Day 99 Dalguete, Cebu #DPC IVTT, ECG

It was a quiet day at the ER. It was so slow the nurses convinced me to have an ECG done. I'll post a picture of the readout once it's up. Other than that, nothing too exciting today.

Day 98 Dalaguete, Cebu #DPC IVTT

I worked the AM shift today and floated between the ER and the floor. It was a pretty routine day. I administered meds via IVTT and prepared the med passes while on the floor and took vitals and helped with OPD's at the ER. It's nice working both the ER and the floor because you get to see how the team works as a unit to give treatment and medication accurately. It's the best feeling admitting someone from the ER and seeing them later at the ward reciving what they're supposed to be reciving -- and almost all of this is done without computers. The only thing they really use the computers for are printing recipiets. There's no electronic medication administration record or treatment administration record; just good old pen and paper.

Pamela also had a dance routine for her school today. Once a year the teachers get together and perform a traditional dance routine for the students in preparation for the annual town fiesta. While my sister was here Pamela asked her to come in as a guest speaker so my sister was able to hang out with her for a day. She told me how the students and teachers have a relationship that's more like uncle and aunt, niece and nephew. I've always been aware that Filipino's are close as a culture, but the way my sister described the schools brings further depth and understanding about that aspect of my culture. The first thing my sister noticed was how the teachers and students have a very relaxed sense of time. Start and end times for classes are not set on a strict schedule. Is it raining hard out? If yes, start class a little later. Is it uncomfortably hot and humid? End class a little bit earlier. Lunch breaks are also very relaxed. My sister said after the lunch period the students went back to the classroom and the teachers took their time discussing their day and their remaining lessons. It sounds disorganized but because the students view their teachers as extensions of their family, they treat them with the same respect they'd treat their relatives. My sister said that after the lunch break she was expecting Pamela to have to come into the classroom and get everyone settled, but when they came in everyone was in their proper spot waiting to learn.

Anyway, here's a picture from the dance routine.

Day 97 Dalaguete, Cebu 7 #DPC Wound Care

I worked the AM shift with Tim at the nurses station. The census was pretty low so I just helped out with vitals, prepped the med pass, and assisted with a wound dressing. As usual, I cleaned the wound with PVPI making sure to work from the inside out. The patient had been involved in a MVA and had some minor abrasions that needed cleaning and was being kept for observation to rule out the possibility of a head injury or opportunistic infection. 

The Dalaguete Fiesta will start in the next few days and I'm pretty excited to see what it's like to celebrate the fiesta in our town. I've already been to a bunch of other town's fiestas but Dalaguete's will be special mostly because I'v spent so much time here. It's been slowly filling up with vendors and the whole seems to have a buzz of excitement. The market, especially, has been super busy as families start buying ingredients for upcoming festivities. 

Day 95 Dalaguete, Cebu #DPC ECG Assist

I worked the noc shift today and it was a super quiet night. We had one patient that came in with chest pain and difficulty breathing so we hooked them up to the ECG and let the doctor interpret the results. Nothing showed up on the ECG so we kept them overnight for observation. Other than that it was a quiet nights so   I just sat outside the ER entrance with the doctor, the ER nurse, and the night guard. One of the things I really love about this place is how close knit the whole hospital is. I'm gonna really miss this place when I go.

Fatima, the nurse on duty with me at the ER.

Day 85 Dalaguete Cebu #DPC Delivery Room, Suture Assist

I worked the NOC shift ER again. It was a fairly busy night. A lot of discharges had taken place the night before so the ward wasn't that busy either. Also, the two admitted to the ward last night were discharged (the head injury patient was ok and just needed to sober up, which is why he couldn't figure out the paperwork and the patient with the high blood pressure had stabilized and had been prescribed maintenance medication for hypertension).

When I came on duty I went directly to the delivery room because there was a birth in progress. By the time I got there, though, the baby had already been delivered, so I helped measure her and injected her with vitamin K.

After I got out of the delivery the doctor was performing a suture on a minor head wound. I assisted like before, by handing him instruments and soaking cotton balls with Providone-iodine so that he could cleanse areas as needed.

After that, the rest of the NOC shift was slow with no one else coming in.

Day 84 Dalaguete, Cebu #DPC Suture Assist, Sterile Procedures, IVTT

I worked the NOC shift today at the ER and the ward.

The first patient that came in had suffered a head wound after falling down (apparently drinking had been involved). I assisted the doctor during the suturing and helped set up the equipment using sterlie procedures. The doctor was going to release him but the patient couldn't figure out how to sign the paperwork so the doctor had him admitted for overnight observation. The doctor said he was pretty sure that the inability to do the paperwork was due to inebriation, but he wanted to keep him overnight just to be sure. The patient had actually started falling asleep during the suturing and the doctor had to keep rousing him. Luckily he was brought in by friends and they stayed the night to keep an eye on him.

The second patient that came in was suffering from dizziness. The doctor order me to take the blood pressure, which I recorded at 220/100. I'm not quite sure what medication the doctor gave the patient, but he was not previously diagnosed with hypertension so the doctor also had him admitted for overnight observation. Although the patient wasn't previously diagnosed with hypertension, after being here for awhile, my guess is that he most likely does have it and just hasn't come in for routine checkups. Hypertension is extremely common here and most people over the age of 35 are already taking medication to help keep their blood pressure in check.

I set up the sterilized instruments while the
doctor scrubbed up.

Sterilized gloves are only used by the doctor
to save on supplies, so when handing the
doctor instruments, I used sterilized forceps
to pick up and manipulate anything the
doctor needed.  

Even though I was scheduled to just work the ER, I helped out in the ward because the census was at 24. That might not seem like a lot, but there are only 2 nurses; the charge nurse does the paperwork and the floor nurse works the floor. Obviously the charge nurse also works the floor but has the added work of charting everything by hand since there is no computer in the ward. I helped out by taking the vitals and prepping the medication for the entire shift. In order to give medication on time, the nursing staff normally organizes the entire shifts medication so that all they have to do is dilute anything that need diluting just prior to handing it out. I also helped give medications and did a little bit of charting (most of it has to be done by the charge nurse so there wasn't a whole lot I could do other than vitals and I/Os). 

NOC shift meds.

Day 83 Dalaguete, Cebu DPC# Delivery Room, Intramuscular Injection, Intradermal Injection

I came back to Dalaguete today and worked in the ER. I did a couple skin tests and received a few patients for OPD checkups.

I also got to help with another delivery today. It was fairly quick and the nursing staff let me help prepare the infant right after delivery. After the baby had skin to skin contact with the mother and had started suckling (which is policy for the hospital here), the nursing staff cleaned off the baby and let me help with the measurements. We measured the circumference of the head, overall height, chest size, and weight. Afterwards, the nursing staff let me inject the infant with vitamin K. It's the first time I've ever injected a newborn and, in many ways, it was much easier than injecting adults. Firstly, the nurses loaded a syringe that we usually use for skin tests because the needle is much smaller and the infant doesn't need a huge dose.

There's a trick for loading such a small syringe (we used tuberculin syringes, which are 1cc). When drawing in whatever medication you're gonna use, the syringe has a tendency to fill with a bit of air (I've noticed this is especially true with TB syringes). That might not cause so much of a problem with 5cc syringes because you can always plunge out the excess air after loading some of the medication. With a 1cc chamber though, the amount of air is significant enough to throw off the measurement. Basically, in order to get an accurate measurement, you have to fill what you can and measure off starting from the bottom of the syringe. So let's say you want .3cc's of some medication. Instead of stopping and measuring from the .3cc line, you pull the plunger back and measure form somewhere near the middle or the back. So .3cc's might be loaded between  .6cc's and .3cc's (instead of 0-.3). Once you have that measured, you plunge out the excess air and you know that the .3cc's you have left are medication. The actual injection was simple because the needle was small enough that I could insert it all the way without hitting the bone (the injection site was the thigh).

Anyway, a pretty interesting day -- it'a always nice when I get to help with deliveries.

Day 70 Dalaguete, Cebu #DPC IVTT

I worked the ward today. Just the same routine of IVTT's and vitals.

Day 68 Dalaguete, Cebu #DPC Intradermal skin injeciton

I worked the night shift (2300-0700) today and it was a night of firsts for me. 

The first patient to come in for the night was a young adult male who was brought in by friends after he deliberately ingested liquid fertilizer. The intent, though unconfirmed because the patient was unresponsive, was attempted suicide. Allegedly he had been having personal problems and, prior to ingesting the fertilizer, had drunk a significant amount of Tuba (a type of "wine" made from the sap of certain palm trees). I did a little research and found the ingredients in the fertilizer that might have been the same type that the patient ingested:

Sodium Ortho-nitrophenolate=0.468%

Sodium para-nitrophenolate=0.893%

Sodium Mono-nitroguaricolate=0.298%

Sodium Ortho-nitrophenolate=0.468%

Sodium para-nitrophenolate=0.893%

Sodium Mono-nitroguaricolate=0.298%

The doctor called for a referral to the city and had him hooked to an IV (plain NSS) and ordered an injection via IVTT of ranitidine. This is the first person I've ever met whose attempted suicide. Even more, he's the first person I've met who is actively undergoing a suicide attempt. The thing that strikes me the most about this encounter is that I didn't have any sort of emotional response until after the patient had been referred to the city -- that is, I didn't think about it as a suicide attempt until after he had been stabilized and referred. It's impossible not to feel some sort of emotion when working with people. That's something I've come to understand working as a CNA. However, one of the things that has weighed heavily on my heart is wondering if I'll be able to cope with emotionally distressing situations. Working as a CNA helped understand part of that -- I have come to view the residents at the nursing home I work with as friends, and therefore we work as a team. But that kind of familiarity comes with time. This suicide attempt was the first time I had been measured against an immediate stressful emotional situation.

I remember about 2-3 years ago I had the opportunity to shadow a doctor at a gastroenterology clinic. I had just finished watching a doctor perform and upper endoscopy on a man and they found that he had incurable esophageal cancer. The doctor was showing me some of the images he had captured of the esophagus and told me had the patient come in just 4-6 months earlier, they might have been able to treat it. However, it was too late and the doctor said the patient had maybe 6 months left to live. The doctor said it without sounding sad, and I remember how I thought it was so dispassionate to just state the facts so plainly.

But now, I've come to realize that you have to maintain a level of emotional distance in order to keep your mind clear. Weighing down your mind with too much emotion can translate into poor decision making which can cause poor performance as a doctor/physician assistant/nurse. It's not that you need to lack passion, you just have to know how to keep it from clouding your judgement.  

Another first for me that happened on this shift was exposure to a contagious patient. Obviously I've been around contagious residents back in Oregon (especially around the winter time with colds and whatnot), but tonight a patient came in and the doctors initial prognosis was TB. Of course, all of us were wearing masks, but it suddenly dawned on me that exposure to all sorts of pathogens will be inevitable when I work as a PA. The good thing is, even though I suddenly realized this, it didn't prevent me from continuing my work. Anyway, since it was after 5 and the lab technician was already gone, the doctor had the patient admitted and put in isolation until further tests could be done to confirm the prognosis.

I also performed an intradermal skin injection on another patient to test for an allergic reaction.

Day 67 Dalaguete, Cebu #DPC Intradermal skin injection

Today I worked both the AM and PM shift (700-2300).

I spent the AM shift on the ward and it was the same routine as usual: help prep/pass medication and take vital signs.

During the PM shift I switched over to the ER and performed an intradermal skin injection to test for an allergic reaction. Later during the evening an adolescent came in with severe stomach pain. The doctor on duty gave a prognosis of appendicitis in less than five minutes. He asked the patient if he had pain or blood during urination, when the last bowel movement was, and if they had measured a fever (yes for the fever which was confirmed after doing vitals upon entry to the ER). The doctor then began to press down on his stomach in four different areas each time getting closer and closer to the appendix. As soon as he touched the appendix the patient displayed extreme pain and the doctor called for a referral to the city. While waiting for the ambulance, the patient was hooked to an IV, given ranitidine via IVTT, and paracetamol PO.

Day 49 Dalaguete, Cebu #DPC Intradermal skin injection, nebulizer, ECG assist, IVTT

Today was a fairly busy night in the ER.

The first patient was an infant that came in with a 39.9 degrees Celsius fever (103.8 degrees Fahrenheit). The doctor order paracetamol PO and kept the infant in the ER for a few hours for observation. The medication reduced the infants fever so the doctor told them to come back tomorrow. Normally, the doctor would order a UA and have them wait for the results, but since it was after hours, the lab technician was already gone and wouldn't be back until tomorrow morning.   

The second patient to come in was an older gentlemen suffering from breathing problems. I administered three rounds of sulfate salbutamol via nebulizer at fifteen minute intervals after completion of each dose. The nurse hooked him to an IV and I injected hydrocortison and cefuroxime via IVTT. Prior to injecting the cefuroxime, I performed an intradermal injection skin test to confirm a negative allergic response to the antibiotic. After the injections, I helped hook him to to an ECG and prepared the printed readouts for the doctor to interpret.

I also prepped the delivery room but it turned out to be a false alarm and the patient didn't deliver that night.

Day 48 Dalaguete, Cebu #DPC Intradermal skin injection

A slow night in the ER tonight. A patient came in around 2:00AM. I performed an intradermal skin injection and the patient was admitted. Other than that, no one else came during my shift. 

Since I don't have much to say about working the floor tonight, I want to talk a little bit about the importance of rice here. I know that, if you're American, you might have heard that rice is the Asian equivalent of the potato. The only problem with that comparison is it doesn't even come close to describe how important rice is. To give you an example of how important rice is here, all you have to do is look at the language.

The word for food/eat in Bisaya is: kaon.
The word for rice in Bisaya is: kaNon.

The only difference between the word food and rice is a single consonant. In colloquial speech, the word for rice can be used to mean food -- instead of using kaon, kanon can be be used.

The word sudan roughly translates to: partner with rice. It describes the food you're going to eat with rice. At first, this word doesn't seem to describe how important rice is. It's only after you think about it that it dawns on you. The word sudan implies that rice is already going to be eaten. The fact that there's a word here that, by definition, means food secondary to rice illustrates how engrained rice is in the culture.

Rice is eaten with every meal. Sometimes rice is the meal. As long as someone has rice, they at least have something to eat. It's on every table weather you're poor or rich. It's eaten with every meal. It's on every menu (even the McDonalds here has rice on the menu). It's on every plate.

From a health perspective, this aspect of the culture is important because the genesis of a majority of health problems can be traced to rice. White rice, to be exact. All the empty carbohydrates from white rice lead to weight problems and diabetes.

The simple solution: stop eating rice.
The reality: rice is part of the culture.

Asking a Filipino to stop eating rice is the same as asking them to stop drinking water. It's the same as asking them to deny a part of their culture.


This type of dilemma is when the scientific aspect of medicine must come secondary to the human aspect. Scientifically, reducing the intake of empty carbohydrates is healthy. From a humanities standpoint, asking someone to deny their culture is inhumane. At what point is living worth more than their quality of life?

Day 46 Dalaguete, Cebu #DPC Nebulizer, Intradermal Injection

I worked he night shift today at the ER. At 3:00AM a patient came in with difficulty breathing. O2 was administered immediately by the nurse at 5mL/min. The nurse went to fetch the doctor and delegated the initial vitals to me. The vitals upon entry were as follows:

HR 120
RR 40
T 36.6 Celsius

Before I could take the BP the doctor arrived and told me to wait until he had an initial prognosis. From what I could make out in Bisaya, the patient has known food allergies and has had respiratory problems before, but she didn't recall eating anything that might have set off an allergic reaction. The doctor order Salbutamol via nebulization; three doses given at fifteen minute intervals after the completion of each dose. He then asked me to take the BP during the first Salbutamol dose. I measured her BP at 110/70; by this time her RR had decreased significantly and she was taking deep controlled breathes. The nurse hooked her up to an IV and Cortisol was injected via IVTT to help reduce the bodies stress by acting as an upregulator in an anti-inflammatory pathway. Since the cause of the constricted breathing was unknown, the doctor also order an injection of Cefuroxime (also via IVTT) to combat an early possible bacterial infection. The nurse asked me to perform an intradermal skin test injection before introducing the full dose of Cefuroxime.

Day 42 Dalaguete Cebu #DPC IVTT

Routine on the ward today. Nothing out of the ordinary. More IVTTs and whatnot -- a pretty slow day overall. I'll be going to Cebu City tomorrow to spend some time with my cousins. Anyway, here's a picture of me with some of my co-workers during our off-duty time.

Day 41 Dalaguete, Cebu #DPC IVTT, IV Removal

Today was another day spent in the ward. I completed the normal tasks: IVTT's medications, syringe loading, vitals, etc. Today, however, was the first time I removed an IV from an infant. It was a little more difficult since the baby is scared and flailing it's arms, but it's basically the same procedure.

For the past month or so, the nurses have been giving me more paperwork to do and just countersign everything I do. It's interesting learning how to chart in a hospital setting. For example, when charting for vitals, I have to plot graphically the temperature and heart rate. This is so when the doctor looks at the chart of the patient, they can see quickly and clearly if the temperature and heart rate are holding steady. I'm not a doctor, not even a med student yet, but after working here, I've noticed that those two specific vital signs are usually good indicators for relative stability in a patient. If the heart rate is abnormal, you can almost be certain that the blood pressure will also be affected. If the temperature is abnormal, that often indicates something is wrong. Why aren't blood pressure and respiration rate good indicators? Blood pressure has a wider "normal" range. Simply eating or drinking something can change blood pressure by a degree of 10 - 15 points, so its often not the best indicator. In addition, hypertension is rampant here and almost every single person above the age of 40 is already on medication for high blood pressure. This means, sometimes, when taking the vitals, the BP of the patient is high because they haven't taken their medication yet or the medication is still kicking in.

Day 40 Dalaguete, Cebu #DPC IVTT

When I arrived in Dalaguete the hospital had started their annual “Sports Fest.” There were four teams and every other week they had sports competitions: volleyball, badminton, a sack race, speed walking, and a 100 meter sprint. Today was the second to last day and my team was competing for third place in volleyball. We won third place! Anyway, now that it's over, all of us well go to Montalongon after the holiday's. I can't quite remember the name of the place, but apparently it's the highest point in Dalaguete. Ricky described how it's above the clouds so the saying is, if you spend the night up there, when you wake up it feels like you're dead – because all you can see are clouds. I'm not sure when the exact date is that we'll go up there, but I'm super excited about it and will definitely post lots of pictures. Anyway, I was back on the floor again and did the same routine: IVTT's, pass meds, take vitals, and record input and output. #

Day 39 Dalaguete, Philippines #DPC Suture, IVTT

I went back to the ward again today. Not too much happened there. Just the usual IVTT's, vitals, passing meds, etc. I did, however, learn how to stitch! The doctor that told me he would teach me how was back today so I bought a pig thigh and he taught me. He let me use old surgical equipment and expired suturing thread. It's not hard learning how – it's hard doing it right. My left hand is fairly weak and has poor dexterity so using the picking forceps with that hand felt awkward. Although there are specific tools used for suturing, supplies here are short, and you have to make do with what is available. I was taught a simple interrupted stitch using a picking forcep and a straight hemostatic forcep. Here's how:

1. Use the picking forcep (with your non-dominant hand) to grasp the piece of flesh you will use as the initial entry point for the needle.
   
2. Take the straight forcep (in your dominant hand) and grasp the needle. Introduce the needle into the flesh you're holding with the picking forceps.
   
3. Grab the piece of flesh (again with the picking forceps) you wish to suture and introduce the needle using the straight forcep.
   
4. Pull the thread until most of it is on the opposite side you introduced the needle.
   
5. To tie off a simple interrupted stitch, loop the side with the most thread around the nose of the straight forcep 2-3 times then grasp the short end of the thread and pull through.
   
6. Cut the excess thread.
   
7. Repeat.

Using the picking forcep was very difficult for me so the doctor said I could just use my hand to make it easier and to strengthen my left hand to improve dexterity. Also, how hard to tie off the knots and how to maintain spacing between stitches (roughly 1cm for most wounds) requires practice. You don't want to tie off too hard because that can end up pinching the skin. Tie off to weak and the stitch falls apart. After the stitching, we had a super delicious dinner!
Anyway, here's some footage:

Day 36 Dalaguete, Philippines #DPC Intradermal Injection

Another routine day. However, I was able to interview and understand an OPD patient using only Bisaya! There were a lot of OPD patents waiting to be interviewed so the nurse on duty just let me interview on my own and had me refer to her if I had questions. I gave another intradermal skin test injection before a patient was admitted.

Day 35 Dalaguete, Philippines #DPC Intradermal Injection

Very quite and very routine in the ER/OPD today for PM shift. More OPD patients for flu like symptoms and fevers. One patient was admitted and I administered an intradermal skin test injection. I stayed at the hospital again for night shift, but only two patients showed up suffering from flu-like symptoms. Neither of them were admitted. Neither had experienced fevers so the doctor told them to be monitored overnight and to come back if they became feverish or started vomiting.

Day 33 Dalaguete, Philippines #DPC CPR, IV Insertion

Typhoon Pablo made landfall in Dalaguete today. Luckily, the news reported that it had lost a lot of momentum once it came in contact with land. It was rainy and windy all day and around 5:00PM the hospital and all of Dalaguete experienced a brownout.

The ER was busy today because actual emergencies (instead of OPD or checkups) occurred. What made it even harder was the brownout. It gets dark here around 5:00PM and around 4:30PM our first ER patient came in. He was a construction worker and had somehow had his arm caught and twisted in an excavator. His left arm was dislocated and fractured at the forearm. The doctor order an IV line and gave him an anesthetic (I can't recall what the drug was), then order an X-ray to confirm the break. Because this is a primary hospital, it's not set up for long term casting, so during the X-ray the doctor order the nurses to construct a splint out of whatever they could find. The ended up using cardboard and neotape and immobilized the patients arm so that he could be referred to the city. However, the patient ended up being admitted because the weather was too severe to be transported to the city.

The second patient was brought into the ER by her family because her NGT was dislodged and needed reinsertion. By this time it was already dark and we had to work by candlelight and flashlights. The hospital has a generator here but it isn't hooked up because they're still waiting for the fire department to process the paperwork. From what I've heard, they've been waiting a few years now. Anyway, the nurse removed the old NGT and the doctor inserted a newer one. However, there was a problem. After the doctor confirmed the correct placement by listening to the stomach (use a stethoscope, push in a little air via plunger, and listen for a gurgling sound), the water he used to flush the new NGT wasn't traveling down the tube freely. If an NGT is placed correctly, water flows fairly quickly through the tubing. This wasn't the case. The doctor reinserted it but placed it a little shallower, reconfirmed the placement, then tried flushing again. This time, there was backflow from the tubing. After a third attempt, a third conformation of placement, and a third failure of correct flow, the family then told the doctor that she hadn't had a bowel movement for 5-6 days. The doctor told the nursing staff to administer a suppository because it was likely that there was an obstruction. Even after the patient was given the suppository, she still didn't have a bowel movement. The doctor told them they should refer to the city in order to get an emergency scan of her stomach and colon since it was likely that she had an obstruction of some sort. The family decided to wait until the next day due to the weather.

The next patient that came in had a deep laceration on her leg exposing part of the Gastrocnemius muscle. Apparently a tin roof had come flying off a house and hit her on the leg. The doctor said, luckily, it was a clean linear laceration so stitching it would be simpler. I've worked with cadavers before, but they were prepared down to the muscle, so this was the first time I'd seen the hypodermis stripped away from the underlying muscle. The nursing staff cleaned the wound, the doctor injected a local anesthetic, stitched the wound, and the nursing staff dressed it. All of this was done using flashlights because of the power outage.

Here is some footage from the ER during PM shift. WARNING, this video shows a minor surgical procedure (the deep laceration). I've grey-scaled any footage that shows blood, but if you don't like looking at wounds or dislocated arms, do not watch this video. Again, I am grateful for the ability to capture these moments on film and will do my best to maintain anonymity and  dignity for those filmed.

I ended up spending the night at the hospital because of the weather, so I also experienced my first night shift. Around 12:00AM a patient was brought in because she had suffered a heart attack. The nurse on duty at the ER started CPR while I used the BVM to give rescue breaths. I'm CPR certified, but that was the first time I had ever seen CPR administered on a real person. I'm definitely glad I got to see how actual CPR looks because it requires a lot more effort than any dummy or training can accurately portray. Sadly, the patient was DOA and we were unable to revive her.

The last thing I want to talk about is IV insertion. Last night one of the nurses here let me try inserting an IV in her. It took me three tries to get it right, and she was totally ok with it. Back in the US, you have to take classes and practice and all that – but here you just have to learn to do it. Most of the nurses here have never taken an official class for IV insertions. Their training was the doctor (or another nurse that already knows how to insert IV's) telling them to insert an IV on a patient while they watch. Their “graduation” from IV school is the second after they insert an IV correctly. The hospital here is understaffed and IV's play a huge role in primary care, so it's important the the nurses all know how to insert IV's. What impresses me the most about this place is the youth. It's the youth giving first care response. Giving CPR. Applying pressure to wounds. It's the youth passing medication. Doing intravenous injections. Intramuscular injections. It's a whole bunch of early to mid twenty-something year olds literally saving lives by reviving. By stabilizing. It boggles my mind how much responsibility is shoulder by the youth and how well they perform given the immense pressure and expectations. The overall health of Dalaguete relies on the ability and dedication of its youth.