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.

Evaluation season

Job performance evaluations are a normal part of a practitioner’s life. The norm is to be evaluated on our medical work, of course, but this skews a bit when working as a U.S. Foreign Service nurse practitioner. In the Foreign Service, the evaluation season theoretically begins on 15 April and ends a month later, when all evaluations are to be in Washington for processing and review. This year, the already-complex system has been “electronically enhanced” to make the procedure run in a more linear, proficient manner, so, of course, we have to start much earlier. To this end, a human-resources expert came to post to teach us the new system.

Each employee, regardless of her or his actual job, has a rater and a reviewer, selected on the basis of organizational hierarchy. I am the chief of my section—medical—so my rater is the management officer, who is responsible for the embassy’s administrative function. His boss, the deputy chief of mission, who is ultimately responsible for the function of all departments of the embassy, is my reviewer. It should be noted that neither of these great guys has any idea what I do medically.

It is incumbent upon the employee to provide the rater and reviewer with a list of accomplishments that can be highlighted in the evaluation. Most of my nonmedical colleagues can speak in specifics, but I must speak in generalities or risk treading on patient confidentiality. I can offer vague statistics that are medically related or, if something is widely known, such as when the bombing happened in Islamabad, I can offer my rater more specific details. But, usually, my evaluations barely touch on the practice of medicine and I am rated more on administrative issues. There is an exception. Once, during each assignment, a regional medical officer or regional medical manager must submit a supplementary evaluation, which does address medical practice and skill.

On the surface, it might appear that there’s a lack of accountability, but that’s not really true. In Foreign Service lingo, it is called “corridor reputation,” which provides the real scoop on how an employee handles his or her responsibilities, and it has a very real effect on that person’s career. If there are problems, it will be known.

So, back to the training provided by the human-resource specialist. To illustrate how far the Foreign Service has come in performance evaluation, she handed out the single-sheet form used in 1949 for all employees. There were 16 areas of evaluation, each containing only four phrases. The rater was asked to underline the one phrase that was most descriptive and cross out the line regarded as least descriptive. Some of my favorite choices are:

• He talks too much.
• He lacks breadth of view.
• He is careless in his personal habits.
• He is too much of an individualist.
• He lacks aggressiveness.
• He is ingratiating.

And my personal favorite:

• He does not wear well as one knows him better!

I’m grateful to say that the evaluation process has progressed light years from this type of appraisal. One other thing: Note that all the phrases begin with he. In 1949, women did not serve in the U.S. Foreign Service. That change might be the greatest advancement of all!

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.