the ferry, when tensions in Tripoli were high and the situation was increasingly dangerous, they all looked remarkably good.

I believe the emotional trauma was the worst of the suffering. People left their homes and nearly everything else behind, perhaps never to see them again. They left Libyan friends and colleagues to an uncertain future. They left beloved pets that were not allowed to travel on the ferry. I heard of at least one family that witnessed people being shot in the street. Their children were clearly distressed. The psychological healing will take some time.

Fortunately, there were no serious illnesses or injuries on the vessel. The physical complaints were mostly the effects of exhaustion, seasickness and the benign, nonspecific physical symptoms that follow the decrease of stress hormones after they have been elevated for an extended period of time.

I have worked through crisis situations before, but never an evacuation. I was extremely impressed with its planning and execution. The staff of the American embassy in Malta really did their homework, and I don’t believe they left a single contingency unexplored. In addition, the Maltese government provided relief workers, ambulances and supplies, and the Maltese Red Cross provided personnel and equipment for escort. The whole episode was a finely tuned operation that went off without a hitch, which was very encouraging since the American-chartered vessel was the first to arrive. Other followed that evening and in succeeding days.

PHOTO: U.S. Ambassador to Malta Douglas W. Kmeic welcomes evacuees from Libya as they exit the ferry. Michael Avina, photographer.


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

I'm sure I am where I am!

My hard drive crashed. That’s a major headache for anyone, but add the oddity of being overseas, and it becomes a major migraine.

Fortunately, my computer is still under warranty. I called the company, which is U.S. based but has an offshore service center. The technician, a very nice man, put me and my blue-screen computer through several diagnostic procedures and then announced that my hard drive had, indeed, crashed and would have to be replaced. The company would send me a new one, and within 10 days of its arrival I needed to return the old one. If I didn’t return the defective drive within 10 days, I would receive a bill for the new one.

I explained that, although I have a U.S. address, I don’t live in the United States and, thus, it takes more time for me to receive mail. Besides, the East Coast was in the middle of several storms, which always slows military-diplomatic mail. Even after I explained it several times, the young man had no idea what I was talking about. He kept repeating that I was giving him a U.S. address, so I could not be in Europe. Finally, we both called a truce and ended the conversation.

Three days later, the phone calls began. I have Skype and a U.S. telephone number that rings on my computer in Prague. A company representative—not the technician I spoke with originally—began calling daily to see if I had received the new hard drive. I explained the situation to him and, no, I had not received the disk. He repeated the U.S. address where the package had been delivered and signed for. Yes, I said, but that is a forwarding address, and now the package gets forwarded to me in Europe. He repeated the address again and reminded me that the package had been signed for, but finally agreed he would give it a day or two and check back.

For the next several days, I came home to voice mails from him—at least it was the same guy—reminding me that the package had been signed for at the address I had provided and that I should call the 800 number and leave a message. I did, once again leaving a detailed message about how this mail-forwarding business works.

Again we spoke, and he told me 10 days had passed since my receipt of the drive, because he had confirmation of delivery, and he wanted to know if I was experiencing any trouble. He seemed very suspicious when I told him I didn’t have the drive, because it had not yet arrived. I went back over my story about the mail-forwarding process. He countered that I had called and left a message for him from a U.S. phone number. The unspoken charge? I could not be in Europe because I have a U.S. address and a U.S. phone number that I both answer and call from. Clearly I am in the United States!

Uncle!

PS: I now have the new hard drive and the phone calls have, mercifully, stopped.

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