For tincture of time, there's no copay.

If you follow this blog, you know I’ve been missing for a bit. I am thankful to my buddy, Betty Ulrich, who penned the last entry, and I couldn’t agree more with her description of medical facilities we see in various parts of the world and how fortunate we are to have U.S. medical care.

So where have I been? Well, I went home for a few weeks to see my family, and then I attended a medical conference before returning to Karachi. Since then, I’ve been in somewhat of a funk! Is that word still used, or am I dating myself?

This is a very common problem in the Foreign Service (FS). We call it “culture shock,” but I think the name is a bit misleading. There is a period of time, usually three to six months after transfer to a new post, when an individual feels somewhat disconnected to the new environment, perhaps longs for the city and friends he or she has left behind and experiences anxiety or doldrums. Clinically, people show up on my doorstep complaining of insomnia, gastric disturbances, lethargy or nervousness. Symptoms are nearly always nonspecific, and a treatment of benign neglect is all that is warranted. I advise a person to eat well, exercise, get a good night’s sleep, do something that interests them in off hours and, usually, that is all it takes. “Tincture of time,” we call it.

No one is immune, no matter how many times the moving process is experienced. Early in my FS career, I was sure I would reach a point when culture shock didn’t occur. I was wrong. It has manifested itself in very different ways, depending on the circumstances, but it has always happened.

When I left Ghana, I really missed the friendships I had created and the many local people I had grown to love. When I left Guinea, I pined for the islands offshore that were such a wonderful place of respite. When I left Afghanistan, I had a haunting feeling of things left undone. When I left Pakistan (the first time), I was plagued by concern for the colleagues that remained.

This time, I think the hardest thing is being away from my children and grandchildren, and this only became an issue with this latest visit home. My grandson Cade, the little guy who used to describe his grandmother as living in a box, because he most frequently saw me on the computer screen via Skype, has the part of Michael in the community theater’s presentation of Peter Pan. I won’t be there, and I’m still deciding if that is acceptable to my vision of who a Nana should be.

When I knew I wouldn’t have the mindset to blog for a while, I wrote to Jim Mattson, editor of Reflections on Nursing Leadership, the magazine for which I write this blog. I told him I was suffering from jet lag, a cold and a bad attitude, and we both agreed the first two would resolve quickly, but the last malady could present a problem. I think the cure is near.

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

Reflections from stateside

I've asked my colleague, Mary E. "Betty" Ulrich, MSN, RN, ANP-BC, FNP, to write a guest post. A nurse practitioner with the U.S. Foreign Service, Betty, a retired U.S. Army major and a member of the Honor Society of Nursing, Sigma Theta Tau International, is presently stationed in Kabul, Afghanistan. — Judie Pruett

Upon my return to the United States from Kabul, Afghanistan for a little R & R (rest and relaxation), I spent some time in a U.S. hospital system when my sister required a biopsy. As a nurse practitioner who has practiced in many places in this world, including Africa, Asia, Europe and the Caribbean island of Haiti, I sat in wonder of the U.S. medical system I had taken for granted.

To my colleagues who also work in remote places, I say, imagine a hospital with clean floors, medications available when the health care provider orders them, an efficient administrative staff, air conditioning in the summer and heat in the winter, a safety-conscious environment, meals delivered to your patients’ rooms, clean linen, disposable gloves, patient call buttons and access to mammography before a lump is palpable. These are all items normally available at U.S. hospitals. Life under these circumstances would be heavenly for those of us in the “field.” Understand that these benefits are not the norm in many hospitals around the world.

In Africa, most hospitals require families to provide meals and perform daily bathing and changing of linens. There are too few nurses to take care of too many patients.

Morocco has recently started encouraging women to get mammograms. Unfortunately, the service is not affordable for most women. In Casablanca, the Institut Pasteur reports that the pathology department is seeing more early-stage tumors. In previous years, most tumors were stage 4 specimens. It’s a sign of progress.

In Hungary, local nurses told me that, historically, disposable gloves were washed on the night shift and reused, as there was no money to purchase additional gloves. Poor funding of public hospitals in pre-European Union days demanded adjustments in techniques. The public hospitals do good work under severe budget restraints, but only privately funded hospitals can afford to comply with all the regulations and recommendations.

In Liberia, a nurse told me she thought piped-in oxygen was a wonderful idea but did not expect to see this modern equipment during her lifetime.

In many hospitals around the world, when a medication is prescribed to an inpatient for PO or IV use, the family must go to the pharmacy, purchase the drug and bring it back to the hospital for the ward nurse to give to the patient.

I remember my African housekeeper asking for extra money to treat her malaria. When I questioned her about the results of her tests, her remarks stayed with me a long time. “We can’t afford both the tests and the medicines, so we buy the medicine when we get the fever.” Education comes in many forms.

I do not want to convey an unwritten message of “Don’t get sick outside the USA.” I have seen many doctors around the world, with excellent skills and little technology, who perform some pretty impressive diagnoses. When X-rays aren’t available, listening to a chest with a stethoscope takes on different intensity. When the nearest CT is 100 miles away or in the next country, a well-performed abdominal exam by an expert physician is held in extremely high esteem.

In many countries, very little high technology is available to doctors who take care of the common man or woman. Consequently, physicians have honed advanced ultrasound skills seldom seen elsewhere.

While I am only days away from ending this R & R and returning to Afghanistan, I am gently reminded that, even though our system isn’t perfect, I am grateful that it does struggle for continuous improvement.

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

Do you know TED?

I’ve been in Karachi over the holidays, and I admit to enjoying the quiet. Many of my colleagues went to the United States during this time, and others used the decreased workload as an opportunity to take a regional vacation. I used the quiet time in the office to do those work things I view as a chore and won’t do, unless I have nothing else on which to focus my attention. So, today, I feel rather proud of myself for starting the new year with a clean slate—no nagging odd jobs to complete.

Not having many people around the compound meant extra quiet time on my “off” hours, too. I admit I have hermit tendencies, so being alone in my apartment with my books, TV and computer is really quite all right for me. Over the years, I’ve perfected the ability to entertain myself when there is nothing else to do.

One of the things I enjoy most is going to the TED website and catching up on all the amazing things that are happening in the world. Do you know TED? “Technology, Entertainment, Design: Ideas Worth Spreading,” is an amazing site of information. Check it out for yourself. I guarantee you will find something that catches your interest. These short 5- to 20-minute videos are perfect for my equally short attention span, and the information is often cutting-edge stuff.

My parents always told me that what you do on New Year’s Day, you do all year long. If there is truth to this, my 2012 will be excellent. I am rested and healthy. I’ve enjoyed Skype visits with my family, watched a good movie, visited with TED and spent the evening with friends. I hope your January 1st was equally as satisfying.

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

The babies of Karachi beach

I never expected my tour in Karachi to present me with a once-in-a-lifetime opportunity, but it has. It turns out that the beaches of Karachi are among the top seven hatching grounds in the world for green sea turtles, so when we learned that the Sindh Wildlife Department had offered to provide a turtle experience for the consulate staff, I was eager to sign up. I’ve never seen a sea turtle outside of an aquarium or a movie and, although I grew up on the beaches of south Texas, turtles don’t visit there. I’ve seen lots of land turtles, of course, but this is different.

Late one night, a group of us were driven to a secluded beach outside the city to view turtle egg laying. We were told there were no guarantees. It isn’t like the turtles make an appointment to crawl up on the beach to lay their eggs. While this is the busier season for egg, there are nights when no turtles arrive, or they come later than we are allowed to stay.

After reaching our destination, the rather long, bumpy ride getting there quickly faded in memory when the scientist running the facility informed us that this was a special night. Not only was there a mama turtle digging her laying hole right then, but a group of turtle eggs had just hatched and we would be able to see them before they were released to the sea. It was like winning the turtle jackpot, since the hatchlings have to be in the water in less than two hours after hatching.

This facility, part of the Pakistan wildlife conservation effort, has been in operation for 30 years. It was easy to discern that it is run on a shoestring budget, but the commitment of the scientists and facility employees was impressive. We were led into a shell of a building about 50 feet from the water’s edge. It was pitch black, except for the flashlights our hosts carried. Inside, we were shown a PowerPoint presentation about the two types of turtles that come to this beach to lay eggs, and given information about various endangered turtle species around the world, the predators they face—humans are the most dangerous— and the destruction of their habitats by pollution and the spread of dwellings onto their spawning grounds.

To prevent the extinction of these majestic creatures, their newly laid eggs are dug up and transplanted to nurseries where they are protected until they hatch, approximately two months later, from the elements and from poachers—both two- and four-legged. Once the eggs are hatched, their caretakers deliver them to the water’s edge and hope for the best. It is estimated that less than .01 percent of the hatchlings will actually grow to adulthood and complete their natural lifespan of around 100 years.

My group was first introduced to the new hatchlings. Why are all babies cute? That must be some type of universal law, and the hatchlings were no exception. Their tiny flippers were in full motion swimming vigorously in the air and, after we each had the incredible opportunity to hold one and get a very close look, into the sea they went.

Next, we were escorted down to the beach and to the laboring turtle. The only light allowed was one dim flashlight aimed at her growing pile of eggs deposited in the 3-foot deep hole she had dug. While she largely ignored us, we were told that lights would confuse her and she would stop laying and return to the sea, and that would not be good. We stood watching this incredible act of nature until the turtle indicated it was over and began to use her hind flippers to cover the hole.

Four men then gently picked her up and moved her away from the hole so the eggs could be retrieved, but she didn’t seem to notice the ride. Her back flippers just kept scooping sand. She would do that for the next couple of hours until some instinct told her it was enough, and she would then return to the sea. The eggs were carefully removed, measured, weighed and taken to the nursery for reburying, and this amazing experience was over.

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

No, a fish pedicure was NOT on my bucket list!

One goal I will never attain is to work in East Asia. The opportunity has just never arisen for me and, since this is my last post, I’ve accepted that it’s not going to happen. So when a friend of mine invited me to visit her in Kuala Lumpur, Malaysia and I discovered there are direct flights from Karachi to Kuala Lumpur, it was too good an offer to let pass.

This past month, in the same week we celebrated the U.S. holiday of Veteran’s Day, several local holidays were also strung together. As a result, only one day of actual office time was required of me that week and thus seemed the perfect time to hop a flight.

When I arrived, I was surprised to find my friend was hospitalized, with discharge still a couple of days away. It gave me the opportunity to learn a bit about the local medical system and how care is delivered.

My friend had an attending physician and several consultants who visited her daily for examination and updates on her condition. The hospital itself might have been in any downtown U.S. city, complete with a Starbucks on the first floor. The only thing that set the Malaysian nursing staff apart from their American counterparts was that they have retained the custom of the nurse’s cap, a tradition I was very happy to see dropped in the United States. The only thing I noticed that was very different, at least from the hospitals I’m familiar with, is that each time a patient leaves the room, the door is locked until his or her return. Otherwise, everything was very familiar and that was a comfort to my friend. It isn’t easy to be in a hospital in a foreign country with no family present. Familiar looking surroundings are a real bonus.

After a couple of days, I brought my friend back to her apartment, and we basically became couch potatoes for the rest of my visit. I did take one day to use the hop-on, hop-off bus that ran through the city so I could get a taste of this peninsular nation. Wherever I travel, I try to use these buses when available, as they usually provide a great overview and an efficient way to cover the highlights of the city I’m visiting.

At the central market, I hopped off the bus to participate in something that has peaked my curiosity since the first read of it several years ago. I had a fish pedicure! I dangled my feet in a large vat of water while small, sardine-size fish hungrily attacked dead skin everywhere they found it.

The first two minutes were almost unbearable, not because it was uncomfortable, but because of the freakish sort of tickle. But after the initial shock, the sensation diminished and it was quite pleasant. A half-hour later I was done, evidenced by the few fish still paying attention to me.

Each time another person came to the tub, however, it was like a feeding frenzy. (Maybe we have different flavors.) The fish would swarm to the new feet and do their thing, then eventually lose interest and disperse.

I can declare two things. This was by far not the best pedicure I’ve ever enjoyed, but it sure was the most unusual, and I have a photo to document it.

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

Babu, a different breed of diplomat

I am typically amused when I see diplomats represented in the movies. The character, who is good looking, tanned, expensively dressed and dealing with international intrigue, is frequently shown attending a cocktail party or driving a convertible down a curved mountain road, hair blowing in the breeze. These people don’t seem to have actual jobs, families or concerns outside of their glamorous lives. In short, they are depicted as living a life of travel and comfort and, if there is an element of danger, it is portrayed as adventure.

That is diplomacy in the movies, of course. In reality, the scene is very different. In real life, diplomats are fairly ordinary people who slog through fairly ordinary jobs, many times under different, if not difficult, circumstances. We do choose this life, of course, and it suits a particular type of person, I think. Not many people would be fond of picking up their lives and relocating every two to three years. But the constant for most U.S. Foreign Service officers is their family. The family is the force that keeps us centered, normal and able to do our chosen jobs well.

Family is defined in many different ways in the Foreign Service. Many officers have the traditional spouse and, perhaps, children. For other officers, family is a parent or partner who travels with them and, for many of my colleagues, family is a pet. For me, an absolute necessity is a reliable Internet connection. I require video chats with my children and grandchildren to keep me on solid ground, and I would not accept a post where that is unavailable. The point is, we U.S. diplomats need a sense of home and a grounding of reality, no matter where in the world we might live and work.

We have a few posts—Karachi is one—where the ability to have that sense of home is compromised. Karachi is an “unaccompanied” post, meaning spouses or other members of one’s household are not allowed. To make matters even harsher, pets are not permitted here, either. People assigned to these posts are literally removed from most of what is normal in their lives, and it is a particularly difficult stress to manage. As the medical officer, I frequently see the physical reactions this stress causes.

Respite from that stress is provided, however, in one small but very significant way. One of our officers, through unexpected circumstances, arrived in Karachi with her Chihuahua, Babu. There was nothing to do but let him stay, and he has become the mascot of the compound. Babu is a very friendly fellow, adored by all who meet him. He considers every person his friend, and he is quite willing to accept petting and scratching from all who wish to give it. When Babu is out for a walk, people come from all directions to speak to him and give him some love, which he happily returns with nuzzles and wagging tail. It is impossible not to smile and get a warm fuzzy feeling when Babu is present.

Babu

As a diplomat in residence, Babu really is living the good life. He has plenty to entertain him, lots of admirers and, when his mistress goes for a swim at the compound pool, Babu hangs out on a boogie board catching some sun. If he could learn to drive a convertible, I’m sure Hollywood would have him star in a movie.

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

Er, Doctor, would you wash your hands, please?

Global Handwashing Day was October 15, so, in keeping with the Southeast Asian time scheme, we celebrated it on October 21. Things are always a bit slower in this part of the world. Anyway, my health unit was asked to “participate” in a program sponsored by the consulate and our public affairs office. We were told there would be presentations to an audience of nursing students selected from various hospitals around the city.

The time was set for Friday morning and, since that is the time I routinely supervise vegetable sanitizing—not to mention that I don’t speak the local language—Mehroon, my Urdu-speaking colleague, volunteered to represent our office. We only heard about this event a week before it was scheduled and, three days before it was to happen, we were told the presentation—now singular—was us!

Mehroon and our computer-whiz administrative assistant put together an amazing PowerPoint presentation, complete with videos from Centers for Disease Control, to drive home the point that hands spread germs and germs make people ill. The presentation especially focused on hand washing prior to touching patients in the hospital and how microbes can be spread from one patient to the next by staff members who are not particular about hygiene.

Mehroon teaches proper handwashing technique.

Mehroon strongly encouraged the nursing students to remind family members, hospital staff and—gasp!— physicians to remember to wash hands or use hand sanitizer between patients. Evidently, there was a bit of worried discussion about the latter suggestion. Sure, it is reasonable to instruct families and other staff members might be amenable, but the physician? The students were absolutely sure that offering this suggestion to the physician would not be tolerated.

I’ve been in medicine for a long time, and I remember those days—not that they are completely gone—when physicians were at the top of the heap, and no one dared to suggest or question. Most of the docs I know now think that type of isolated existence is lonely and not very safe, and they welcome rapport with the health care team. It is a worthy concept, and I hope some of these nursing students take the dare and mention what they learned for Global Handwashing Day, maybe even to a physician.

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