Day 103 Dalaguete, Cebu

I worked the ER noc shift with Tim tonight. Totally quiet night. Just spent the shift catching up on my blog and talking with Tim.

Day 102 Dalaguete, Cebu

Worked the PM shift in the ER today. It was pretty routine with not much going on except for one particular case where a child (she was probably between 5-7) came in with a pretty nasty burn on her leg. Other than it being a pretty bad burn was that the mother and father had rubbed chili pepper leaves over the burn and the child wasn't crying. I asked Tim why they did that and she said the mountain people use chili leaves as home remedies but she wasn't sure if it actually worked. I looked up the effect of chili leaves being used as a remedy for pain and found an interesting article explaining how the capsaicin in the chili binds to pain receptors blocking out the actual signaling in the body. It wasn't the most reputable site but it does make me think there's some science behind remedies that persist over generations. Strangely enough, the girl didn't cry until the wound was being cleansed -- perhaps washing away the capsaicin opened up those pain receptors again. Because the patient was a small child and in severe pain, I just observed as the nurses and doctor performed wound care. 

The type of chili plant the leaves were most
likely taken from.

Day 101 Dalaguete, Cebu

I spent the second day of Dalaguete's fiesta walking around the town with Tim. A big part of the celebration is visiting the town church. Each town has their own and are super old and tied, historically, to the Spanish empire. Tim gave me an unofficial tour of the church and we spent the rest of the night walking around the town and enjoying the sites.

The inside of Dalaguete's church Sn. Guillermo
de Aquitania. A quick search online says this
church was founded in 1711!

Tequila! Drank the same everywhere!

One of the rides set up for the fiesta. 

Day 100 Dalaguete, Cebu

Today was Dalaguete's fiesta. I spent most of the day and night with Ricky and his family. Fiestas are a huge deal in the Philippines and it was finally Dalaguete's time to celebrate! Ricky and I stopped by his friend's house who was making a roasted pig for us (sadly, all the pigs Ricky had bought to rear died from illness so he had to buy a pig and pay to have it roasted). His friend told me they start as early as 3:00AM and roast pigs all day to sell. While we were there checking out the progress of our roast, I was able to see the process of roasting a pig starting from livestock all the way to finished product. Even though I've already seen a pig prepped for market, it still amazes just how quickly people can go from a live pig to on a spit using a length of rope, a knife, and a bucket. The roasting "oven" is just a fire pit with a length of bamboo sticking through the pig and is manually turned. I can't imagine doing that at 3:00AM, but during fiesta families can make a lot of money just by selling roasted pigs. We spent most of the day preparing for the evening meal, which is a huge part of the celebration. Ricky took me early in the day so we could have the freshest pick of produce. Here's some pictures of our trip to the market.

I spent the rest of the nigh with Ricky's family. People stopped by throughout the day and evening (including most of the people from the hospital). The roasted pig was delicious!

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 94 Dalaguete, Cebu

I spent the day catching up on this blog. Since the internet here goes out frequently, I've had to write out all my entries in word and upload them here when there's good connectivity. On my off days I spend most of my time at the hospital because they have internet here and all the friends of made are usually at or close to the hospital.

Anyway, not much going on today so I'll leave you with some extra pictures from my trip.

At the ER with Larzy and Zyra (left to right). 

A hut in the mountains.

The only way to travel to certain mountainous regions, just be sure to hold on.

In Dumagete where we were stranded for Chirstmas.

At the nurses station with me, Fatima, and Zyra (left to right).

Day 92 Dalaguete, Cebu

We left Boracay today and headed back to Dalaguete. We took the scenic route back taking a 2.5 hour bus ride that went around the island. Today was also my official last day of duty, however, since I extended my trip until February 20, the nursing staff said I could keep coming in and helping out until the day I leave. Here's some pictures of the ride back!

Day 88 Dalaguete, Cebu

I worked the noc shift today. The only person that came in was the mayor, who had been suffering from a cold and wanted to make sure it wasn't anything more serious. Other than that, it was a quiet night.

Tomorrow I'll be going on a vacation to Boracy (an island) with some of the other nurses. It's supposed to have lots of white sand and is a tourist destination so I'm excited to see some of the touristy places since tourism is a huge part of the Philippine economy.

Anyway, here's a random picture of some native peppers that I've gotten rather fond of.

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.

Dy 76 Dalaguete, Cebu

Another slow night in the ER. A few patients came in with minor coughs and colds persisting for less than two days so they weren't admitted just told to come back if the symptoms get worse or if they want to have a CBC or UA done in the morning.

Anyway, let's have three cheers for the metric system, since that's what's used here and makes calculating things much quicker and easier to comprehend (for me at least).

I mean, think about it, if on a scale from 0-100 where 0 is the freezing point of water and 100 is the boiling point, it's easier to conceptualize what 37 must feel like: less than the half the heat of boiling water but much closer to 40 than 30, akin to a warm/hot shower. Who would want to use this (°C × ⁹/₅) + 32 = °F just to convert to a system that is harder to relate to?

Day 75 Dalaguete, Cebu

It was pretty busy night shift in the ER today. 

The first patient that came in was complaining of pain in her eye after having cement flung in it. The doctor checked out her eye and rinsed it with plain NSS. He sent her home and told her to come back the following morning to get it rechecked and referred to the city if necessary. 

The next patient came in after having vomited ten times in one day accompanied with dizziness. After the doctor talked with the patient, we leaned that he had already been diagnosed with chronic hypertension and was already prescribed maintenance medication for it. The doctor didn't know for sure what was the cause but had a hunch that it might have to do with his dosage so he had him admitted and put under observation.

We also had an unusual MVA case. The patient came in walking under his own power but was bleeding from the head and upper and lower extremities due to scrapes from the accident. However, the patient was very drunk and refused care by physically making himself inaccessible to the nursing staff. It was a difficult situation because the nursing staff can't exactly hold him against his will, but if he signs a wavier that states he refused care, they can let him go. He was so drunk though, that he couldn't figure out how to sign his name on the release form. Luckily, his friends were with him and they convinced him to stay until his parents showed up and signed the papers. While he was there the doctor and nurses did their best to assess his condition and told me it appeared he suffered only minor scrapes and would most likely be alright. 

Our second admission was a 6 month old baby with a cough persisting for 4 days. The doctor hooked her to an IV line and ordered ampicillin via IVTT after the nurse confirmed a negative allergic reaction to the medication.

Finally, the last patient of the night came in with a fever persisting for 2 days and rashes all over the body (which has been one of the ways the flue has manifested itself this year in this region of Cebu). The doctor told the parents to monitor him over night and bring him back tomorrow for a CBC and UA to confirm a prognosis of season flue.

On a totally medically unrelated note, I drove a scooter for the first time today! Here in Dalaguete (and everyone in the Philippines) motorcycles and scooters are the main type of personal transportation. After our last ER patient, the night was quiet so one of the nurses told me to try riding his scooter. That's another strange thing I've noticed about the ER -- all the patients seem to come in groups. The business seems to come in waves. It'll be totally quite and uneventful for 2-3 hours and the suddenly three people will show up basically at the same time and once their gone it's quiet until the next group of people suddenly appear. I'm not sure but maybe there's data somewhere showing how accidents occurring between 2300 - 0700 happen in a cyclic fashion. Maybe I'll have to try and look that up later. 

Anyway, here I am on a scooter:

Day 74 Dalaguete, Cebu

Another PM shift in the ER and another quiet night. I went to the ward to help out a bit and prepared some medications, but other than that nothing too exciting I'm afraid.

Day 73 Dalaguete, Cebu

I came back from Cebu City today. I went around the mall with my dad for awhile because he wanted to get some pants made (having your clothes tailored here is super cheap). I decided to buy some cloth so that I can get scrubs tailored in Dalaguete.

Anyway, when I got back to Dalaguete I worked the night shift at the ER. No patients came in during that shift so I spent the time brushing up on self blood pressure measuring.

Day 71 Cebu City, Cebu

I went back to the City today after working the AM shift at the hospital. Just the usual OPD patients and paperwork at the ER. My Mom goes back the states tomorrow so I'll be spending the weekend here in Cebu City to see her off. We went back to Colon and I was able to take a quick snapshot with my phone:

Day 70 Dalaguete, Cebu #DPC IVTT

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

Day 69 Dalaguete, Cebu

All quiet today on the ER night shift. The night passed without anyone being admitted and the only people coming in and out were family members bringing in food, medicine, and water to admitted patients.

I did learn, however, that the patient with an initial prognosis of TB was confirmed and started on IVTT antibiotics.

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.