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.