Have Nurse Practitioner Degree...Will Travel - Part 2
Read Part One.
We left Florida on January 18, 2012, sailing to the Bahamas to pick up the students, who are at the heart of every Semester at Sea voyage. We roamed the decks, looked out at the steel-blue Atlantic, and got to know our neighbors, chatting excitedly about our plans for the upcoming ports. (Many of the faculty and staff visited informally with me about their health concerns, and I realized that professional boundaries were more flexible in the shipboard environment.) Our kids also made friends and met the two teachers coordinating the children’s program. The ship seemed spacious now, but soon the empty halls and classrooms would be filled with approximately 450 college kids from all over the world.
We were to embark on our world tour the next day. The whole medical team kept busy checking medical forms, greeting students and Road Scholars (an organization of older travelers, formerly known as Elderhostel), and storing controlled substances. Dr. Yeaton had previously reviewed most of the health history forms and had the opportunity to decline any persons who could not be safe in the shipboard environment. Although no one was turned away for medical reasons, we had many patients, or “voyage participants,” with significant chronic medical issues, including type 1 diabetes, hemophilia, inflammatory bowel disease, breast cancer, major depressive episodes, and a history of anaphylaxis, among others.
I was surprised at the number of college students on multiple medications. Most prescriptions were for Adderall, Ritalin, and other attention-deficit-disorder medications, but there were a number of students with long-term prescriptions for benzodiazepines, sleeping pills, and selective serotonin-reuptake inhibitors. Several people carried narcotics in case of back pain, migraine, or other problems. For safety reasons and to avoid theft, we locked quantities beyond a month’s supply in the clinic, where they could be checked out as needed. This obviously added to our workload, but it also gave me a chance to talk individually with students and assess them at the start of the voyage. One of the two voyage psychologists joined me during this process, and I was happy that referring patients for counseling would be much simpler than at home.
We set sail from the Bahamas on a typically perfect Caribbean day. However lovely the weather, the ship still rocked, and our first sea day was spent treating seasick students, faculty, and staff of all ages, none of whom were immune. It is preferable to take antinausea medications like meclizine and scopolamine before the nausea hits, but there was a steep learning curve. We gave 50 mg of promethazine IM for vomiting.That first day I faced the challenge of drawing up meds from a glass vial without spilling a drop on a pitching ship. Fortunately, the doctor and I felt fine, having premedicated with meclizine.
For the first several days, I spent about 14 hours per day working in the little warren of rooms that constituted the clinic. Besides tending to nauseated voyagers, I inspected medical clearance forms, reviewed vaccination records, counted pills, and documented visits. While I labored away under fluorescent lighting, my fortunate family explored the ship, swam in the pool, played ping-pong, and met fascinating individuals from all over the world. Meals were eaten quickly; if I did not get to the dining hall on time, I missed lunch! Would the whole voyage be like this? Had I taken unpaid leave, taken my children out of school, and urged my husband to take a leave from his job, all so I could ferry an emesis basin around below decks? Fortunately, my situation improved as we reached the Caribbean.
Although Cuba had been our first scheduled stop, the Institute for Shipboard Education (ISE) had ultimately been denied entry, thereby providing our first glimpse of the impressive flexibility inherent in the Semester at Sea program. After a few phone calls, the ship was diverted to Dominica, a tiny island that had famously served as the setting for the Pirates of the Caribbean II and III movies.
Because of Global Studies class, which students were required to take and voyagers were encouraged to audit, we knew that Dominica had escaped the worst sort of colonial aggression that left its mark on many of our destinations. Its rocky terrain and location at the edge of major trade routes made it less desirable than most of its neighbors as a site for sugar cane production. Even today, Dominican farmers grow a variety of crops for profit and to feed their own people. Without much in the way of sandy beaches, Dominica is not especially attractive to tourists; although it remains in the lower half of the world’s economies, it is more prosperous than nearby islands, which rely heavily on tourism.
We also learned about Dominica during “pre-port,” which were mandatory presentations to the entire shipboard community describing important cultural and logistical information about the next day’s port. As the ISE physician, Dr. Yeaton was responsible for the medical pre-port. For Dominica, he described the importance of avoiding mosquito bites, sunburn, and traveler’s diarrhea. The students listened in fascination as he described some of the tropical diseases that we might encounter in several of our destinations, including dengue, chikungunya virus, and toxic algae, to name a few. Clearly, I needed to bone up on tropical medicine.
My family had registered for a Field-directed Practicum (FDP), snorkeling in Champagne Reef with one of the faculty zoologists. Although the air was warm and breezy as we trundled down to a rocky beach and awkwardly put on our flippers and snorkel gear with the aid of local guides, the water was unexpectedly cool. It took nerve to plunge into the ocean, walking backwards to avoid tripping on our suddenly huge feet, but it was worth it. When I submerged my face, I could see the “champagne” bubbles that gave the reef its name dancing up from the porous rock. Fish of every color darted in and out of recesses in the reef, and I even spotted a moray eel lurking. Some students caught a glimpse of a purplish octopus. It was fabulous, but the water was too cold to enjoy the adventure for more than an hour or so.
We also visited the Dominica museum, where I learned that the novelist Jean Ryhs lived on the island and wrote her classic novel The Wide Sargasso Sea there. We took a taxi tour with a friendly driver who showed us the island’s lesser-known marvels: the many waterfalls, the unique plants, the cricket stadium…and the famous school bus still lying where it had been crushed by a tree in a 1975 hurricane. He commented that health care is free and readily accessible, and the elderly are entitled to residence in an assisted-living facility. While many Dominicans travel outside the country to work, they generally come home to retire. I could easily imagine wanting to return to this lovely spot.
On port days, we held clinic at 7:30 am, and the last day we also stayed open for a couple of hours before sailing. While in Dominica, we saw several people for lacerations from coral and sharp rocks. Even shallow coral cuts are prone to infection and are best treated with a fluoroquinolone. A few passengers had contusions from falls, and several people complained of vomiting and diarrhea. Dr. Yeaton, a veteran of many voyages, explained that gastroenteritis (GE) from norovirus has been a major problem on many cruise ships, including some that shared a harbor with us in the Bahamas. Viruses can easily jump ship because port agents visit all the ships and, while ashore, cruise passengers tend to eat, drink, and use the bathrooms at the same places. Norovirus confers only temporary immunity, allowing repeated reinfection; it is highly virulent, surviving for hours on fomites like railings and door handles. Since the virus could spread exponentially among our passengers over the 5 days it would take to sail to Manaus, Brazil, we needed to get on top of the problem— STAT.
When I heard the first code blue announcement over the intercom, I literally dropped everything and ran to the scene, followed quickly by crew members with a stretcher and code kit and by Dr. Yeaton. A tearful student explained that she had fallen on the stairs and twisted her ankle. My racing heart slowed when I realized that a shipboard “code” did not necessarily mean a life-threatening situation.
In addition to minor injuries, we were completely absorbed by two issues: malaria and GE. Malaria, which had sickened past voyagers, was on everyone’s mind. Although many infected individuals only experience fever, myalgia, and gastrointestinal upset, malaria can be quite severe and even fatal, especially in children. Dr. Yeaton’s seminar on the topic was followed by numerous questions. Although participants had been encouraged to visit a travel clinic before the voyage, they had not received uniform advice. One student insisted she did not need prophylaxis because she had received two injections of malaria vaccine, which, unfortunately, is not commercially available in the United States. About a dozen people had been given chloroquine, which was ineffective in several of our destinations. Strangest of all were the prescriptions for tiny amounts of malaria medication. One young woman had 5 tablets of Malarone, which has to be taken daily while in a malarious area and for at least a week afterwards, making her short about 50 pills. We had plenty of Malarone in the clinic, but many people objected to paying $10 per tablet for a supply for the entire trip. Doxycycline was much cheaper, but we had complaints about gastrointestinal side effects, including esophagitis when the pill was swallowed without a large glass of water. Mefloquine was a weekly pill that would work well in South America and Africa, but not in Asia, where there is widespread drug resistance. In Vietnam and Cambodia, travelers would need to practice serious mosquito avoidance or risk contracting a disease that is extremely difficult to treat.
And then there was the sea cruiser’s bugaboo—GE. Lots of students were put under “mandatory cabin rest,” which is ship speak for quarantine. The medical staff explained that if 2% of the passengers were diagnosed with GE, we needed to report to the maritime authorities, which would set a chain of interventions in motion that could prevent us from docking. Unfortunately, the criteria could include people experiencing simple vomiting with abdominal cramps and/or with simple diarrhea. While distributing (sometimes holding) emesis bags, dispensing Phenergan and loperamide, and starting intravenous (IV) fluids, we also decided which miserable individuals were “reportable.” Those unlucky folks had to fill out a surveillance questionnaire and move into separate cabins, where they would receive “sick trays” consisting of bland, nondairy foods from the kitchen for a day or two. We redoubled our efforts at prevention, pleading with everyone to use hand sanitizer before entering the dining hall, wash their hands repeatedly, and observe the rules of isolation. I insisted my family use what my daughter called “hanitizer” countless times per day, and my own hands were starting to feel unpleasantly waterlogged and dry. The last thing I needed was more patients, particularly in my own cabin.
When I was not working, I sat on the upper deck and enjoyed the Amazon. The river voyage offered a reprieve from the waves and constant motion of the Atlantic. For 4 days on the giant river, land was nowhere in sight. Birds and bugs were everywhere, delighting the kids; beneath the water’s surface swam piranha and other exciting fish. With no cities in sight, the stars were glorious, and the deep green water was flat and calm.
We landed in Manaus, a former center of industry in the rubber trade, where, as Global Studies taught us, European architecture and culture were expressed in cathedrals and the famous opera house. As synthetics replaced real rubber over the 20th century, the previously grand capital of Amazonia became less prosperous, but it still bustled with commercial activity. Vendors lined all the humid streets, selling everything from thong underwear to bubblegum from flimsy kiosks.
On my day off, my family and I visited a dolphin preserve. After a rainforest hike, where we swung on vines, learned about the venomous bullet ant, and spotted one tiny tree frog, we swam in a part of the river where one local family has been feeding the unique, freshwater dolphins for many decades. The dolphins are pink and enormous. Although they live in the wild, they come to the preserve once a day for the free fish. They swam among us, bumping us with their heads and tails and doing tricks for a fishy reward. It was unexpectedly scary to be in the murky water, not knowing when a dolphin would surface or nip at me (painlessly) with its large teeth. When we emerged, we all needed showers since we were coated with yucky dolphin slime. Still, interacting with them was incredible.
That was my only day off. Otherwise, I was busy caring for a patient with shortness of breath and fatigue. With her O2 saturation around 95%, she needed a good-quality chest X-ray, so I accompanied her to the local hospital. We visited the emergency department, which consisted of one room with 12 reclining chairs, each one holding a patient in pain, bleeding, or vomiting profusely. We also made a brief stop in the intensive care unit, which was crammed with misery. Obviously sick patients lay in beds a foot or so apart, their dignity further compromised by being half-dressed. The nurses must have read my mind because they provided a privacy screen to shield my patient and me. We were VIPs here, perhaps due to the high-end insurance coverage provided to all voyage participants.
With the doctor recommending IV antibiotics, respiratory therapy, and frequent nebulizer treatments, my patient decided to fly home from Manaus after being stabilized. The travel insurance company paid for everything, and its helpful staff made flight and hotel arrangements and sent for a US nurse to accompany the patient home. In addition, they provided a Portuguese-speaking medical consultant who reviewed the treatment plan and spoke with the Brazilian doctor. I was impressed. Imagine a world where everyone had such coverage...
After 7 days at sea, our next stop was Ghana in West Africa. In Global Studies, our inter-port lecturer, Ghanaian musician Sheriff Ghale, used dance and music to teach us about the many connections between African and Brazilian culture. Hundreds of thousands of slaves were brought to Brazil in the 1700s and 1800s, and virtually all of them came from the cape coast area of Ghana. Over the centuries, Ghanaian food, language, religion, and music were adapted by Afro-Brazilians.
Although the clinic remained busy, I was able to enjoy some of Shariff’s performances and even played guitar and sang with him once. I also took a few drumming classes—immensely satisfying at the end of the day—with the resident ethnomusicologist. We sat in a circle where there were big “father” drums, medium sized “mothers” and small, high-pitched “children.” Although I found it counterintuitive that each drum was played at a different rhythm, the sessions always made me smile.
I was excited about Ghana for another reason. Two professors were leading an FDP to a maternity hospital. My home practice is an OB/GYN clinic, and I have a particular interest in the obstetric fistula, which is found all over rural Africa. Fistulae occur as a result of protracted, obstructed labor, when the tissues between the vagina and bladder and/or rectum become necrotic and slough off, causing permanent incontinence via the vagina. Virtually unheard of in the developed world, where C-sections are readily available, fistulae are a devastating complication in women with protracted labor. Adding to the tragedy, most babies cannot tolerate days of obstructed labor and die. (Please see the film “A Walk to Beautiful” and/or visit the Fistula Foundation website for more information.
The maternity hospital was rustic and homey. We first saw the OB department, where several women were undergoing labor in a shared room. Although there was no privacy, the beds were a comfortable distance apart, and the open windows admitted a breeze. Some women were eating a light meal that was apparently brought by family members in attendance. One woman was waiting to be admitted, and she huffed and puffed at intervals while seated on the bench; however, no one appeared to be in distress. Our tour guide was a brisk, English-speaking woman who showed us the birthing stool and chair that most women preferred for active labor. The hospital is operated by midwives and nurses, while the one physician on duty keeps busy doing C-sections, hysterectomies, and other gynecologic surgery in 24-hour shifts. Protocols for postpartum bleeding and other problems were written in marker on poster board; however low-tech, they were consistent with protocols at home.
The hospital was part of a compound, and we toured the family planning, prenatal, and pediatric clinics. Waiting rooms were outside under a canopy, and women in colorful headscarves and dresses chatted, ate, and stared at us while waiting to be called. Children played, babies were weighed and immunized, and health and prenatal classes were conducted outdoors. In one instance, privacy becomes critical. Although HIV medication is available for pregnant women, many are reluctant to take it because of the associated stigma. The importance of the medication is stressed and the subject is dealt with in absolute secrecy, making women much more likely to take the medications that will keep their children HIV-free.
I was happy to learn that obstetric fistula is not a major issue in Ghana. Although the country is poor, it has the infrastructure to support emergency care, and conditions are better than in many sub-Saharan African countries. Perhaps this has less to do with economics than with politics. Ghana is a democracy, Shariff explained, and if people are unhappy with their leaders, they vote them out of office. Ghanaians generally like the United States and seek to imitate our model of democracy. No doubt, President and Mrs. Obama’s visit to Ghana 2 years ago did not hurt matters.
Stay tuned for Part 3 – South Africa and Asia...
Jennifer Hanlon Wilde is a nurse practitioner and an English Instructor at CGCC who lives, works and writes in Mosier, Oregon with her family. She is an alumnus of American University and did her graduate work in nursing at the MGH Institute of Health Professions in Boston, and in English at Portland State University in Oregon. As a shipboard nurse practitioner, she had the opportunity to circumnavigate the globe with the Semester at Sea program in 2012, helping to care for students, faculty, staff and their families as they traveled and studied throughout South America, Africa and Asia. In addition to traveling, she enjoys reading, knitting, and making music with friends.