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 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 70 Dalaguete, Cebu #DPC IVTT

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

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 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 32 Dalaguete, Philippines #DPC Delivery Room, IVTT

I moved back to the ER today for PM shift (1500 – 2300). It's slower than AM shift because no one comes in for consultations that late. However, it means when someone does come in, it's usually an emergency.

The bulk of my time today was spent in the delivery room (DR), because I finally got to assist in a delivery! The mother was brought into the DR from the ward after reaching full dilation (10cm). It's pretty intense here because they don't give epidurals or any type of anesthesia during the birth. I mostly observed and rinsed off the vagina every so often and fetched gauze and stitching equipment (for after the birth) since the doctor had to maintain sterile conditions. The actual process was a lot of waiting and a lot of encouraging. The mother was super calm the entire time. When the babies head was about 2 inches from crowning the mother was too tired to push on her own so the midwife/pharmacist came in and physically helped push the baby out of the womb. I didn't have the best view of the midwife so I couldn't actually see how she was positioning herself, but the baby came out pretty fast after she started helping. As soon as the baby started crowning, it was clear that there wasn't enough room so the doctor had to make an incision along the bottom of the vagina to make more space. As soon as the baby was delivered the doctor set her on the mothers stomach, clamped the umbilical cord, then cut it. The nurse then took the baby and begin cleaning, measuring, and injected vitamin K. It was the first time I'd ever seen a newborn immediately after birth. I didn't realize babies are extremely pale the first few minutes after they come out of the womb. While the nurse was cleaning and preparing the newborn, the baby began to gain color and looked pretty healthy. As this was going on, the doctor was helping remove the placenta. After the placenta was removed, the doctor injected a local anesthetic near the vaginal incision and began stitching.

When I got back to the ER, there were two admits waiting. One was in because of dizziness and vomiting so he was admitted, given Renatidine vit IVTT (for hyperacidity) and admitted for observation. The nurse at the ER let me fill out the admitting paperwork and countersigned anything I signed. I then had to follow out the doctors orders and fill out how many Plain NSS IV's needed to be hooked, what medication was to be given at what dosage and when, the admitting diagnosis, and secure a signature for consent of admission. After all this, I had to go to the ward and endorse – physically read off the doctors orders to the charge nurse at the ward and list off everything that had been done and what needed to be done.

The second came in because of possible vaginal bleeding. It turns out the patient was two months pregnant and had suffered a miscarriage. She was admitted and the nurses in the ward were told to observe and to let the doctor know when the fetus was expelled.

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.