BOOK REVIEW -- NURSES BEYOND BORDERS

     For a week or two after Port-au-Prince was flattened by the Haiti earthquake, we were glued to the TV while the human drama of recovery from a disaster was played out live, unscripted, made possible by the sophisticated technology of TV and global communication. We saw the recovery crews pulling out the people or their remains, watched the reporters interview nurses overwhelmed by the sheer numbers of patients, watched as mobs of desperate people swarmed the trucks delivering food and water, which was at first dumped out the back of the truck as it moved along, barely in control. The images highlighted the heroic nature of relief work. This epic disaster now moves to a quieter phase as it takes its place alongside the stories of 9- 11, Katrina, the Tsunami, wars and other manmade or natural events of history.
     What was has been striking about all of these is the growing recognition of the role that nurses play in these events. At one hospital the CNN crew was referring to the workers as doctors, until the people delivering care came over to correct them. This has always been true about disaster publicity - the care is delivered by whomever happens to be there and more often than not it is a nurse.
     And so this is the background from which I discovered the writings of Nancy Harless. I was fortunate to receive an advance copy of her latest book, Nurses Beyond Borders, around the time of the earthquake. Like Ms. Harless, I have worked overseas and written about the experience. And like her, I have spent time trying to make sense of the experience, trying to explain it to others who I am not certain are really interested. Ms. Harless has worked in Mexico and also the Balkans during the recent war. Her previous books explore previous travels.
     Nursing Beyond Borders is an anthology. Two dozen nurses told their story about working in different parts of the globe. In some cases it was wartime - our own Viet Nam War or one of the civil wars of Africa. In other cases, the nurses may have been on a short-term mission trip or travelling. The stories are loosely organized into four categories - transition, shadows, humor, and looking back. There is no overarching "plot" nor is there any moralizing about the choices made by the nurse or the patients. As in the tradition of the best nursing "war stories" the clinical exemplars are just told, not a lot of frills or embellishments. and the reader is allowed to draw their own conclusions or ask their own questions. Ms. Harless wrote the introduction and a sort of study guide which is appended to the back    
     The introduction is probably the clearest statement about the phenomenon of becoming a Global Nurse, of any that has been written. I found myself wanting to cut-and-paste the whole thing into this review. I knew I was in for a treat when she wrote "....Sit back. Get comfortable...." and then a few sentences later followed it up with "..... And then get uncomfortable -very uncomfortable - so uneasy that you too, feel the call for action...." My reaction was, here is a person who gets it and knows from whence she speaks.
     There is a danger in describing overseas experiences, which is to romanticize the events, or the people who do this sort of thing, or their thinking. During a war, there will be periods of time that are boring, or where senselessly awful things happen for which there is no whitewash. Or we are led to think that the person telling the story has led a spotless personal life; or that the person never experienced fear and doubt during the experience, which is a particular failing of stories told by Christian Missionaries. It was something to which I was determined not fall victim in my own writing. Telling the real truth is something nurses pledge to each other at work and in their professional lives, and Ms. Harless deserves praise for that same commitment to truth she has continued in this work. These storytellers shared the aspects of global nursing that make it intense and very rewarding as well as a journey of personal discovery and service to humanity. Bravo.
     And so, I recommend this book to any nurse that is thinking of getting outside their personal bubble of comfort zone and out in to the big wide world. Get comfortable. Read… the get Uncomfortable… very uncomfortable……

Joe Niemczura RN, MSN: Nursing Instructor a the University of Hawaii University at Manoa, Honolulu, Hawaii. and author of “Hospital at the End of the World” 

                                                                                                                                                      

Until Next Year

     Here I sit in my comfortable living room. My children are healthy and well-fed, intelligent and kind. They are well clothed, with shoes that fit and coats that keep them warm..... They have regular access to medical care, getting their dental, medical and eye check-ups yearly. My pets are not emaciated or flea ridden... My husband and I both have well paying jobs. for miles in ill fitting shoes. ....I have a car that runs well, on streets that are paved, well-maintained. I have heat to warm us in the winter, air-conditioning to cool us in the summer. We have hot water. We have washing machines and dryers. We have electricity, cable TV, reliable internet access. We have so much to be thankful for. We have each other, family and love. Those three things are universal. The “stuff” is just a perk.
     This was my 4th trip to the clinic in San Raymundo. Please do not think of me as a self-sacrificing, amazing person who goes for completely altruistic reasons. It is not true. I go because every year, I receive so very much. Personally, it puts into perspective, my life, my goals, my desires. Do I really need a new phone, a new pair of shoes, another gadget? It helps me to rely not on diagnostic testing, as there is very little available to me when in clinic. But, rather, it helps me to develop my hands on skills and diagnostic abilities based on patient presentation, what I see, what I feel.
     I bring back the blessings of hundreds of people, thankful for a moment with the gringos and the care we provide. I bring back the stories of love, hope and sorrow. I bring back knowledge from every single member of the team I travel with...they all teach me so much. The students I worked with this week made me a better teacher.
     The translators, our voices and our ears, infuse the spirit of their people into English that we can understand. And, sometimes no words are needed, simply a tearful hug says so much more than any language can convey. I come home with more friends, the camaraderie of the providers, the long hours, the tears that we’ve shared, bond us in a way that I’ve never been bonded to others before. Do not think of me as a giving person. Think of me as a person who has been enriched beyond anything she has hoped to be enriched, loved more than ever, taught in a way that she’s not been taught before and thankful for things she’s never been thankful for.
     As I sit here and attempt to put into words the week that I had, I find it difficult. I arrived in San Raymundo with a bus of about 45 other volunteers. The team is made up of many different people with unique skills. We had pharmacist, pharm tech, non-medical people, surgeons, students, nurses, nurse practitioners, laboratory techs, dental hygienist....so many skills, so many uniquely appropriate for this trip. We arrive on Saturday and unload our belongings, claim bunk-beds, set up rooms, ORs, labs, pharmacy. I was able to help do some physical exams on some patients who came in that night in hopes of having surgery in the morning. Clinic then runs from Sunday thru Thursday. We start at 7:30 and go until the last patient is seen. Meals are provided and prepared by a staff of local women. I miss that already. ………
     We saw sicker patients this trip than I’ve seen in the past. More grossly abnormal clinical findings. More heartbreak than before. More joy than before. We had several patients that we simply had to say, there is nothing we can do for you, your condition will ultimately lead to your death, we are deeply sorry. It is such a difficult conversation to have in this country. But, to have it with a patient and their family that have the wild hope that the gringos can fix anything can cause my heart to stop for a moment. We hold hands with these patients, we offer comfort medications, we help the family to understand how to help these people have a peaceful death. We pray with them. We cry with them. …..
     Andrew and I had a patient that came to us. She had a history of stomach cancer about a year ago. She presented to us with a mass in her abdomen, weight loss, decreased appetite. It was obvious to us that her cancer had returned. After consulting with other providers, we were sure that there was no medical treatment left other than comfort care.
     Nancy came in to translate for us. I was the medical voice, the one that gave Nancy the words to speak. The woman’s family came in, her niece, daughter, sister, brothers. Such an amazing family ready to take her home and love her, to give her comfort and care in her last days on earth. The patient clung to me, I held her, kissing her dirt streaked cheek, answering questions from the family. The love enveloping her was palpable. The family embodied strength for me. I cannot help but think about my own personal story here. My dear uncle is terminally ill with metastasized prostate cancer. My family embodies the same strength, the same palpable love, the same joy and appreciation for my uncle and one another. I couldn’t help but cry then. I am crying now as I type this. Family love is universal.
     In the midst of the tears, the sometimes hopeless feeling that we are unable to help, to do anything....we were blessed with the joy of a birth in clinic. Our midwifery student, Deb, took the lead. The room was full of counting...I’m certain I can count to 10 in Spanish now after doing it several times. Mom was stoic, dad was quiet. This was their 8th child. I was not in the room for the birth, but to hear that newborn cry across the clinic. To see our students deliver, comfort, assess and beam with pride was amazing. There is so much hope in a new child. So much joy. So much awe.
     Guatemala is a lush, green country. The volcanoes, flowers and amazing weather make it a fantastic place to visit and enjoy. As we drove from clinic to our 2 day stint in Antigua (where we were able to unwind and be tourists), I plugged myself into my ipod and stared out the window. It is also a country of poverty. of garbage strewn across the countryside. Of children running down the dirt roads with no shoes. Of dogs running wild and emaciated. Of people lying beside the streets, on makeshift sidewalks. My hope is that they were simply asleep there, that they were still breathing, but I cannot be sure. …..
     What made this trip the best ever for me? It’s hard to sum it up in a sentence or two. The entire
medical team was amazing.We worked together with a seamlessness and efficiency I have yet to encounter. No one said “I don’t want to do that” or “I cannot do that”. Everyone was ready, willing and able to go outside of their comfort zones, they were able to move away from things they knew and were able to do well, to find new and creative ways of treating and caring for their patients, to help other members of the team....no question was too dumb, no provider knew everything. Patients were receptive and thankful. Difficult situations posed all of us opportunities to grow, to empathize and to learn.
     I have come home more content with my life. My family, my loves. I am happier with my career and where I am. I am a better student. I am a better teacher. I would not be half the practitioner I am if I did not take these trips. I am able to use skills that I don’t always use in the states, but am reassured that I still have them ready and waiting should I need them. I am more thankful for my health, my friends and the health of those around me. I am more thankful for mi familia, my friends and my colleagues. I am more than when I left. I thank you all for being with me in spirit, in kind and in body. I am just thankful and blessed. I am ready to go again. Until next year....
Jennifer Tucker, FNP

Jennifer Tucker is a Family Nurse Practitioner. She resided in Medina, Ohio with her husband of nearly 17 years, Jeffery, and their two children, Jillian, 13, and Joseph, 10. She works full-time at the CVS Minute Clinic. Recently, Jennifer was awarded the Lifesaver Award at the annual Convenient Care Clinician Congress in Orlando Florida. She received this award for successfully managing a full cardiac arrest and anaphylactic incident in her stores this past year. Jennifer was a ONAAT schlarship recipient in Feb 2010 and she just made her 4th trip to Guatemala this October, 2010. Jennifer precepts students from her alma mater, Case Western Reserve University, on a regular basis.

ONE NURSE AT A TIME by Staci Kelley

Treating Sexual Violence in Guatemala

ONAAT's own, Sue Averill, RN leaves on Sunday for Guatemala City to serve as interim Medical Coordinator of a Sexual Violence Program with Doctors Without Borders/Médecins Sans Frontières(MSF).  Sexual violence affects thousands of people every year in Guatemala, but, there has been little assistance provided to survivors by the national health care system. Doctors Without Borders/Médecins Sans Frontières operates a clinic in Guatemala City specifically to treat these patients. See the entire article at about the program Sue will be working in at :

http://www.doctorswithoutborders.org/news/article.cfm?id=3741&cat=field-news

Healing Beyond Borders - One Nurse At A Time

     Travel and working abroad have a way of stretching us. As our awareness of a wider world and other traditions expands, so does our capacity for compassion and love. As nurses and nurse practitioners , when we experience working in a new and different environment—perhaps with fewer resources than what we are accustomed to—we learn “up close and personal” how others live and provide health care, however meager it may be. We adapt our practices to fit within the culture and the resources available to us. Our nursing framework of ideal practices has to be put aside and replaced with the need to do what we can with what we have.
     Recently, while serving as editor for Kaplan Publishing’s anthology, Nurses Beyond Borders: True Stories of Heroism and Healing around the World, I was privileged to read hundreds of stories written by nurses who have served in the arena of international health care. And, while I could only choose 25 of their wonderful stories to be included in the book, I recognized that each of them was undeniably a very special person who reached out eagerly—though not necessarily without fear—for new, rich experiences.
     One contributor’s commitment to nursing and passion for global health struck a particular chord with me. This “angel of mercy” has not only served numerous times abroad herself, but she also helped found the nonprofit organization One Nurse At A Time (ONAAT), which has a mission to assist other nurses and NPs in enhancing our profession as they, too, look for opportunities to serve locally, nationally, and internationally.  Read all about how ONAAT began and what we are doing to support nurses an to bring an awareness of what it means to be a 'Humanitarian Nurse 

TO READ THE ENTIRE ARTICLE CLICK HERE: http://www.nursetogether.com/Volunteer/VolunteerArticle/tabid/360/itemId/2406/Healing-Beyond-Borders-%e2%80%93-One-Nurse-At-A-Time.aspx 

 

Reprinted with permission, NP World News, Nov/Dec 2010, www.webNPonline.com, NP Communications, LLC

Healing the Children in El Salvador

     I was not sure what to expect. The Presbyterian Hospital Main Operating Room is all I have ever known in my nursing career of four years. I knew practices and standards would be different. I knew that there would be a lot of improvising. That was all I knew of El Salvador: diversity. The severity of it I was about to find out….The entire team met up first thing Sunday morning. There were 12 of us: 2 surgeons ,2 anesthesiologists ,2 scrub nurses , 1 circulator , 1 medical student/anesthesia technician, 1 nurse interpreter , 2 recovery room nurses , and of course Bobbye, the trip administrator. These 11 people would be my family for the week.
     When we got to the hospital the waiting area was packed. There were even people lingering outside in the courtyard. …   First thing first: figure out which specialty gets which room. Technically, LDP has four operating rooms but one of those rooms is used for deliveries. Dr. Carcomo had assigned general surgery to the room with a better overhead light (nicknamed the “Starship Enterprise” for is size and shape) and the ENT surgery room had the instrument washing sink in it….There was a lot of equipment switching for the first couple hours until finally, the equipment found its way to the correct specialty and plugged into working electrical sockets.
     More often than not the group ate dinner together. It certainly created a sense of camaraderie and bonding. The team worked really well together. I had expected more tension and “all-business” attitudes but was pleasantly surprised at how well we got along. That unity helped make the week go by smoothly and joyously.
     On Monday morning we slept in because our bus could not pick us up until 8 o’clock in the morning. Bobbye had arranged government transportation for us for the week. This made me feel much more secure to go between the hospital and the hotel. Monday morning though, the driver was about two hours late—something about the contract or gas or both. I felt so terrible for our patients. Some of them had gotten to the hospital as early as 5:00 am! At least all of them were present when we arrived and each child already had their IV started. As far as I know, none of the families complained about the wait. There may have been some questions and concerns but all the families stayed. In the States, the families would have left and maybe threatened a lawsuit!
     The general team only had three surgeries to do. There were two sets of instruments we brought with us from the States. After each surgery I washed, dried, and wrapped the used set. Then I gave that set to Hilda—the Salvadorian nurse—to be sterilized while we did surgery with the other set. That set would then be ready for the following case. After the third surgery both sets were given to be flashed for the following day. The last patient for both teams was discharged from PACU around 4:30 pm.
     On Tuesday, our bus picked us up at 6:45 am. We had four surgeries scheduled for the day…I also taught Jessie how to scrub in to surgery—how to wash her hands and stay sterile at least. There was a limited supply of gowns and gloves so I could not teach her how to glove and gown herself or set up, but she was able to see more of what Dr. Linda was doing and help retract. After the first case I showed Jessie how to wash, dry, and wrap the instruments. Kay gave us an indicator to place with the set. When I saw the results, I wished she had not.
     The outer tape and the inner sterilizer tape changed on all of our sets. The indicators, however, never reached more than half way to the acceptable on the strip…The biggest culture shock for me involved the lack of regulations and standards. The autoclave did not get hot enough to kill worms and the staff simply continued on with surgery like nothing was wrong. The staff asked us to save the disposable cautery pencils we brought with us. They would soak them in a bacterialcidal solution and reuse them over and over.
     Wednesday was our busiest day. We did six cases total. Since there were only two sets of instruments, we spent some time waiting for them to be turned over. Eventually we put together a third set from the hospital’s instruments…Thursday was our slowest day. The general team was done before lunch time. So while Dr. Linda saw potential patients for Friday, I inventoried the remaining supplies. One of the doctors at the hospital, Dr. Riviera, scrubbed in to the surgeries with us on Thursday and Friday. He was a big help, although he may have slowed us down a bit because we were teaching him during the surgeries and he did not always understand our English.
     Friday was our final day. We did five simple cases and were done by lunch time. Our last two cases were difficult. They were both patients who Dr. Linda had not screened on Sunday—technically speaking “add-ons.” The second to last child needed a cyst removed. The general surgeon at a sister hospital, the surgeon who would follow up with all of our patients, brought to our attention the possibility that this patient may have a tuberculosis infection. It was the only specimen that we sent off for pathology. There was no lab in the hospital. It had to literally be “sent off.” I am still unsure of the outcome.
     Then the last patient was HIV positive. We actually knew this and had decided to do this surgery last because we were so uncertain of the sterility of the instruments. We did not want to pass inadvertently pass on the virus to another child. I realized later that we should have taken more precautions to kill microorganisms on the instruments we used on the patient with HIV because of the immunocompromised condition of the child.
     There are many things I would have done differently that week. But many things could not have been done better. This week changed my views on healthcare: it helped me to be more flexible, taught me to improvise, and showed me how to do things without advanced technology. All in all though—some things were very familiar. There were patients misunderstanding what time they needed to arrive at the hospital. There were parents wondering why they could not feed their child a big breakfast the morning of their surgery. And of course, there was dealing with noncompliance. Maybe things were not do different after all.

Jaren Gravagne, RN, BSN, CNOR is a third generation surgical nurse and currently is the General Surgery and Kidney Transplant Coordinator in the Operating Room. In addition to general surgery and kidney transplants, she also specializes in pediatric surgery and Wound VACs. She is currently training for her first half marathon and plans to keep running as long as possible. Her goal in life is to visit at least one country from every continent—except maybe Antarctica (it’s too cold!). In her spare time, she loves to experiment with gluten-free cooking and baking. Jaren lives in Albuquerque, New Mexico with her husband Anthony. She served with Healing the Children on a pediatric surgical mission in Santiage Texacuangos, El Salvador from February 27 through March 6, 2010. 75 children received surgery and medical care from the mulitdicipinary team.