Have Nurse Practitioner Degree...Will Travel - Part 3
Cape Town, South Africa, has got to be the most beautiful city in the world to approach by sea. The busy port town, with its lovely mix of Victorian and modern architecture, is dwarfed by reddish-gold Table Mountain in the background.
South Africa has a history of institutionalized racism that has left deep scars on this nation of 50 million. The era of official apartheid came to a stuttering end in the 1990s when a series of laws was passed giving “blacks” and “coloreds” equal rights and was dramatically punctuated by the election of former political prisoner, Nelson Mandela, as president in 1994. The incredible beauty of the landscape remains marred by townships where millions of black South Africans live in shacks without electricity or plumbing, eking out a living working as domestics or by selling crafts to tourists.
I spent most of my time on the ship since Dr. Yeaton was going on safari for several days. Although I was nervous, it was reassuring to know that Cape Town has excellent medical care, with services available in English everywhere. (I had the chance to observe a colonoscopy performed on one of our passengers.) Meanwhile, students and their teachers went on a series of fascinating excursions: some worked with Habitat for Humanity, others attended an HIV clinic and shelter, and another group visited a program for children who had been liberated from trafficking and slavery.
I spent my day off walking around the harbor; visiting Robben Island, where black dissidents were sent to live and labor in gruesome conditions with very little hope of escape; and riding around Cape Town on the tourist bus. The tourism infrastructure was so efficient that we were able to visit the aquarium, the bird park, and Izama township all in one day. As we hopped off the bus at the township, a lovely young woman offered to take us on a tour. We spent the next hour walking about and visiting the modest homes and businesses, many of which were cleverly constructed of shipping containers. Children ran up to us, and our guide explained that many foreign visitors bring school supplies to distribute. We had not planned ahead and had nothing to offer but smiles and polite greetings, which were returned graciously.
Mauritius and the “Drunk Tank”
As we set off from South Africa to Mauritius, a peaceful, ethnically diverse, increasingly prosperous island nation, most of us were unaware that a typhoon was on a path that would intersect with our route. Our captain headed east to avoid the storm, and we never experienced severe weather, just choppy seas. Because we went so far out of our way, our scheduled stop in Mauritius had to be brief. We had only 6 hours to explore the island but—hooray—I was off duty! Along with friends, we decided to pay the outrageous taxi fares and spend the morning swimming in the temperate, called it the “the postcard beach” since it was so idyllic. We spent a too-short morning swimming and sunbathing, enjoying the kids’ happy screams.
My hair wasn’t even dry and my feet were still sandy when a crew member plucked me out of the embarkation line at the ship and asked me to go to the clinic right away. When I arrived, the place was in chaos. Every available chair, bed, and stretcher was occupied by students. Some were moaning, others were ominously quiet and still, and still others were retching into buckets or on the floor. A young woman was draped over the intake counter crying. The nurses were zipping around with tense looks on their faces. Tin-tin appeared, looking stressed, and said, “Go watch these two; they don’t look good,” and waved me into my usual exam room.
To my dismay, the students inside looked awful: clammy, greenish, and completely still. Their breathing appeared shallow, and they were hooked up to IVs. I attached the O2 sat monitor and found they were both at 98-100%. “Who are they? What are their names?” I called out; nobody answered. I started with the one who looked worse. “Wake up!” I said. No reply. I shook her gently, and her eyes opened, glazed and unfocused. “Hello! I’m nurse Jen. What’s your name?” She mumbled something garbled and closed her eyes. Her pulse was strong, and her BP was 100/72. Well, at least she was arousable, I thought, and moved on to the next student. On closer examination, this young woman looked a little better, and she woke up easily. “Sorry,” she said, smiling. “I guess I had too much.” “Too much what?” I asked. “Vodka,” she said and closed her eyes, “then rum, tequila, and, um, gin.” I had to keep waking her to get additional information. “Did all of you do this? How much did you drink?” I don’t know…a lot,” she said. “We just passed the bottles around.” “Did you take anything else? I asked. “Did anyone? Please, I have to know so I can help.” She explained that they had just been drinking before smiling sweetly, turning her head, and vomiting on the floor. After making sure she didn’t aspirate, I placed her in the recovery position and went back to contestant number one. Although her vitals remained stable, she was obtunded the longest, and the doctor, other nurses, and I ended up monitoring her and five other students for hours.
As the day wore on and the ship sailed for India, the danger of serious complications passed, and we pieced together what had happened. Several dozen students had decided that 6 hours wasn’t long enough to do anything but get drunk. They hit the liquor store and then the beach, where they sat in the sun guzzling alcohol. For the rest of the day, the clinic was virtually shut down for any other purpose, and passengers and crew with minor injuries (like coral lacerations) or illnesses (like food poisoning) simply had to wait. We used up at least a dozen IV sets along with other supplies. The whole medical staff and several resident directors were occupied making sure no one died of respiratory depression from alcohol poisoning. Since these kids were supposedly some of the best and brightest, I imagine we lost a few billion brain cells in the clinic that day. What a waste!
After we docked at Kochin in India, it was my turn to leave the doctor on solo duty and take off for a few days. My family had registered for the “Child Labor Village Homestay” tour, which involved taking a train across the continent and visiting Tamil-speaking Chennai. The heart of this trip was visiting Rural India Development Education (RIDE), a homegrown nongovernmental organization whose goals include the eradication of child slavery. RIDE works on a tiny budget and is run by a married couple out of their home and a tiny guesthouse. The accommodations were basic but comfortable as long as the electricity was working. When the power went out in the middle of the night, the ceiling fans stopped, and the heat and mosquitoes we awful. The home-cooked vegetarian food was terrific, though!
Along with about a dozen college students, we spent three days with RIDE, visiting schools, farms, and the marginal communities it serves. We met children who spend most of their days working in a rock quarry carrying rocks from one side of the quarry to another or hitting larger rocks with hammers and breaking them into gravel. The sun is blinding and the heat is incredible. RIDE offers a “bridge school” where kids who haven’t been in school full-time can catch up—and catch a break from quarry work — if their parents agree.
Somehow, the children still have their smiles, and they were eager to play with us, especially with our children. The language barrier presented no problem at all as we played ball, clapping games, and tag. Although the quarry situation was depressing, we learned that in the early 80s, there were tens of thousands of children working in slavery—sometimes called bonded or forced labor—in the textile industry. Little hands and little bodies are useful to loom operators. With the cooperation of law enforcement, over a number of years, RIDE was gradually able to eradicate bonded child labor in Chennai. The secrets to their success? Patience and cultural sensitivity. “I am from here,” Mr. X explained. “The loom owners knew my mother and father. I speak the same language. And after I was beaten up the first time by the loom owners, the police made me a deputy out of respect. Now, people listen to me.”
Singapore and Onward
As you might expect, the shipboard clinic was busy after leaving India. A number of students developed traveler’s diarrhea although many others were prepared and self-treated with their own antibiotics.
I was busy preparing my pre-port talk about tropical, prosperous Singapore. I’d never been there, but the research told me that Singaporeans are healthier than Americans, with a longer life expectancy. The tap water exceeds World Health Organization guidelines for safe water, and food poisoning is almost unheard of: you are likelier to become ill eating out in Seattle than in Singapore. Therefore, I determined to focus my preport on the real threat to our young population: bad judgment! Most of the danger to young people is the same as in the United States—traffic accidents, suicide, and homicide are disproportionate in the 15–24 age group. Since alcohol and other substances increase the risk of all of these, I cautioned students to beware of the “Singapore Sling.” Many of them seemed to have learned their lesson since we had no repeat customers to the “drunk tank.” Most people spent the day at the zoo or the local amusement park or crammed in as much food as possible from the world-famous food carts.
From Singapore, we headed to Vietnam. What a bustling place! Ho Chi Minh City (formerly Saigon) is in nonstop commercial motion. Thousands of motorbike taxis share the streets with cars and buses, and the waterways, of which there are many, are plied constantly by ferries and fishing boats. Every street corner is jammed with kiosks.
Unfortunately, our staff was also kept busy with one crisis after another. One student had an apparent psychotic break after ingesting a suspicious drink; another crashed on a motor-bike taxi and required emergency surgery. Not only that, but a lifelong learner became ill and dehydrated, resulting in renal failure. Dr. Yeaton, who had planned to visit Cambodia during this stop, was unable to leave, as we were both needed on the ship. This was disappointing, but he said that it happens from time to time and coping with unexpected emergencies is reflected in our contract. He was truly a good sport about it.
Our injured student was a patient at the French Vietnamese Hospital, where he received excellent care. The facility was hyper- modern and I enjoyed visiting it. Not only were the clinical areas immaculate and the staff professional, but they had a gelato bar in the lobby! Unfortunately our student, who would be unable to bear weight for several weeks due to bilateral lower extremity fractures, was unable to continue the voyage.
Once we landed in Hong Kong, we left the ship and flew to Beijing to tour the Forbidden City and visit the Great Wall. We also visited an orphanage that houses about 60 kids whose parents are dead, incarcerated, or for other reasons can’t provide a stable home. The facility was modest, with a somewhat grim trash-strewn backyard, but the children were like those anywhere— boisterous and playful, with hope in their eyes. The students and residents played basketball together and soon everyone was laughing. Once again, the language of play proved to be universal.
Beijing offered highlight after highlight. We visited a Kung Fu academy and watched the kids perform amazing physical feats. After the show, the lithe, nimble Chinese students offered to teach us a few moves. We Americans—relatively plump and stiff—did not do very well, I’m afraid. (Personally, I silently vowed to lose weight and do more yoga.) Later that night, we enjoyed an acrobatic show that made kung fu look like child’s play! The show defies description, but imagine the Cirque de Soleil performed by an all-Chinese cast with the athleticism raised a few notches. Later that night, we ate a delicious home-cooked meal of soup and dumplings in one of the ancient stone-built homes of the Hatong district.
In the morning, we visited the Temple of Heaven. While the temple was stunning, I was more interested in the people at the park surrounding it. Chinese citizens of all ages danced, practiced tai chi, and played hacky sack in the cool morning air. A smiling elderly lady silently invited us to join her. My son overcame his shyness to accept a paddle and join a slow badminton-type game, while my daughter attempted to simultaneously hide behind me and imitate some of the dance moves we were seeing. I decided that we Americans, with our rising obesity and diabetes rates, need to emulate the Chinese practice of daily outdoor exercise.
We flew to meet the ship in Shanghai, where more unbelievable sights awaited us. The skyscrapers went on and on, with each architect outdoing the last. Outrageous buildings flashed neon colors, reflecting off the water every night. It was like Disneyland for bankers, and apparently business was good! What a contradiction there was between the official communist position of the government and the extravagant display of capitalism here in Shanghai. With nearly 2 billion people, China may just be too big to be contained by any one economic model.
The Last Lecture
I was scheduled to give one final “pre-port” talk, and I wanted to communicate to the students in a way that would not be a boring lecture but would help them go on to live healthy lives. Truly disturbed by some of the risky behaviors I had seen, yet impressed by the work ethic, compassion, and adventurous spirit of so many of the students, I struggled to put my thoughts into words. I decided to simply share our experience in the clinic.
“Many of you may be interested in what it is we’ve been doing down there,” I said. I told them we had performed over 610 medical encounters, averaging about 7 visits per day over 105 days. We gave out over 1500 packets of meclizine for seasickness and over 700 condoms. The top three reasons for visits to the clinic were gastroenteritis, respiratory infections, and motion sickness. We also saw people for rashes, sore throats, musculoskeletal injuries, problems with malaria medication, and insect bites, including one botfly infestation. We saw broken bones, head injuries, pneumonia, dehydration, cellulitis, and alcohol poisoning. We treated burns, coral lacerations, animal bites, sea urchin wounds, and splinters. We gave out emergency contraception at least 10 times, and we vaccinated four people for rabies.
Some of the health problems were concentrated geographically. For example, we had lots of rashes and insect bites in the tropics, especially in Brazil and Africa. In China, the asthmatics suffered due to poor air quality, and almost half of travelers developed a cough. Traveler’s diarrhea was common after visiting India. And in Vietnam, due to the ubiquitous motorcycle taxis, we had 15 serious leg burns from hot exhaust pipes.
“Many of you are making very healthy choices,” I told them. I congratulated them for eating healthily—plates in the dining hall were routinely piled high with salads— exercising vigorously, and wearing sunscreen. Very few of the students smoked cigarettes. But there were some unhealthy choices, too, I explained. Binge drinking, defined as four or more drinks in one evening, was common when in port. (They were limited to a maximum of three per day on the ship.) It was common to see students ignore our advice about wearing long pants and sleeves for health reasons as well as cultural ones in some tropical countries. Lying in the sun for hours in a bikini at the equator is just dumb, no matter how much SPF you put on. And while using Plan B after sex is great, it’s much wiser to use “Plan A” and employ reliable contraception in the first place.
In Americans 15-24 years of age, over 70% of deaths are from just three causes. When I asked the students what they were, they guessed AIDS and skin cancer. Many of these educated young people were surprised when I shared the real primary causes of death: trauma, suicide, and homicide. “Do you see a common denominator?” I asked. Silence. “Drugs,” someone finally guessed. In fact, alcohol—or more accurately the overuse of alcohol—is the most common cofactor in trauma, suicide, and homicide. So, I explained, it wasn’t just to kill their fun that we nagged them about drinking too much, and it wasn’t just an overreaction when we kept them in the clinic for observation when they got well and truly blotto. Going forward in life, the single best choice the students could make (besides not smoking) is not to drink excessively. Moderate alcohol use for women is one-to-two drinks per day, with a maximum of 14 per week; for men, up to three drinks per day, with a maximum of 21 per week. It is important to note that more than two or three drinks per day counts as excessive drinking even if a person only indulges once or twice a week; they don’t get to save up their quota and have four or five drinks per night on weekends.
Furthermore, alcohol overuse is related to a number of nonfatal, negative outcomes. Alcohol is the most commonly used drug in drug-facilitated sexual assault.It is the original “date rape drug,” far more common than the “roofies” many were worried about. Physical altercations, accidents, and injuries of all kinds are more common when you’re drunk, or the people around you are. Judgment is affected, leading to additional poor choices that can lead to hurt or heartbreak.
There were some skeptical faces in the Union as I finished, but I believe that for some of them, this information sunk in. I can only hope that they remember it when it matters.
The remaining stops in Japan and Hawaii were blessedly uneventful. Knowing there were only a couple of weeks left in our voyage inspired all of us to slow down and enjoy each moment of the trip. We watched baseball in Japan, swam with sea turtles in Hawaii, and deepened friendships with our shipmates on the 11-day trip between these destinations. It took another week to reach San Diego. The students were busy with finals, and it felt that the work of the trip was almost over.
With more time to sit on the deck and stare out at the Pacific Ocean, I asked myself: what made Semester at Sea so special. For one thing, we saw so much more of the world than I could have dreamed. My kids played with wild dolphins in Brazil, rode the subway in Tokyo, saw Nelson Mandela’s prison cell in South Africa, and even sailed down from the Great Wall of China on a luge! And it wasn’t just in port that they had great experiences. They learned Chinese calligraphy and sign language from the college students. They enjoyed their big brothers and sisters, attended global studies classes, and played long, leisurely games of Monopoly and gin rummy with new friends. They also had the luxury of their dad’s undivided attention, who took to home-schooling them with the same energy and purpose he employs in his regular job. Perhaps most striking, they played with children who will most likely never leave their village, who may never get an education, and who may be married with children at the same age when my children will start high school. It is humbling to realize how privileged we are.
As for me, although I worked a lot, I got to see hospitals around the world. I sang with Sheriff Ghale, took a poetry class with the Pulitzer-prize winning poet Paul Muldoon, and made friends with terrific, globally-minded friends all over the country. Writing this down months later, I realize there were more opportunities and blessings than I could possibly fit into this article, long as it is!
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.