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.

Question to ponder

In my previous posting, I mentioned the guide, Danny, who took me to the Mountain Gorilla Reserve in Rwanda. There were just the two of us in his Land Rover on the three-hour trip each way, so we had plenty of time to get to know one another. On the return drive, I asked Danny about the 1994 genocide where more three quarters of a million people, mostly Tutsi, were slaughtered. The rivers literally ran red with blood. Danny is a Tutsi and he told me a story of great courage.

In 1994, he was in his early 20’s with a wife and a 2-year-old daughter. He lived in Kigali but the rest of his family lived in rural Rwanda. On the night the radio instructions to kill Tutsi’s was broadcast, Danny’s neighbor, a Hutu, came to his house and told him he wanted to hide Danny’s family to protect them. Danny’s family went with this man to his cornfield and they hid there for three months. Every few days, the neighbor brought them food and water, at great risk to his own safety. When they were finally able to go home safely, Danny learned that, other than a teenage cousin who was away in Uganda when the genocide began, his entire family and his wife’s family were dead—more than 20 men, women and children.

Following the genocide, Danny had worked hard to build a successful business and give his three children a good life. When I asked him what he had told his children about the genocide, I was surprised to learn he had not spoken to them about it at all. He said they learned the history in school, but that he was waiting for the time when his children were “ready” to hear the worst of his story and mature enough to consider the question he would put to them.

Danny remembered that hundreds of thousands of ordinary people were faced with a choice. One choice was to comply with instructions and do something terribly wrong—kill innocent people, including family members and neighbors. The other choice was to acknowledge the evil and refuse to participate. Danny said there were many people he considered good people who picked up their machetes and went out and murdered as instructed, because they feared for their own lives or the lives of their family if they did not follow the order. There were also people, like his Hutu neighbor, who refused to do what they knew was wrong and many of them were killed for helping the Tutsis or for resisting the genocide.

So the question Danny said he will put to his children is, “If faced with a decision such as this in life, which person will you be?” Danny believed most people think they would be on the side of good but, until this decision actually faces a person, one cannot know for sure!

I will remember our conversation for a lifetime and I tell it often. Danny’s story is the most heartrending example I know of how ordinary people can do extraordinary things—for good or evil!

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

Where does an 800-pound gorilla sit? Anywhere it wants to.

Four years ago, I experienced one of the most magical and meaningful experiences of my life. I was in Kigali, Rwanda for a three-month tour and was lucky enough to find a last-minute ticket to the Mountain Gorilla Reserve, a real triumph since these spaces are sold out a year in advance. I contacted a recommended guide, Danny, to drive me to the reserve the day before our 7 a.m. hike into the forest. I would spend the night before the trek at the Gorilla’s Nest Hotel.

You may remember something about Dian Fossey and her fight to save the mountain gorillas from poachers in the 1970s and ‘80s. Her death in 1985 brought the publicity needed to stop the near extinction of these remarkable creatures. Her work inspired the book and 1988 movie, Gorillas in the Mist. Today, the gorillas are out of danger, well protected, well funded and a fitting living memorial to Fossey’s life and work.

The current families of gorillas living in the mountains have grown up in the wild but, during their lifetimes, their forest has always included humans. While humans are not allowed to interact directly with the gorillas, they continue to study and track them. There are five gorilla families on the Rwanda side of the reserve and, every day of the year, eight humans are allowed to visit each family for a maximum of one hour.

When you arrive at the reserve, you are assigned one of the families. Wherever that family is foraging for the day is the goal of the hike. For me, it was approximately a two-hour hike up a very wet and muddy trail through the bamboo forest. It was miserable. More than once, I wondered if it was worth the effort. Then, unexpectedly, a small gorilla swung out of a tree, careened over the back of one of the guys in the group and ran off. That started the vocalizations and the rustling in the bamboo, and we realized we had arrived.

First, we came on the silverback. Wow, he was huge! Calmly chomping on bamboo, he barely even looked at us, but we knew he knew we were there, and we were acutely aware he was in total charge of his area. Standing in a straight line—eight visitors and two reserve workers—we watched and snapped pictures. We had been told not to talk, as that can agitate the gorillas. This was not a gorilla we wanted to agitate. Other than camera sounds, we were absolutely silent.

After about 10 minutes, he started through the forest. Before we ran into the silverback, one of the guides had to chop through the forest with a machete to make a way. Once we were following the silverback, there was no more need to cut a trail. As he moved through the forest, the bamboo was trampled under him and we just followed the cleared path.

Eventually, the silverback came to a small clearing and flopped down. Within a couple of minutes, three females—one with an infant—and three juniors came into the same clearing and settled around the big guy. For the next 40 minutes, we watched and took pictures. We could hear other gorillas in the bamboo, but no more came to join the group. The juniors played and tumbled, and the females groomed each other. Our group stood about 5 feet from the silverback, with the females behind him. The juniors were anywhere they wanted to be, including inches from us, as they played. It was remarkable.

Before setting off on this expedition, I had high expectations but it was more than I could ever have imagined. For half of the reward, I would have climbed twice as high and still been awe-struck.

These creatures, along with their few cousins that live across Rwandan border in Uganda or the Congo are the only mountain gorillas in the world. If you ever find yourself in this part of Africa, do not pass up the opportunity to make this incredible journey.

I like to classify my exceptional travel experiences in terms of being Top 10. The mountain gorillas are Top 5, no contest. Seeing them was magical. Next time, I’ll tell you about another meaningful part of this trip.

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

Only when stressed

One of my responsibilities, using U.S. Department of Transportation guidelines, is to evaluate local employees who drive embassy vehicles. Ninety percent of the drivers evaluated are men who are 100 percent worried that they won’t pass and will be suspended from driving, which rarely happens. Hypertension is usually the biggest health issue that presents in these physicals and, regardless of the actual BP reading, the drivers always blame it on “white coat syndrome.” Most of the time, the initial conversation goes something like this.

Me: I see your blood pressure is a little high today. Do you have high blood pressure?
Driver: No, I’m just nervous to be here.
Me: Really, there is no reason to be nervous. Do you take any prescription medication?
Driver: No, unless my doctor gives me something.
Me: Has your doctor given you anything recently?
Driver: I have those little pills I take when I need to.
Me: What are those pills for?
Driver: For when I get stressed, like now, and my blood pressure goes up, but I don’t have blood pressure problems unless I’m stressed.
Me: How often do you take those pills?
Driver: Well, my doctor told me to take them every day, but I only take them when I’m stressed or I know I’m going to be nervous.
Me: So, you are being treated for high blood pressure?
Driver: Yes.

OK, now we are getting somewhere!

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

They haven't forgotten

Europeans, especially eastern Europeans, honor pivotal WWII events annually. Allied troops marched into what was then Czechoslovakia in May of 1945 and, under the command of General George S. Patton, liberated the Czechs from Nazi occupation. Even though the Czechs fell under USSR domination after the war was over, they still view American forces with fondness.

The kickoff for the month’s many memorial events held around the Czech Republic for this, the 65th anniversary of the liberation, was held in Prague on Friday, April 30. There was a parade of WWII military vehicles and several dozen Czech citizens dressed in the uniforms of Allied-forces troop personnel. The parade wound its way through Prague and ended in front of the American embassy where a 1940s-style swing band was playing themed music. It wasn’t a huge event; there were perhaps 300 people in attendance. Still, it is gratifying to be an American and experience the appreciation that is still held for Americans who left their shores to defend the freedom of other peoples. It is especially welcome to those of us who serve our government in foreign countries, since there is a fair amount of anti-Americanism overseas, and we are more often on the receiving end of disrespect. The big band music was icing on the cake.

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

Nine things I've learned since coming to the Czech Republic

I’m in my seventh month in Prague, the weather has warmed to pleasant spring perfection and I’m really enjoying this beautiful European city. I’ve been in the Foreign Service long enough to know each location has its particular culture and individual points of interest, so I’ve been reflecting on what I’ve learned since I’ve been in the Czech Republic.

1) Some people in Prague walk faster than I do. This may seem odd to you, but it is the first place I have ever lived where people on the street routinely pass me. I walk especially fast; not intentionally, it is just what I do. My 6-foot 4-inch son, who has a very long stride, doesn’t walk as fast as I do and asks me to slow down. I have been places where people look at me oddly, wondering where the fire is, I suppose, as I scoot past. Here, I am frequently outpaced, and I love it.

2) Prague is the sixth most visited city in Europe but only about 8 percent of tourists are American. I guess that means Prague is a best-kept secret from Americans but, believe me, other countries’ citizens love to come here. The CR is full of Europeans, South Americans and Asians.

3) Czechs are not friendly until after you say hello. Maybe this is a holdover from the insecure times of communism, but Czechs generally don’t make any eye contact with someone they don’t know, whether on the street or in a store. But the minute the other person says, “Dobrý den (hello),” that reserve melts away and he or she becomes open and friendly.

4) The Czech language is HARD! I think there is a reason only 11 million people speak this language, and it isn’t just because there are only 11 million Czechs! I have learned to get by in Czech when I order a meal or go to the grocery, but I will never be able to hold a simple conversation.

5) Czechs over 30 are not particularly interested in learning English. They were required to learn Russian or German—languages of occupying forces—and they are nationalistic about maintaining the Czech language. Who can blame them? I believe their thinking is, because they live in the Czech Republic and have their own language, foreigners who visit or come to live should make the accommodation to get by in the local language. I agree! We Americans think the same way. I just wish Czech wasn’t so hard.

6) Most Czech women are in the normal weight range. This is probably because almost all Czechs participate in a broad range of sports, but I have a sneaking suspicion it is also because refrigerators are tiny. Keeping the fridge stocked requires several trips a week to the market, on foot. I only feed one person, and I know my physical activity has increased just from grocery shopping. Additionally, once I’ve done the shopping and have lugged the groceries back to my apartment, I’m not too interested in eating.

7) Flowers are important. Prague is a city, but it blooms. Flower shops (květiny) are no more than two blocks away, no matter where you are in Prague. Citizens take great pride in displaying plants and flowers, and bouquets are a common gift. It really adds to the ambiance.

8) Czechs love tea! This was a total surprise to me. The CR is famous for its beer and Budweiser Budvar Brewery, home of the original Budweiser beer, is here, but tea shops with exotic teas from around the world are common. Many restaurants have a special tea menu with dozens of choices. By the way, local beer is often less expensive than tea, coffee or colas!

9) Finally, until 1989, every Czech baby had to be named from an official list of names. Legally, a non-Czech first name was not permitted on a birth certificate, and this tradition had been in place for centuries. Each name—male or female—had a “name” day on the calendar, and name days were celebrated rather than birth days.

No doubt, as I live here longer, I’ll learn more interesting facts about my temporary home. But I think the most important thing I’ve learned about Prague is—I’m happy living here.

Photos:

Top: Astrological clock

Bottom: Tyn Church, Old Town, Prague

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

When personal overlaps with professional

I suppose being in practice in the Foreign Service is akin to working in a small town—a very small town. While a few embassy populations are quite large, with more than a thousand staff members and families, most are well below the 500 mark. I am responsible for the occupational health needs of fewer than 200 people in Prague, plus another hundred local staff.

This means my patients are also my colleagues and friends. It is not uncommon for me to have lunch or dinner with someone I treat in the clinic the same week. Rarely are we in a situation where we provide care for people we don’t see frequently outside of the health unit, even if it is just passing in a hallway.

I have always had mixed feelings about this unusual practice environment, as having such a close relationship with one’s patients has both advantages and disadvantages. Under this system, my feeling of responsibility for a patient’s medical outcome is both professional and personal. My medical colleagues and I have to maintain clinical objectivity at the same time we have a very special interest in the people we are treating.

Recently, one of my patients has been very ill and has required advanced medical care within the Czech health system. I am thankful there is such competent care available in Prague, but the length and severity of the illness has cost me many tossing-and-turning nights. I worry and wonder if all the people making decisions in this case—myself included—are making the right decisions. From the beginning, there has been a high chance of complications, and I am acutely aware that, if things don’t go well, my embassy colleagues might look at me with a critical eye. But that isn’t the cause of my fidgety sleep. I have tremendous regard and respect for my patient, and it is that personal connection that causes the angst!

At my first post—Accra, Ghana—I was forced to hospitalize a septic 3-year old. The parents were on their initial overseas assignment and had been in country for exactly one month. The mom was a lovely young lady who stood about 5 foot 2. After admitting the baby to the hospital and initiating IV infusion of the drugs that were going to save her, the mom turned to me, literally grabbed me by the shirt and pulled my face down to hers. “Don’t let my baby die!” she cried.

That was the first time I felt the full force of the responsibility this practice can bring. Unfortunately, it hasn’t been the last time but, in that case, the child did well and left the hospital in less than a week, her mother having never left her side.

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