Day 29 Cebu City, Philippines

It was my day off so my friend and I went and explored Cebu City. Here's what the traffic looked like on the way out sped up 10 times:

Just before I started filming, the bus we were taking stopped working as soon as we started moving up an overpass. It was one of the last buses to leave for Dalaguete so we waited for about 45 minutes hoping they'd figure out what was wrong. Luckily they did. Five minutes after that, the bus driver accidentally backed into a taxi, so we had to wait another 45 minutes for them to sort that out. We left the bus station around 8:00pm and with all the traffic and delays we finally arrived a little after 12:00am. Anyway, a long ride home but fun nonetheless.

On a sad note, a friend from work (in Oregon) notified me that one of the residents there had passed away. I know you're not supposed to "get close" with any of the residents you work with, but as anyone that has ever worked in the medical field can tell you, it's impossible not to form some sort of relationship with the people you are caring for. Anyway, this particular resident was extremely nice and very thoughtful and I will miss him/her greatly.

Day 28 Dalaguete Philippines #DPC IM Injection, Intradermal Injection, Wound Care, IV Removal

Today was pretty busy and I got to perform a lot of direct patient care procedures

• 3 IM Injections
  
• 1 Intradermal Injection
  
• Wound Care
  
• Tube Feeding
  
• IV Removal
  
• and the usual syringe loading, vital signs, medication passing, and paperwork
  

The first two IM injections were for a patient who was involved in a mine collapse in Mantalongon. I injected two rounds of tetanus toxoid on the left and right deltoid muscles. Prior to those two injections I also performed an intradermal skin test injection to confirm a negative allergic reaction to the vaccine. My initial (albeit amateur) prognosis was a severe concussion because the patient seemed to be confused and had difficulty maintaining balance. However, after reading his chart, the doctor had diagnosed him with a ruptured eardrum and mild concussion. I wasn't there during the doctors initial prognosis or during the doctors diagnosing, but I'll haphazard a guess that his confusion might have been caused by his loss of hearing and his inability to balance due to the concussion further exacerbated by the torn eardrum. I'll also guess that tetanus toxoid was prescribed due to the likelihood of an ear infection. Tetanus here is almost as common as Dengue Fever, but since they can prevent tetanus with tetanus toxoid, I have yet to see a patient with tetanus symptoms.

The third IM injection was given to a pediatric patient – my first IM injection on a child. This one I was nervous about because the nurse told me I had to estimate how far to inject the needle. I'm not sure if there are different needle lengths for children compared to adults, but supplies here are short so the needle length used on this pedia patient was the same length I used on the full grow adult. With adult IM injections it's fairly easy because, most of the time, you can insert the needle fully without worrying about hitting a bone. However, this particular pedia patient was not only small, but fairly skinny, so I had to ensure the needle was inserted deep enough for the medicine to take, but not so deep as to hit the bone. But, like I had written in a previous post, confidence goes a long way in ensuring you can perform medical tasks correctly, and the nurses here are all very good at boosting my confidence. The pedia patient was the definition of calm and didn't cry or flinch during the injection. I was so pumped up that I had performed an IM injection on a pediatric patient correctly that, like an idiot, I totally forgot to tell the patient that they had done well. I'll have to remember that next time.

I was also able to perform another IV removal as well as tube feeding.

The nurse today also documented most of my direct patient care procedures with my video camera, but I won't post those until I can edit out faces and such. I will, however, post a few still frames here so you can check out a little bit of what I'm doing.

It is worth noting that every single person who appeared in the video or is captured on film is aware and has given consent that I am documenting them for educational purposes. I am extremely grateful for the people who have allowed me to do this and will do my utmost to respect their privacy and maintain their dignity.

It is also worth reminding you that, while it is standard operating procedure to wear gloves when doing any sort of direct patient care, supplies here are always low and/or nonexistent, so gloves are reserved for when risk of infection is great.

IV Removal

IM injection of tetanus toxoid.

NGT tube feeding.

Wound cleaning with providone-iodine (PVPI)

Day 27 Dalaguete, Philippines #DPC IVTT

Daily routine:

1. Vitals BID at 0800 and 1200 (or PRN per doctors orders).
   
2. Load syringes for IVTT's
   
3. Pass Medication at 0800, 1000, 1200, and 1400 (or PRN per doctors orders).
   
4. Tube feeding at 1000 and 1300 (or PRN per doctors orders).
   
5. Paperwork

Today there were two brownouts that lasted a total of about 2-3 hours. The patient who is in a persistent vegetative state is attached to a ventilator so as soon as the power went out me and one of the nurses had to run to the room and hook them up to a bag valve mask so the care taker in there could continue with manual respiration. Brownouts don't affect the ward as much as the ER because there are no computers here in the ward – all the paperwork is done by hand.

Anyway, other than the brownouts, just steps 1-5 today.

Day 26, Dalaguete, Philippines #DPC Baby Delivery Prep, Sterile Procedures, IVTT

I almost got to deliver a baby again. The doctor and nurses allowed me to prep the delivery room using sterile techniques. All the instruments needed for the delivery were pre-wrapped in a sterile cloth and they had me remove and lay out all the tools. The doctor also gave me some tips on how to rest my hands while keeping them sterile. What I was doing was just mimicking what I've seen doctors do on television. You know, keeping my hands away from each other and having my fingers point towards the ceiling. The doctor told me that if I do that, my arms will get tired so I can either:

- Fold my hands. Since the gloves are already sterile, it's alright to clasp them together. This allows mobility while maintaining sterility. It also helps prevent accidental contamination because your hands are in front of you where you can see them easily.

or

- Rest them on a sterile surface. The cloth that has all the instruments on it is sterile, so you can rest your hands there. It rests your hands better because you can put all your weight on the table but you're less mobile.

The mother ended up being referred to a tertiary hospital in the city for several reasons:
1. Age: She was a first time mother and already in her early thirties.

2. Mass/Size: She was only 30kg and about 5'0.

3. Time: The policy here is, once the mother is fully dilated, the baby must be delivered within an hour or the   patient needs to be referred. This is done mainly to protect the patient because if there are complications, the hospital here isn't equipped to handle certain types of births (i.e. Cesarean section) unless the surgeon happens to be in (which is only twice a week during the weekends)

Other than that, just more routine today. IVTT (intravenous through tubing) injections, passing out medication, and paperwork.

Day 25 Dalaguete, Philippines #DPC IV Removal, Wound Dressing Assist

Routine, routine, routine. Vitals, IVT's, passing meds, and tube feeding.

However, a rather peculiar case was admitted when I was off duty last night so it was new to me this morning. A patient came in with a rather ferocious looking wound on his right shin. When asked what happened he said that he suffered from ant bites then tried to use an herbal remedy to cure the wound. It turns out he had an allergic reaction to the remedy, which further aggravated the site causing more damage. I was able to help assist in dressing the wound. He was given an antibiotic ointment, told how to clean and dress the wound, and then was sent home.

Today was also the first time I was asked to remove and IV without any supervision. It was pretty nerve racking but I just ignored all the what-if scenarios and focused on doing the right steps and it came out easily. The hard part is making sure the medical tape is completely removed before pulling out the IV. The tape gets pretty sticky especially if the patient has had it on for awhile but cotton and alcohol helps remove the adhesive.

I'll be switching back to the ER next week for PM shift.
Cheers!

Day 24 Mantalongon, Philippines

I became a godfather today, or as they say here, a Ninong. My godchild's name is Raymond. Raymond's father, Migs, and I now call each other Pare as is the custom here.

My Godchild, Raymond.

My pare, Migs (in yellow), and I.

The ceremony was in Mantalongon. This is the part of Dalaguete known as the "Vegetable Basket" because it's high in the mountains and produces a large percentage of vegetables that make its way to Cebu City. The weather up there felt great and reminded me of Oregon!

Anyway, here's what it all looked like:

At the very end of the video they two men are loading and firing a home made cannon. The fire it during celebrations because it's cheaper than fireworks!

Day 23 Dalaguete, Philippines #DPC Stitching Assist, Newborn MAS Assist

I was called in this morning because a baby was being delivered! Sadly, I didn't make it in time for the actual delivery – apparently when the mother came in to the ER she was already crowning. By the time I got there the baby was already delivered but there were some complications. The infant suffered from meconium aspiration syndrome (MAS), which is when the meconium (the infants stool while in the womb) makes its way into the babies lungs and stomach. One of the doctors on duty told me how, normally, they would use a laryngoscope and an endotracheal tube to ensure proper suctioning but there was no time to prepare so the doctor manually inserted the suction without the aid of the laryngoscope. The fluid coming from the lungs and stomach had a yellowish tinge and the babies overall skin color was a light grey. The doctor kept flushing and suctioning until the fluid was clear. Afterward the baby started regaining color. While that was going on, a second doctor was stitching the mother because of a tear that had occurred along the vaginal wall during delivery. The doctor asked me to assist so I held open the vagina and sponged away blood while the doctor stitched.

The stitching was amazing for two reasons. First, there was so much blood I had no idea how the doctor even knew what she was doing. Secondly, and even more impressive, was that the doctor stitching only has a thumb and shortened pinky finger. I'm not sure if she lost the fingers or was born with a condition, but it was awe-inspiring watching her work. It just goes to show that anyone can practice medicine if they're willing to learn.

Anyway, the doctor on duty two weeks ago told me if I bring him a pig leg, he'll teach me how to stitch on it. Then we'll cook it up later and eat it.

Here's a couple pictures of how things are organized here:

Each ticket is color coded describe if the medication is OD, BID, TID, or PRN.

Self-explanatory 

Day 22 Dalaguete, Philippines

Another routine day. IVT's, tube feeding, refilling prescriptions, etc. The nurses here have started putting me in charge of taking and recording all the pediatric patients vitals. I was a little unsure at first because infants have a broader normal range in terms of heart rate and respiration, so the first few times I took them I thought I was reading them incorrectly.

The doctor on duty also said I should put my number on the bulletin board so I can be on call in case anything interesting happens. Hopefully something interesting happens soon.

Anyway, here's a video of me loading syringes.

Day 21 Dalaguete, Philippines

Another routine day on the ward. More IVT's, more syringe loading, more passing out meds. I say routine because, for the nurses it's routine. For me, though, it's exciting every time I get to load a syringe or prep an IV. The nurses also requested that I ask the patients their input and output as well as measure the remaining fluid in any IV bags.

Asking for I &O's has definitely been the hardest part so far. Why? Because I have to speak in Bisaya.
“Pila ka ihi sa buntag?”
“Pila ka inom tubig sa buntag?”
“Pila ka lebang?”
The nice thing is, since everyone can understand English, if I say something wrong, I can switch to English to clarify. Speaking with the patients here, listening to them, is making it easier for me to understand Bisaya.

I also met an American from California today. He's been married to a Filipina for 40 years and speaks fluent Tagalog and is currently learning Bisaya. He told me he graduated as a linguist major from Fresno State and has been here in Dalaguete for 2 years. One of his friends (who is also an American) was admitted to the hospital so he was dropping by to visit. Having an American here was nice because the nursing staff wanted me to do all the explaining of medication so I got a taste of what direct communication with a patient in a hospital setting will be like.

Day 20 Dalaguete, Philippines #DPC Assist NGT Insertion

Today was fairly slow in the ward. At the end of shift, there were only 10 admits (apparently last week they had something like 20 – and there are only 2 nurses on duty).

I got to perform several more intravenous therapy (IVT) injections giving me more opportunities to practice my needle skills. I've learned the best way to avoid air bubbles is to slowly pull the needle out of the injection vial as you load the syringe. Doing this keeps the needle submerged in liquid the entire time your pulling back on the plunger. It's a small easy step that cuts loading time (for me at least) in half. It also helps you use the medication efficiently because you're wasting less of it since you don't have to keep ejecting air pockets. You know how in the movies when someone is about to give an injection they push the plunger down until a bit of the medication squirts out? It's true, that does happen, but only if you're not a well practiced nurse. For example, when I load syringes, I have to squirt a bit of medication. However, the nurses here have performed countless injections and are always short on medication so they've perfected the art of loading syringes. They can load medication right up to the beginning of the needle with zero air bubbles and no loss of medication.

I also assisted with an NGT insertion because a patient came in who had suffered stroke. It was kind of unsettling because, although the patient was in a semi-stupor, she could still move and was struggling as the tube was inserted through her nose. I asked the doctor how she could tell she wasn't inserting the tube into the lungs and she told me, with patients that can still swallow, it's easy – just tell them to swallow and the body automatically closes the nasopharynx cutting off access to the lungs. You can try it yourself. Swallow, and during mid swallow try to breath through your nose. If the patient cannot swallow, then it's trial and error. However, the doctor told me that, with practice, you can just feel that you've entered the lungs. She also told me how, normally, you're supposed to measure the tube before placing it in the patient, but they don't practice that here because the measuring it first increases the risk of infection. The risk of infection is greater than the doctor placing the tube too deep – that's how clinically skilled the medical staff is here. I had to look up on the internet how to measure the NGT tube and it requires starting that the patients nose, looping it around the ears, and measuring approximately 5cm below the xyphoid process. The doctor here used sterile procedures (including sterilized surgical gloves) and when the patient was brought in, she was anything but sterile. So I definitely understand why the doctors don't want to dangle a sterile tube around the patients ears and nose right before inserting it directly into their stomach.

The staff here has told me how I'll be able to do an IV insertion at some point. Because there is only one doctor on staff, the nurses here all know how to insert IV's. Although IV insertions require training and certification, most of the nurses here just received on the job training. If the doctor or certified persons were to do all the insertions, there would literally be no time in the day for anything else – that's how often IV's are used here. I expressed how I was nervous about it and I the charge nurse gave me some of the best and most practical advice I've been given thus far in terms of practicing medicine. I'll paraphrase:

Trust yourself. Be confident. Choosing medicine as a career is already proof that you want to help others, so don't think that learning skills will harm the patient. If you don't give an IV because you're too scared of hurting them, then the patient will never get better. You'll make mistakes, and if you truly want to be here, then you'll learn from them.

Anyway, I'm enjoying my time in the ward. It's a little bit more routine, but I get to practice needlework more often and am exposed to a lot of clinical skills that I'll have to master if I want to become an effective PA. I'll leave you with a picture of me about to load a syringe.

Day 19 Dalaguete, Philippines

Day two in the ward seemed routine for the nurses.

One thing I really enjoy here is that I get to work with children. Back in Oregon, since I work as a caregiver in a nursing home, I work with a strictly geriatric demographic. I thoroughly enjoy working with the elderly, but working with children presents its own set of challenges.

For example, I learned today that when giving an IVT injection, it's common practice (here at least) to kink the IV line so when the medication is introduced it goes straight into the vein instead of backflowing through the tube. This ensures a quicker delivery. Sometimes though, the antibiotic can be a little strong, causing a stinging sensation. With adults, the pain is easily dismissed, but for a pediatric patient, it can cause unneeded stress. So, the nurses here often don't kink the tube so the medication goes into the veins a little bit slower (due to backflow), resulting in a reduction of pain.

An even bigger challenge is trying to perform an IVT injection after the child has just had an IV inserted. They see you walk in with a needle and they assume you're going to poke them again. Even babies recognize needles pretty quickly after getting an IV. It's a challenge, to say the least, trying to insert a needle while the patient is flailing about.

Anyway, aside from pediatric exposure, I was also more acquainted with proper medical dispensing techniques:

1. Ask the patient their name.
   
2. Check their wristband.
   
3. Describe what the medication is for (this is the tough part for me because I still can't speak fluent Bisaya).
   
4. Watch the patient take the medication.

The more clinical exposure the better. Cheers!

Day 18 Dalaguete, Philippines #DPC Intramuscular Injection, IVT Delivery, Tube Feeding

I went back to work at the hospital today. I've been moved from the ER/OPD to the Nurses Station/Ward and will be in this position for about a week before going back to the ER on night duty. It's my first day in this portion of the hospital and already I got to perform two direct patient care procedures I'd never done before.

The first was in intramuscular injection. Surprisingly enough, the IM injection is much easier than performing a skin test. With a skin test, you have to be fairly precise. You can't come in at too steep an angle and you don't want to push the needle too far. Also, once the needle is in place, you have to have steady hands or you might push the needle out from under the skin. With the IM injection, all you really have to do is find a nice meaty spot on the arm and inject. The hard part is pulling back on the plunger to ensure now back-flow of blood (as I explained in one of my earlier entries, back-flow of blood into the syringe means you've hit a vein and you should immediately pull the needle out). I'm going to apply some rudimentary physics education here: the plunger resists a pulling motion because the diameter of the needle is so small and the amount of “stuff” (muscle tissue, body fluid, etc.) in the persons arm acts as a barrier between the hole and the plunger creating a small vacuum. Long story short, it was hard pulling back on the plunger before introducing the medication. The nursing staff was very encouraging and just told me to be confident and, with time, I'll develop a method that's easier, quicker, and more painless.

The second procedure I got to do was NGT feeding. They have a patient here who is in a persistent vegetative state and requires an NGT to eat.

1. First ensure the tube is directly in the stomach. Simply take a stethoscope, place it on the stomach, and use a plunger to push a tiny bit of air into the feeding tube (they lack a proper plunger here so what they use instead is something like a big medicine dropper). What you're listening for is a gurgling sound, which indicates the air has made its way into the stomach.
   
2. Next is the pre-flush. Kink the tube and pour in 5cc's of sterile water. Un-kink and let it drain freely.
   
3. After that, pour in the liquid food. This part is tricky because the food is rather viscous. Use giant medicine dropper to help push the fluid through the tube. However, push directly on the top of the medicine dropper and not on the sides or the top of the dropper will keep popping off.
   
4. Once the fluid is consumed, flush with an additional 10cc's of sterile water.

Aside from those two things, I also got deliver medicine via intravenous therapy (IVT). Pretty straight forward: sterilize the port then inject the medication. My needle work is getting a little bit better, too. It's easier for me to premix solutions and fill the syringe without getting too much air in.

Working at the nurses station also allowed me to see the safeguards in place to ensure correct patient medication. Everything is confirmed. Before shift, orally give a report that the follow shift must write down by hand. Check the kardex. Check the doctors order. Check that the medication matches the doctors order. Check the patients wristband. Ask the patient their name. Tell them the medication and what it's for. Give the medication. There are probably way more safeguards than I mentioned, but those were the ones I could pick up on because they move fairly quickly because they're used to it and because a lot of the medication is time sensitive; perhaps a combination of both, really. What's really impressive is the report for the next shift. The head nurse on duty says the patients name, age, medication received (or refused), how fluid much is left in an IV bottle before needing changing, the drips per minutes for said IV bottle, how many total bottles have been consumed since admission, the time the bottle was hooked, the time any medication was given, the time any future medication must be given, and any procedure done to the patient. The head nurse says all of this in about 3 – 4 minutes while the relieving nursing staff writes it all down by hand. The attention to detail and the listening skills required are incredible. Maybe I'll get footage of it next time.

Day 17 Dalaguete, Philippines

I'm back in Dalaguete and just met a couple of Ricky's friends who are also in the brotherhood. They are from Mantalongon, which is up in the mountains and where most of the vegetables that supply Cebu City come from. I've actually been up there before, but forgot to bring my camera. Luckily, I'll be going there this Sunday. One of Ricky's brotherhood friends is having his baby baptized and invited me to be one of his son's Ninong. The equivalent in American terms would be Godfather.

This is a predominantly Catholic nation, so my responsibilities as Ninong is to assume parental care if the parents are neglecting the child physically or spiritually. However, in modern times, it's more an honor than an actual obligation. I asked some of my coworkers what a Ninong really is supposed to do and they said nowadays Ninongs just pray for their Godchildren and send Christmas/Birthday cards. I know that he probably invited me to be a Ninong for the experience, but it's nice that I'll have ties to Dalaguete even if it's only ceremonial.

Somewhat of a tangent, but one of the cultural differences here I've noticed is how direct everyone is. It's not rude, just very honest and direct, and I'm beginning to think it's because of how the language is constructed. My parents always had trouble explaining the language to me because there are multiple meanings for everything. I know that sounds complicated but it simplifies the language because you can express how you feel or what you experience in multiple ways. The diluted nature of the language makes the connotation of individual words less positive or negative and more general. For example, the word “luoy” roughly translates, in English, to “pathetic.” However, in English, the word “pathetic” carries a somewhat negative connotation. If someone breaks their arm, you wouldn't go up to them and say, “how pathetic.” That would be rude, at least, in my mind that would be rude. But in the Philippines, you could say “luoy” without it being rude. The lack of specificity reduces the overall ambiguity. I know that sounds totally counter intuitive, but there are so many meanings for sadness in English that the overall emotion you're supposed to feel is lost in the diction. In Bisaya, there are many words for sad, but they all carry about the same amount of weight in terms of connotation. Not to say there aren't more specific words in Bisaya, just, in general, everything is more general. See, even trying to explain this in English is making my writing seem convoluted.

It's amazing because most of the people in this region are trilingual: Bisaya, Tagalog, and English. Tagalog is a different Filipino dialect, but to assume Bisaya and Tagalog are similar would be incorrect. I asked one of the nurses awhile ago how the two are different, and she said it would be like comparing English to Native American dialects.

Anyway, it's incredibly interesting just trying to understand life using a different language. It feels like a different way to view reality. I think maybe when I get back home, I'll continue learning Bisaya but also revisit Spanish since the two are so similar. Who knows, maybe I'll even become interested in learning more languages.

Day 16 Cebu City, Philippines

My Aunt and cousins took me to the bukid (the mountains) today. My aunt has an investment in pigs up in the mountains so she wanted to see how they were doing. Investing in pigs here is fairly common. It takes at least two people and works like this:

1. You front money for piglets or for breeding (in this case, my aunt invested in breeding since it's cheaper to breed piglets than it is to buy)
   
2. The pigs are now “yours” so you help pay for food and medicine.
   
3. The second person keeps the pig on their land and manages the upkeep.
   
4. Once the pigs reach a certain age, you can either slaughter the pig and sell the meat, or sell the full grown pig directly to another buyer.
   
5. The profit is split between you and the second person.

It's insane how the people that live up in the bukid get around. Motorcycles, motorcycles, and Caribou. The motorcycles they use definitely aren't built for off road traveling, but the people here modify stock parts in order to make it work. The motorcycles here built for two at most, but here in the bukid it's normal to see up to four people piled on one dinky little bike that's chugging along overtaking slower bikes and occasional work trucks. The most intense part was the ride back down. There were three of us, full grown men, riding on one motorcycle flying downhill. All I could think of was F = ma.

Anyway, getting to the bukid is an adrenaline rush. Some trucks might be able to make the climb, but the roads get alarmingly narrow the higher up you go and pavement begins to disappear completely. It'd be more fun just to show you (I was able to film on the way up, but on the way down I definitely needed both hands to hang on):

Mom and Dad: I'll definitely invest in a helmet soon.

Day 15 Cebu City, Philippines

Today my Aunt and cousins took me to the docks in Cebu City because they wanted to ball room dance. Beforehand we went to the biggest/oldest/main church in Cebu City and attended mass. Every Friday they close off part of the streets because it's like a mini fiesta. Street vendors sell food and toys. One of the customs here is to buy candles from the poor and they'll light it and say a prayer for you.

The view from ball room dancing.

Day 14 Cebu City, Philippines

Today was my Grandma and Grandpa's 60^th wedding anniversary! It was also my Dad's birthday! Congratulations Grandma and Grandpa, and happy birthday Dad!

It's always quite the task trying to explain to everyone here what exactly a PA is. As far as I know, PA's are only in the US and have yet to make a foothold in the global job market. I basically tell everyone that I'll be in between a nurse and a doctor.

Anyway, I just celebrated today and met a lot of relatives from my mother's side. I'll be visiting them at their place next time I'm in Cebu, City.

Some of the extended family.

Day 13 Dalaguete, Philippines

Earthquake! There was an earthquake during my lunch break today! It's the first time I've ever experienced one. Back in Oregon, there have been a few earthquakes, but I've always been asleep and didn't even realize anything had happened. This time I was sitting at a restaurant eating and I thought I felt the room shake. It wasn't too bad and only lasted a few seconds.

I only worked a half day today since I'm going back to Cebu City for the rest of the week. It's my grandpa and grandma's 60^th wedding anniversary tomorrow, so I requested the rest of the week off so I can attend and visit other family members in the city.

Today was rotation day for the doctors. The IM doctor was replaced by a pediatrician and I got to see her perform an IV insertion on a baby that was less than a week old! It's one of the most skilled IV insertions I've ever seen. Birthing practices here are very holistic. The hospital is pro breastfeeding and there are rules against any soliciting of baby formula within the hospital. Baby formula companies cannot fund anything at the hospital because they want to keep the birthing practices away from money. I can't remember the term they use here, but after the baby is born, the mother holds child until the baby breastfeeds for the first time.

The rest of the day was quite slow because of the rain. Rain here in Dalaguete is similar to flash flooding except the people here are prepared for it. All the houses have cement built ditches that empty out away from homes and businesses. When it rains like it did today, everything basically stops. Literally, everything stops. If you're outside, and too far to get home, you just go to the nearest cover and wait. It'll rain for hours at a time with small breaks, which gives people time to get home, but the hospital is empty for most of the day because people just stay indoors.
Anyway, I made it to Cebu City and experienced some of the night life here with my cousin.

Day 12 Dalaguete, Philippines

Today was slow. Just a few outpatient consultations but nothing too exciting.

The hospital here practices the 5S business model, which is a smaller part of an overreaching idea of the Japanese business model Kaizen. I cannot verify this, but I'm pretty sure I read somewhere that Japanese car companies based in the US practice this type of business model, and it's so effective that some US car companies have adopted these principles into the workplace.

Kaizen
5S

The 5S principal basically moves away from micromanaging so that staff members are accountable fore each other. Self-discipline is key and, if done correctly, the work place is more efficient. It's not all the different from US business practices except that the focus is more on self-management instead of traditional managing.  

So today, the staff was separated into groups and given areas of the hospital to implement 5S practices. My group had the ER so we spent of the day cleaning, sorting, and disposing of anything that wasn't of practical use.

After work some of the nurses took me around Dalaguete and showed me the local beach. All in all, a slow but good day.

Day 11 Dalaguete, Philippines #DPC Foley Catheter Insertion

It was pretty busy at the hospital today. Lots of admits with lots of fevers. I got to perform my first catheter insertion today! The doctor on duty showed me how to put on sterile surgical gloves and guided me through the process of inserting a Foley catheter.

1. Take the Foley catheter and wrap it around your non-dominant hand leaving slack near the bladder opening. Wrapping the catheter tubing around your hand ensures the tube won't accidentally touch a non-sterile surface.
   
2. The nurse or nurse assistant will then take lubricant and apply a fair amount on the back side of your dominant hand. In order to maintain sterile conditions, the nurse/nurse assistant will make sure the tip of the lubricant bottle never touches your gloves – she/he will squeeze and wait until the lubricant disconnects from the opening on it's own.
   
3. Take the bladder opening portion of the Foley catheter and apply a generous amount of lubricant. This is done by simply twisting the tip on the back side of your dominant hand.
   
4. Insert the catheter by using your dominant hand to pull up on the tip of the penis. This is the reason you want the catheter to be in your non-dominant hand – maneuvering of the penis requires more dexterity.
   
5. Insert the catheter until drainage starts to appear in the tube. In this case, drainage didn't appear for me until I had reached the fork between the urine drainage port and the balloon port. As soon as the happens, the nurse/nurse assistant will inject saline into the balloon port in order to anchor the catheter in place.
   
6. Last is to measure the output rate. Do this by kinking the tube then un-kinking at five minutes, allowing 100cc of fluid to drain. After 100cc is reached, re-kink and wait another five minutes. Do this until the output can no longer reach 100cc after five minutes. Once this point is reached discontinue kinking and allow the catheter to flow normally. 100cc/5mins is a flow rate of 20cc/min. I'm not quite sure how this is useful, or what the doctor would do with this information, but it's a quick way to establish a flow rate. I'm guessing there's an average amount of times a healthy person will fill the bag with this given flow rate, so maybe it's just a way to gauge whether or not there's something wrong with either the patients bladder, or with the insertion of the tube. 

Along with fevers, car accidents, and UTI's diabetes is a huge problem here, especially among the older population. There's not enough supplies for preventative maintenance (i.e. insulin) and the food consumed here is often high in sodium and cholesterol leading to high blood pressure further aggravating diabetic conditions. The high cholesterol intake causes most of the population to develop early onset arthritis caused by the buildup of uric acid. The onset of arthritis prevents regular exercise allowing diabetes to gain an even stronger foothold among the population.

A patient came in because her right toe was slowly decaying. The reason? Diabetes. The doctor cleaned her toe as best he could, then refereed her to another hospital to get it treated or perhaps amputated.

It's a complex situation here. The natural diet of Filipino's is rather healthy, especially in Dalaguete because of the abundance of fresh vegetables and seafood. However, as technology allows the transportation of food more quickly and at a lower cost, the intake of pork, beef, and chicken is steadily rising causing an increase in sodium and cholesterol intake. This is also a culture that doesn't like to waste food so every part of the animal is consumed, even if a lot of those parts are unhealthy to eat. Pork and beef used to be more expensive, so they weren't consumed so often, but now, it's different. That combined with high intake of white rice are probably the root cause of diabetes here and in most places in the Philippines. Luckily, people here know that their diet is causing diabetes, so most of the parents here teach their children to eat a balanced meal.

Day 10 Dalaguete, Philippines

It's another day off for me here in Dalaguete. It rained pretty hard for quite awhile today. I was raised in Oregon, so I know how hard it can rain when it pours. It was definitely pouring today.

It was steady rainfall like that for several hours.

Anyway, when it stopped raining super hard, I went with Ricky to one of his Brotherhood meetings. Ricky is part of a local group that refers to themselves as the "Brotherhood," and they support the community by organizing beach cleanups, feeding the hungry children, and whatever else helps benefit the community. I'm not sure what Ricky's position is, but all the members "blessed" him when they came in.

Let me explain "blessing." In the Philippines, when you greet an elder (it doesn't matter if you're related to them or not) you take their right hand, palm down, and bring the back of their hand towards your forehead. It's a sign of respect, and during holiday's, the elders will sometimes sit in a line and when the children bless them, the elders give them a little bit of money. I was raised to do this to my parents and to other Filipino's, but it's something that tends to phase out once you get older.

I'm assuming Ricky is the leader because he organized the flow of the meeting and because everyone that came in blessed him even if they were older.

A few nights ago Ricky was explaining how they were going to start raising money to help feed the starving children in the community. They've done it before and they make a type of dish called puspas. It's basically a rice porridge, but they add eggs, meat, and all types of vegetables in order to give it a full compliment of vitamins and minerals. He told me last time they fed close to three hundred children and that I could help once they're ready. I asked him how much it costs to fund a session like that and he told me 5,000 pesos. At the current rate of exchange, that's only $125 dollars. I offered to fund it so they wouldn't have to wait so long. Before I left for the Philippines, I calculated that I would have 4,000 pesos per week, but didn't realize I had another check coming from work. Plus, 4,000 pesos is already more than enough to survive a week here so I'll have a surplus anyway. Besides, if you do the math, it means the price of feeding each child is less than 50 cents!

Ideally, what I'd like to do is propose an outreach program to my work once I get back to Oregon. This is how I envision the outreach program working. I'm going to make a conservative estimate and say there are probably 50 people on the payroll back where I work as a CNA (Avamere Court at Keizer). If every payday, those 50 people donated just one dollar from their paycheck, that would be enough to basically fund one feeding program per month (we get paid biweekly, so $2 per month). In actuality, there are probably more like 100 people on the payroll, so essentially, if those 100 people donated just 50 cents per paycheck (or $1 per month), it would go towards feeding 300 starving children once per month. I know feeding children once per month doesn't seem like much, but imagine what the Brotherhood chapter in Dalaguete could do with 5,000 pesos that wasn't spent towards their monthly feeding program! I'm inspired by the people here because, even though everyone is suffering from poverty, they are still willing to help those who are even more impoverished. Anyway, the feeding date is set for December 2, so I'll make sure to take lots of pictures and videos so I can bring it back and prepare a presentation for work.

Anyway, I'll leave you with a video clip and picture. If you don't like eight legged creatures, you better not look at the picture.

This is what it sounds like outside of the hospital. What is that noise? Frogs, geckos, and probably birds.

Found this sucker between my bed and the wall the other night. It could've easily fill up my entire palm. Not even kidding. I'd been waking up with bites that were definitely not from mosquitoes, so I didn't feel bad for squishing it with my flip-flops. I'm not sure if those bites were from this guy, but I'd rather be safe than sorry. Needless to say, I wrapped myself up in a thin blanket that night and just ignored the fact that I felt hot.

Day 9 Dalaguete, Philippines

Today was my day off, so all afternoon I watched and took notes on these videos:

I'm super glad I found these online because it focuses on the overall grammar of the language. Basically, I  just have to memorize vocabulary and I can start using these rules to start speaking broken Bisaya. One of the most basic, but most important things I've learned by watching these is the general sentence structure:

Verb :: Subject :: Object.
Though, with adjectives, it varies a little bit.

This one rule alone has already helped me pick up on what people here are saying. The second most valuable thing I've learned from these videos is how Bisaya uses existential verbs in sentence structures. I would highly recommend watching the 5th video even if you aren't interested in learning Bisaya because the concept of how Filipinos structure their language is, in itself, interesting.

[Graphic/Weak stomach warning ahead].

We went back to Boljoon tonight to finish celebrating the Fiesta (the Fiesta's last for two days). While I was there I had a very good in depth conversation with a couple of Ricky's friends explaining my reasoning for wanting to help slaughter some animals while I'm here. What surprised me is how they wanted me to understand I didn't have to prove anything. I told them how I felt it was necessary to experience killing the animal if I'm going to eat it, and they told me it's sufficient enough that I understand the importance of killing an animal for survival. They let me know it's difficult to kill larger animals because you can hear them suffer. I think what they really wanted me to know is that, even here, where taking an animals life is an everyday occurrence, the butchers are there in order to prevent people from having to physically kill animals on a regular basis. The butchers slaughter the animals to spare others from having to do so. (This next part will be honest, which means graphic, in order to fully convey my message) The crux of the whole conversation was to point out that the physical act of killing can be less helpful in the long run because it can make it harder to consume the animal afterwards (what's the point of killing the animal yourself if you won't be able to eat it afterwards?). Watching the slaughter is important for understanding the respect you must have for animals. However, physically taking a knife and holding it up against another living creatures neck, then slicing, and watching the animal hemorrhage massive amounts of blood while it squeals in agony mere inches from you -- being the one to actually carry that out isn't for everyone. They also pointed out that, if I fail to slaughter the animal correctly, I'll prolong the animals suffering, which in turn will increase my suffering. I'm considering their words carefully because just watching pigs being slaughtered was difficult. Talking with them has helped me look at butchers here in a totally new way. In a sense, they jeopardize a piece of their humanity so the rest of us don't have to.

Just being here is almost indescribable. There are only a few instance in my life where I can point out I was molded as a person (moving to a public school, meeting my best friends, the deaths of friends, working on cadavers, taking summer physics, and working as a CNA). This will be, and already has been, one of those moments. I've never fully understood my parents because I've never fully understood the Philippines. I know that even after three months, there will be things I'll never fully understand about the Philippines, things I'll never come to know, but I can at least try and appreciate the differences. How will this relate to my career as a PA? If I truly want to understand why I'm driven towards a career in medicine, I have to first fully understand myself.

And I've come to this conclusion:
To know myself, is to know my parents.
To know my parents, is to know the Philippines.

Anyway, bah, enough of that sappy stuff. I'm planning to compile a video comprised of one to two second clips for everyday that I'm in the Philippines. So I'll leave you with a tiny clip of us in Boljoon during the middle of a brown out:

Day 8 Dalaguete, Philippines

It's my Friday! The hospital has decided to let me keep a state side work schedule, so I'll get Saturday's and Sunday's off as well as major holidays. It's starting to feel fairly routine, I know what to do when patients come into the ER. The only thing I'm still nervous about is approaching patients without other nurses present because of the language barrier. I'm starting to catch clips and phrases of the speech easier, but I can't exactly understand an entire conversation. I like listening to the nurses talk to each other because it gives me a chance to work on my bisaya comprehension skills.

I almost got to do an IM injection, but the patient was nervous since I had never done it before and requested that a nurse do it instead. Can't say I blame her. Would you feel comfortable if a foreigner who doesn't even speak the language wanted to stick a needle in your arm?

I spoke with Sister Reginal Pastrana (the head of administration here at the hospital, and the person who graciously allowed me to come volunteer) today and we talked about how the hospital was founded.

Apparently the late Catholic Cardinal of the region witnessed numerous motor vehicle accidents occurring during the transportation of vegetables from Dalagute. He decided to have a building donated for use as a hospital in order to provide primary care and stabilization for serious injuries until patients are able to receive care at tertiary facilities. She wanted me to understand that the hospital here is underfunded, but that in the major cities the hospital are comparable with the rest of the world. I totally believe that, but primary facilities like this one are of immeasurable importance because of the amount of early care given. On a macroscopic scale, hospitals like this keep the entire country healthy because they keep economic highways healthy. What I mean is, places like Dalaguete are where natural resources are abundant (in this case, vegetables), but they are far from bulk populations. By keeping the population of outlying regions healthy, the rest of the country can continue to function.

Anyway, here are some pictures from first few weeks in the Philippines:

Mr. Vonnegut helped me survive the 11 hour flight from Seattle to Korea.

Typhoon helped me out with the flight, too.

My Grandma and Grandpa's house in Cebu City.

Animal feed sold at the market in Dalaguete.

The best way to get around in the city.

Some of my awesome coworkers! From left to right: Lim Lim, Natalie, and Ian.

Me prepping a syringe for a skin test.

This is the girl from my previous post who knocked out her front teeth
in a motor vehicle accident. I'm cleaning one of the wounds here.

After work, Ricky and his family took me to a fiesta in one of the neighboring towns. A fiesta here in the Philippines is actually a celebration for the patron saint of the town. Here's what it looked like: 

That's the closest I've ever been to commercial fireworks! We were probably about 20 yards away from the launching tubes. A few times I could feels bits of material on my face that fell after the fireworks exploded. This video doesn't do it justice, but the fireworks were loud enough to set off a car alarm.  

Day 7 Dalaguete, Philippines #DPC Intradermal Injection

That's me on the back of the motorcycle. The first part of the video makes Dalaguete look rainy and overcast all the time, but I guarantee you that's not the case. It was super warm this morning and the clouds made it feel twice as humid as it normally is.

It's not on the video but I got to do my first needle work today! I performed a couple skin tests. The hard part isn't really the injecting part since the allergen in question is only injected intradermally. Prepping is, what I feel, separates pros from amateurs. Compared to the nurses here, I'm obviously much slower, and I'm clumsy when loading the syringe. It feels awkward holding the vial in one hand and using the other hand to steady the syringe while pulling back on the plunger. Both times I let a ton of air in and had to keep reintroducing the needle to the vial to fill the chamber completely. I'm sure it's something that gets easier with repetition, so hopefully I'll get better at it.

Ricky's son (Ricky is my second cousin and whose house I'm staying at – that was his daughter, Pearl, in the video) came in today to get his stitches removed and they let me do it. It's not hard at all. Just snip the stitches and pull up at the ends where the knots are. I think the nurses here are amused at how excited I get when I get to do something hands on.

An older gentleman was admitted after he fell flat on his face right into the dirt. I'm not really sure how it happened but Ricky showed me how to x-ray the skull (Ricky is the RadTech at the hospital), which you can see in the video. Luckily the attending physician at the time said there was no bone damage, but he prescribed a tetanus shot and a few other antibiotics.

An adolescent female was also admitted due to a motor vehicle accident. The accident knocked out her four front teeth and she had some pretty painful looking scrapes, but other than that she was ok. She was also given a tetanus shot as well as a couple other shots – one intravenously and one intramuscular. The nurses asked if I wanted to perform the IM shot, and I said yes but that I'd never done it before, so they decided to let me watch this time. I asked how they avoid hitting the bone and they told me it's not that hard. The tricky part is making sure you don't hit a nerve or rupture a large collection of blood vessels. The technique is to inject first, then pull back on the plunger a bit. If blood starts seeping in, then you immediately pull the needle out, if not you're good and can start introducing the medication.

After work, around 1800, Ricky took me to the local slaughter house. This next gigantic bulk of writing is going to be a personal spiel and have nothing medical related at all, but I still feel it's extremely important to talk about. It will get a bit graphic, so prepare yourself for that if you have a weak stomach and want to keep reading. Prior to my visit here I started practicing a pescatarian diet. I kept at it for about a year and a half and told myself that when I got to the Philippines I wouldn't force my eating habits on Ricky's family.

I have no problem with people consuming animals. I think it's a very natural thing, and healthy for the human body since there are some nutrients our body needs found primarily in animals. I know the argument can be made that supplements can be taken in order to offset any negative side-effects of a vegetarian or vegan diet. However, I would challenge proponents of that philosophy to think about the impact manufacturing said supplements would have on the environment. It requires energy to produce concentrated forms of any chemical, and sadly, clean renewable energy isn't the main source of electricity yet. Anyway, that's a topic for another time. What I'm trying to say is, I don't think there's anything wrong with consuming animals, but I do feel there is a very large disconnect between people (especially among Americans) and the food on their plate. I was always raised to take only as much food as I could eat, and to reduce waste as much as possible. My decision to abstain from meat, aside from fish, is because I feel it's necessary to experiencing killing the animal you choose to consume (that's why I still eat fish). Taking an animals life in order to continue yours reinforces the idea that you have to take care of the things that take care of you.

When Ricky took me to the slaughter house I didn't realize they were going to be slaughtering pigs right then. For anyone that has already butchered animals before this next part might sound silly, but I have to mentally, nay, spiritually, prepare myself for the act of killing an animal. This is a rural area, so they still slaughter animals by traditional means: a knife, a length of rope, cold water, and hot water. They also take care to use as much of the animal as possible, so the most efficient way of killing the animal is slicing it in the jugular and letting it bleed out. I knew prior to coming here that the butchering wasn't going to be modernized, but what I wasn't prepared for was the noise. Pigs know they are going to be killed, and they squeal extremely loud. The pig only survives a few minutes after the jugular is cut, but they continue to squeal and struggle up until their last moments. That for me is the hardest part. Hearing the animal suffer saddens me greatly, but all I have to do is look at how malnourished most of the people are here and that outweighs any sort of protest I might have against the butchering of these animals.

I'll be going back on Sunday to help slaughter a pig. I'm extremely nervous about it simply because I know it will be hard mentally and emotionally, but it's something I feel I need to do in order to help me fully understand the importance of waste reduction. I also feel it's the best way for me to pay my respect towards a creature whose existence I am using in order to continue mine.  

Day 6 Dalaguete, Philippines

Wohoo! I was able to find a universal battery charger at the market today, so more pictures will be coming soon.

I worked in the ER/OPD again today with a different set of nurses. Everyone here is super helpful and totally willing to help me learn the language.

Unsa imu pa consulta? = Are you here for a consultation?

Naa na kay record diri? = Do you have a record here?

Nalipong is dizzy. Hilanat is fever. Cotas, dyspnia.

Both my parents speak Bisaya (which is the dialect here) at home, but only to each other or their Filipino friends, so it makes it a tiny bit easier to pick up on what people are saying – but only a little.

Here's my chicken scratch.

Today I helped admit four or five patients for consultations. Its not all that hard, but the language barrier makes it difficult. I can ask all the necessary questions, but when they start telling me what's wrong I can only pick up on about 25% of it. It can also be time consuming because the hospital is in the process of digitizing all it's paperwork and it's exceptionally difficult when brownouts are common (there were two in the eight hours I was there for my shift). All the new admits are still being recorded on paper because they have a ton of records to back catalog. There's a walk in closet stacked from floor to ceiling with boxes filled with every single person that's walked through the door since the dawn of time. I kid, but it's a lot. It's all organized, just daunting to look at. Here's how I admit patients for consultations:

Do you have a record here (Naa na kay record diri sir/maam)?

Yes, let me go find it in the giant paper closet.

No, lets start one.

Name?

DOB?

Age?

Gender?

Health insurance?

Why are you here/What's the problem?

I'll take your vital signs, ok?

Then there's more paperwork: filling out billing, filling out lab tests, filling out prescription orders. I truly don't understand how the nurses here have the time to do all the paperwork plus all the direct patient care. It's an insane workload, plus I found out that they work 14 days and the get two, sometimes 3, days off. I've always had great respect for nurses, but now more so than ever.

On the bright side I got to prepare a couple IV bags, assisted in a catheter insertion (not really something new), adjusted an IV drip, saw what happens when diabetic patients neglect to come to the hospital when their foot gets infected, and met a super cool guy from Australia who, unfortunately, was suffering from pneumonia due to COPD and was having trouble controlling his diabetes.

Anyways, I also got to feed the chickens and washed my clothes using a couple buckets and a spigot. Ricky also had an old mountain bike repaired for me so I'll be able to bike wherever now. Hopefully I'll still get to learn how to ride a motorcycle seeing as how that's the main mode of transportation here.  

Day 5 Dalaguete, Philippines

So I have my schedule for the next three months. I'll be rotating morning (700-1300), swing (1300-1900), and noc (1900-700) shifts between the emergency room/outpatient department and the nurses station/ward (which is inpatient care).

November 6-16: ER/OPD (Morning)

November 19-29: Nurses Station/Ward (Morning)

December 3-7: ER/OPD (Swing)

December 10-14: Nurses Station/Ward (Swing)

December 17-21: ER/OPD (Noc)

December 26-28: Nurses Station/Ward (Noc)

January 2-4: ER/OPD (Morning)

January 7-11: Nurses Station/Ward (Morning)

January 14-18: ER/OPD (Swing)

January 21-25: Nurses Station/Ward (Swing)

January 28-31: Nurses Station (Morning)

Today was mostly orientation and I got an idea of how the Julio Cardinal Rosales Memorial Hospital operates. There are five doctors but only one attending physician at a time. They work 24hr shifts for five days, then switch (and I thought back to back doubles were hard). There is one general practitioner, two internal medicine specialists, and two pediatricians. They have three OR's which are attended by a surgeon every Saturday and Sunday and one delivery room which is used by the midwives, but an obstetrician visits every Sunday. The hospital isn't set up for major surgery (there is no anesthesiologist), so whenever there are sever injuries (i.e. stab wounds, gunshot wounds, severe motor accidents, etc) they stabilize and refer them to the nearest hospital equipped to handle major surgeries...which is an hour away.

What this means is the medicine practiced here is purely clinical. They have an x-ray machine and a lab that can process some hematology measurements including CBC's as well as biochemical (lipid counts, blood sugar, etc), urinalysis, and fecal tests, but other than that it's just good old fashioned use-your-brains-clinical-diagnosing. One of the nurses asked if I wanted to perform an allergy skin test injection, but since I've never injected anything, I figured I should at least observe first.

I want to give you a perspective of the remoteness of this place compounded with the poverty, but before I do, please consider the following words carefully: It is easy to practice sterile medical procedures when a country is wealthy. This is a poor country, filled with the poor, and healed by the poor. Most of the western sterilization practices are not done here simply because they do not have the means to do so. They do, however, practice clean techniques whenever possible. You can condemn them for not practicing sterile procedures, but when it comes down to it, would you deny treatment to an entire region simply because they can't adhere to standards that are above their fiscal means? I certainly hope not.

Ok, go.

All of the toilets here (including those at the hospital) do not have conventional pressurized flushing systems. Every time you need to eliminate waste, you have to fill up a bucket of water and pour it into the toilet. On top of that, the water (in the homes, at least) stops running at 7:00AM. I still haven't figured out when they turn back on.

Disposable gloves are hardly ever used. I worked about five hours in the ER today and one patient (a child) had a broken arm that wasn't set properly because he wasn't brought in for treatment until a few weeks after the break. The attending physician had to inject directly into the bone, and this was the one time I saw disposable gloves used (probably because the risk of infection was greater due to the depth of the injection).

The only soap I can find is in the kitchens. Other than that, alcohol based solutions are used in lieu of soap. However, most of those alcohol based solutions are either out, running low, or very hard to find.

Temperatures are only taken axillary and probe covers are nonexistent.

The pay the RN's and midwives receive are below the minimum wage set by the government. Here, private companies are allowed to set their own wages (it's only government positions that must adhere to the minimum wage law). Since the hospital is run by a cloister of nuns, the finances (including the wages for the workers and the upkeep of the hospital) are completely dependent on the amount of patients it receives. I realize this is similar to private practice hospitals in the US, but let me walk you though a typical bill. Dengue fever is a common ailment here especially among the young. Today a patient presented symptoms of Dengue fever so a UA and CBC was order to confirm the diagnosis. Intravenous Ampicillin was prescribed (even though Dengue fever is viral, I think an antibiotic was given since the patient was in an at-risk demographic for opportunistic infections) along with a skin test to confirm the patient wasn't allergic to the antibiotics. PRN Paracetamol was also prescribed, given orally, to reduce the fever. The cost of all of this (IV bag, meds, tape for the needle) including the consultation fee? Around ₱1400, which is roughly $34. I asked the nursing staff if this was considered expensive in this particular region and they said yes. Imagine trying to run a private hospital when $34 is considered expensive.

If you still can't imagine how remote this place is, imagine waking up to 30-40 rooster cock-a-doodle-dooing around 5:00AM (it sounds like an exaggeration, but everyone here has roosters and chickens and pigs). Then imagine six dogs right next to your window barking because they're there to guard said roosters. Imagine for every house there's at least one gecko, that you can see, just chilling out on the ceilings and walls.

This place is alive and actively reminds me that the pinnacle of human “civility” and “achievement” is built upon human compassion, ingenuity, and the unrelenting tenacity people have to thrive in any environment.

To leave you on a lighter note, today I tried balut.

If you have a weak stomach consider this your warning. 

This is balut (according to Wikipedia, which I can now verify): A balut is a fertilized duck embryo that is boiled and eaten in the shell. It is commonly sold as streetfood in the Philippines.

Here is what it looks like (taken from google because, like a dummy, I left my camera charger at home):